The correlates of RV dysfunction differ in HFrEF compared with HFpEF and HFmrEF patients. Regardless of the extent of LV dysfunction, the TAPSE/PASP ratio is a powerful independent predictor of prognosis in all heart failure patients.

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is associated with increased morbidity and mortality, but the identification of LVAD candidates at risk for RVF remains challenging. We undertook a systematic review and meta-analysis of observational studies of risk factors associated with RVF after LVAD implant. Thirty-six studies published between 1 January 1995 and 30 April 2015, comprising 995 RVF patients out of a pooled final population of 4428 patients, were identified. Meta-analysed prevalence of post-LVAD RVF was 35%. A need for mechanical ventilation [odds ratio (OR) 2.99], or continuous renal replacement therapy (CRRT; OR 4.61, area under the curve 0.78, specificity 0.91) were the clinical variables with the highest effect size (ES) in predicting RVF. International normalized ratio [INR; standardized mean difference (SMD) 0.49] and N-terminal pro-brain natriuretic peptide (NT-proBNP) (SMD 0.52) were the biochemical markers that best discriminated between RVF and No-RVF populations, though NT-proBNP was highly heterogeneous. Right ventricular stroke work index (RVSWI) and central venous pressure (CVP) (SMD -0.58 and 0.47, respectively) were the haemodynamic measures with the highest ES in identifying patients at risk of post-LVAD RVF; CVP was particularly useful in risk stratifying patients undergoing continuous-flow LVAD implant (SMD 0.59, P < 0.001, I = 20.9%). Finally, pre-implant moderate to severe right ventricular (RV) dysfunction, as assessed qualitatively (OR 2.82), or a greater RV/LV diameter ratio (SMD 0.51) were the standard echocardiographic measurements with the highest ES in comparing RVF with No-RVF patients. Longitudinal systolic strain of the RV free wall had the highest ES (SMD 0.73) but also the greatest heterogeneity (I = 74%) and was thus only marginally significant (P = 0.05). Patients on ventilatory support or CRRT are at high risk for post-LVAD RVF, similarly to patients with slightly increased INR, high NT-proBNP or leukocytosis. High CVP, low RVSWI, an enlarged right ventricle with concomitant low RV strain also identify patients at higher risk.

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Aims Uncertainties remain on the biological and prognostic significance and therapeutic implications of loss in body weight (W‐LOSS) in chronic heart failure (HF) patients. We assessed whether W‐LOSS added additional prognostic value to classical clinical risk factors in two separate and large cohorts of patients with chronic HF. The factors associated with W‐LOSS were studied. Methods and results W‐LOSS and estimated plasma volume changes were measured serially in the GISSI‐HF (n = 6820) and Val‐HeFT trials (n = 4892). In both studies, experiencing at least one episode of ≥5% W‐LOSS during the first year of follow‐up was considered a sign of wasting. In GISSI‐HF, self‐reported unintentional W‐LOSS ≥2 kg between two consecutive clinical visits within 1 year was also considered a sign of wasting. W‐LOSS occurred in 16.4% and 15.7% of the patients enrolled in GISSI‐HF and Val‐HeFT, respectively (unintentional ≥2 kg W‐LOSS occurred in 18.9% in GISSI‐HF). In multivariable analyses adjusting for a number of baseline covariates as well as for plasma volume changes, W‐LOSS was found to be independently associated with mortality and adverse cardiovascular and non‐cardiovascular outcomes, with a significant net reclassification improvement (cfNRI) and an increase in integrated discrimination improvement (IDI). W‐LOSS was independently associated with several features representing the severity of HF, including baseline NT‐proBNP and high sensitivity C‐reactive protein (hsCRP) in Val‐HeFT. Conclusions W‐LOSS was a frequent finding in the GISSI‐HF and Val‐HeFT trials, associated with multiple patient features, and added additional prognostic information beyond clinical variables of HF severity, including estimated plasma volume changes.

AimsTo test whether canrenone, an aldosterone receptor antagonist, improves left ventricular (LV) remodelling in NYHA class II heart failure (HF). Aldosterone receptor antagonists improve outcome in severe HF, but no information is available in NYHA class II. Methods and resultsAREA IN-CHF is a randomized, double-blind, placebo-controlled study testing canrenone on top of optimal treatment in NYHA class II HF with low ejection fraction (EF) to assess 12-month changes in LV end-diastolic volume (LVEDV). Brain natriuretic peptide (BNP) was also measured. Information was available for 188 subjects on canrenone and 194 on placebo. Left ventricular end-diastolic volume was similarly reduced (218%) in both arms, but EF increased more (P ¼ 0.04) in the canrenone (from 40% to 45%) than in the placebo arm (from 40-43%). Brain natriuretic peptide (n ¼ 331) decreased more in the canrenone (237%) than in the placebo arm (28%; P , 0.0001), paralleling a significant reduction in left atrial dimensions (24% vs. 0.2%; P ¼ 0.02). The composite endpoint of cardiac death and hospitalization was significantly lower in the canrenone arm (8% vs. 15%; P ¼ 0.02). ConclusionCanrenone on top of optimal treatment for HF did not have additional effects on LVEDV, but it increased EF, and reduced left atrial size and circulating BNP, with potential beneficial effects on outcome. A large-scale randomized study should be implemented to confirm benefits on cardiovascular outcomes in patients with HF in NYHA class II.--