Pharmacological therapies constitute the cornerstone of treatment for patients with heart failure. However, the presence of structural abnormalities worsens their prognosis. Certain procedures, such as cardiac resynchronization therapy, ventricular assist device implantation, or structural interventions on specific valvular diseases, have demonstrated efficacy in selected scenarios. Others are in the process of being implemented into routine clinical practice. 

This article aims to summarize the various percutaneous interventions that can be performed in patients with heart failure. It categorizes the procedures according to their mechanisms of action: promoting left ventricular reverse remodeling, reducing pulmonary capillary pressure, or correcting valvular abnormalities. 

Percutaneous devices targeting left ventricular reverse remodeling physically alter the shape or size of the ventricle. The objective of these devices is to reduce ventricular diameter, either epicardially via surgical access, endocardially through a retroaortic approach, or intramyocardially via the coronary sinus. The most advanced device, the AccuCinch Ventricular Restoration System®, is anchored below the mitral annulus through a retroaortic arterial approach and has demonstrated reductions in left ventricular end-diastolic volume, along with improvements in quality of life and 6-minute walk tests one year post-procedure. Other devices, aimed at modifying ventricular geometry, include surgical exclusion of necrotic regions via mini-thoracotomy or transcatheter apex isolation, currently under development. 

Reduction of pulmonary capillary pressure is achieved by creating an interatrial shunt with left-to-right flow. Two mechanisms are proposed for maintaining shunt patency long-term: device implantation or tissue ablation/excision. The most evidence exists for percutaneous devices such as the Corvia Atrial Shunt® and the V-Wave Ventura Interatrial Shunt®, which, while not showing benefits in terms of mortality, heart failure, or stroke, are associated with improved quality of life and ventricular remodeling parameters in selected populations. 

Cardiac valve interventions are divided into those targeting the aortic, mitral, or tricuspid valves. The most robust evidence pertains to the aortic valve, with transcatheter aortic valve implantation (TAVI) being a Class I recommendation for patients over 65 years old with severe symptomatic aortic stenosis, or for asymptomatic patients under 80 years old with reduced ventricular function (LVEF < 50%). A new prognostic staging classification for aortic stenosis, based on imaging evaluation of extravalvular cardiac involvement (left ventricle, mitral valve/left atrium, pulmonary pressure/tricuspid valve, and right ventricle), is currently under consideration. Specific scenarios demonstrating TAVI’s safety and efficacy include patients with cardiac amyloidosis (greater one-year survival compared to placebo), degenerated aortic bioprostheses (excellent three-year outcomes for initial prostheses larger than 23 mm), or cardiogenic shock (TAVI implantation with mechanical circulatory support is a safe procedure with similar mortality to elective procedures beyond the first month). Special mention is made of aortic insufficiency, with two specific prostheses described: Trilogy Valve® and J-Valve®, the former showing evidence of safety and efficacy, and the latter in feasibility phase. 

Regarding the mitral valve, percutaneous mitral valvuloplasty is described for rheumatic mitral stenosis, along with percutaneous options for previous surgical treatments (valve-in-valve and valve-in-ring), with better outcomes for transcatheter prosthesis implantation on mitral bioprostheses compared to annuloplasty. However, the true development of percutaneous procedures lies in native mitral valve regurgitation, where devices are categorized by mechanism of action: annular reduction, chordal repair, edge approximation, and transcatheter prosthesis implantation. Annular repair with the Carillon Mitral Contour System® via the coronary sinus demonstrates reduced mitral regurgitation and improved functional class. NeoChord DS 1000® is a chordal replacement device with transapical access, with transseptal venous access in development. Mitral edge-to-edge repair with devices such as MitraClip® and PASCAL® is widely implemented in patients with cardiomyopathy and secondary mitral regurgitation, where benefits in morbidity and mortality have been shown over a five-year follow-up. For patients ineligible for edge-to-edge therapy, transcatheter prosthesis implantation, either transapically (Tendyne®) or via transseptal venous access (Intrepid®), can be considered. 

Finally, tricuspid valve procedures include edge approximation, annular reduction, and orthotopic or heterotopic valve replacement. Edge-to-edge therapies (TriClip® and PASCAL®) and annular reduction (Cardioband®) have demonstrated symptomatic improvement. Orthotopic transcatheter prosthesis implantation (EVOQUE®) shows improved functional class, quality of life, and 6-minute walk tests, with a trend towards reduced mortality. Other orthotopic prostheses, such as Lux Valve® or Cardiovalve®, are under development. Lastly, heterotopic prostheses implanted in the venae cavae, such as TRICENTO® and TricValve®, may provide symptomatic relief in inoperable patients and those not eligible for other percutaneous therapies. 

COMMENTARY: 

This article comprehensively reviews the various options structural interventions offer to patients with heart failure. Hemodynamic changes, neurohormonal activation, and a proinflammatory state promote ventricular remodeling and impair myocardial contractility. While pharmacological therapies positively influence ventricular remodeling, concomitant structural abnormalities limit their efficacy. Thus, structural interventions are proposed at various levels to enhance contractility and reduce interstitial fibrosis, wall stress, filling pressures, or vascular resistance. 

The most substantial evidence exists for valvular procedures, such as TAVI for aortic stenosis or edge-to-edge repair on mitral or tricuspid valves, demonstrating prognostic or symptomatic improvements to varying extents. Although ventricular remodeling or interatrial shunt therapies show promise, they lack robust results. Ongoing studies will confirm in the coming years whether these therapies can be incorporated as part of the therapeutic arsenal for heart failure patients. 

REFERENCE:

Hahn RT, Lindenfeld J, Lim SD, Mack MJ, Burkhoff D. Structural Cardiac Interventions in Patients With Heart Failure: JACC Scientific Statement. J Am Coll Cardiol. 2024 Aug 27;84(9):832-847. doi: 10.1016/j.jacc.2024.05.061.