Dr Iqbal Malik
Consultant Cardiologist, Hammersmith Hospital and One Welbeck Heart Health
Dr Andrew Flett
Consultant Heart Failure Cardiologist, University Hospital Southampton
Mike Galloway
General Manager and Director, Occlutech UK Ltd
Heart failure occurs when the heart is not pumping efficiently. Under physical activity, the effects (symptoms) of heart failure are even more pronounced such as shortness of breath.
Sometimes, heart failure symptoms persist, even though doctors and patients are doing their best to manage the condition.
Interatrial shunting
A technique developed in the 1960s known as interatrial shunting can potentially improve symptoms. They make a tiny opening in the wall between the two atria of the heart (interatrial shunt) that acts like a pressure valve. Blood can flow through the opening from the high to the low-pressure side.
Interatrial shunting has been used in many patients with pulmonary hypertension. Doctors have started to use the technique in heart failure patients. It is under investigation to see if interatrial shunting can improve symptoms and outcomes.
Many patients experience reduced symptoms and feel better. But interatrial shunting only works if the shunt remains open. The Atrial Flow Regulator (AFR) is a tiny device that can be used to keep the interatrial shunt open and control its size. The AFR is implanted using established and safe, minimally invasive techniques performed by specialised doctors (interventional cardiologists).
Publications have shown that the AFR and other devices developed in recent years can be safely implanted and improve symptoms in selective heart failure patients.
The AFR is CE-marked for use in patients with heart failure and is available both on the NHS and in private healthcare.
Heart transplants and artificial hearts are not realistic options for most patients.
Varieties of heart failure
Heart failure (HF) comes in two main varieties: 1) Heart failure with reduced Ejection Fraction (HFrEF) — the pump is not squashing down properly and 2) Heart failure with a Preserved Ejection fraction (HFpEF) — it is not the squashing down, but the relaxation after that is the issue.
For HFrEF, many drugs can help. Plus, complex cardiac pacemakers can help re-synchronise the heartbeat, help symptoms and prolong life. For HFpEF, the list of drugs is much shorter, and the pacemakers don’t work as well. Heart transplants and artificial hearts are not realistic options for most patients. Sadly, the prognosis is as bad as it is for cancer.
In addition to these treatments, we are trying to see if taking pressure off the lungs can help symptoms. The FROST-HF trial will see if those with the most severe symptoms of HF may benefit from creating a ‘pressure release valve’ from the left atrium to the right atrium, reducing the pressure on the lungs and making a meaningful difference to sick patients with severe HF. The AFR device is fairly easy to place. It will be interesting to see if it adds to our list of treatments for these highly symptomatic patients.
Studies in the field
There have been several key advances in the care of patients with heart failure over the last 10 years, and treatment can be very effective.
However, for patients that don’t respond and for those with a specific type of heart failure — that is where the heart is stiff and under high pressure — we have few options. These patients can suffer from intractable symptoms of shortness of breath and lethargy, and some need frequent hospitalisation. This is frustrating for patients and their cardiologists and expensive for the NHS.
The concept of interatrial shunting and atrial flow regulation is an exciting prospect which could unload the high pressure in the heart, with the potential to improve symptoms and quality of life.
We already know that it is a safe procedure, and early data supports that it has a positive impact on wellbeing. If it can also reduce hospitalisation rates and improve prognosis, then it could also be highly cost-effective. I look forward to seeing the results of the important large-scale research studies currently being undertaken in the field.
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