Scott Feitell

Aims: Congestion signals heart failure (HF) progression and drives decompensation. Reliable management strategies remain poorly developed. We evaluated 12 months of congestion-guided clinical management following implantation of an inferior vena cava (IVC) sensor. Methods and Results: Data were combined from two prospective studies (FUTURE-HF and FUTURE-HFII) (N =65, mean age 65.7 ± 9.5 years; 75.4% NYHA III; 90.8% heart failure with reduced ejection fraction. Patients recorded daily IVC parameters. Adjudicated safety outcomes, sensor-derived IVC area measurement versus CT imaging, medication adjustments, and clinical outcomes at 12 months were analysed. No adjudicated device or procedure-related serious adverse events occurred. Excellent correlation was observed between sensor-derived and CT-derived IVC area (n = 44; R2 = 0.97; mean relative error <5%). Patient adherence was 93%, and a sustained, significant reduction in IVC area was observed (8.1%, P < .005), correlated with clinical improvements (P < .001), despite no significant change in body weight. Improvements were observed in the New York Heart Association (NYHA) functional class (Class III: 74.5% improved to 40.0%; P < .01) and N-terminal pro-B-type natriuretic peptide (median 1697 reduced to 998 ng/L; P < .001). HF events (HFEs) were lower post-implant (0.31/year, 1.67/year pre-implant; 84.5% relative reduction; rate ratio: 0.18; 95% CI: 0.08–0.29). Medication adjustments (n = 415) included diuretic titration (57%) and increased use of guideline directed medical therapy from baseline to 12-months (28%). Conclusions: Congestion management through ambulatory IVC monitoring demonstrated excellent safety, sustained accuracy, and high levels of patient adherence at 12-months after sensor implantation. This was associated with improved HF congestion status and a lower observed rate of HFEs, supporting investigation of congestion-guided management using IVC monitoring in a pivotal randomized clinical trial.

Left ventricular assist devices serve as a salvage therapy for patients with advanced heart failure. Complications such as thrombosis and obstruction can lead to acute device malfunction, posing significant clinical risks. A multidisciplinary approach is crucial for management. Few cases in the literature have demonstrated the safety and efficacy of percutaneous intervention, which holds significant value due to its less invasive nature and minimal risk of morbidity, especially in high-risk surgical patients.

McLeod’s syndrome (MLS) is an X-linked disorder caused by mutations in the XK gene with neurological manifestations as well as cardiomyopathy. This is a case of acute exacerbation of heart failure in a 44-year-old White male with a confirmed diagnosis of MLS, which was managed with guideline-directed medical therapy and placement of an implantable cardioverter defibrillator with recovery in ejection fraction.

Background: Cardiac sarcoidosis (CS) and arrhythmogenic right ventricular cardiomyopathy (ARVC) are rare causes of ventricular arrhythmias and are associated with sudden cardiac death. Differentiation between both is important for proper management. Case summary: We present a 56-year-old man with sudden cardiac arrest and was diagnosed to have ARVC based on cardiac magnetic resonance imaging (MRI). He developed gradually worsening shortness of breath over the next 1 year. CS was unmasked after a cardiac positron emission tomography (PET). Patient was treated with methotrexate. A repeat cardiac PET scan showed improvement. Discussion: The distinction between ARVC and CS is challenging. Both these entities have a patchy involvement and can have similar presentations. ARVC has a predominant right heart involvement. It is diagnosed with the help of an MRI, which shows regional right ventricular wall motion abnormality. These findings can have an overlap with CS. It is important to note that, even though sarcoidosis is a pathologic diagnosis, cardiac biopsy is rarely done owing to its patchy involvement. Cardiac PET scan has a high sensitivity and specificity to diagnose this entity. Once diagnosis is made, patients should be treated with immunosuppressants and should be closely followed. Repeat imaging should be considered at intervals to monitor disease progression. This case highlights the importance of multimodality imaging and tissue diagnosis to unmask the diagnosis of CS, a treatable infiltrative disorder which shares features with a potentially untreatable ARVC.