We present a case of successful intracardiac echocardiography guided left atrial appendage catheter closure in a patient with esophageal varices using deflectable delivery sheath to improve ICE-catheter stability.

Heart failure with reduced left ventricular ejection fraction (LV EF) (HFrEF) is a significant issue of health care due to increasing indexes of morbidity and mortality. The emergence of a number of drugs and implantable devices for the treatment of HFrEF has allowed improvement of patients’ well-being and prognosis. However, high mortality and recurrent decompensated heart failure remain a substantial issue and stimulate the search for new methods of CHF treatment. Cardiac contractility modulation (CCM) is a method of managing patients with HFrEF. Available data from randomized clinical trials (RCT) indicate the efficacy of CCM in improvement of patients’ well-being and quality of life. The question remains open: what effect does CCM have on LV reverse remodeling? Experimental data and results of observational studies suggest a possibility of reverse remodeling by CCM; however, this has not been confirmed in RCT. Also, it remains unclear how CCM influences the frequency of hospitalizations for decompensated heart failure and the death rate of patients with HFrEF. Results of both RCTs and observational studies have shown a moderate improvement of quality of life associated with CCM. Furthermore, RCTs have not found any increase in LV EF due to the therapy, nor has a meta-analysis of RCTs revealed any improvement of the prognosis associated with CCM.  Further RCTs are needed to evaluate the effect of CCM on reverse remodeling, survival rate, and to determine the place of CCM in the treatment of patients with CHF.

Aim. This study aimed to evaluate the efficacy and safety of cardiac contractility modulation (CCM) therapy in elderly patients with heart failure with reduced ejection fraction (HFrEF).Methods. Sixteen patients older than 65 years old (median age 70 years) undergoing CCM Optimizer (Impulse Dynamics) device implantation due to HFrEF (NYHA class II - 9 (56%), III - 4 (25%), IV - 3 (19%)) were enrolled in this two-center observational study. Before implantation 6-minute walk test (6MWT), transthoracic echocardiography (TTE) was performed on all patients, and NTproBNP levels were assessed. The follow-up duration was 12 months with 2, 6, 12-month follow-up visits. Control 6MWT, TTE and NTproBNP tests were performed at 6-month and 12-month follow-up visits.Results. Two patients died during follow-up due to HF decompensation. The remaining patients showed a significant improvement in 6MWT (350 m vs 402.5 m, p=0,01). We also noted a tendency towards the left ventricular EF improvement (33% vs 40%, p=0,2) and lower values of NTproBNP levels (1112 pg/ml vs 527 pg/ml, p=0,19).Conclusion. CCM therapy is a safe and efficient additional treatment option to manage elderly patients with HFrEF for reducing signs and symptoms of HF.

Aim. Cardiac contractility modulation (CCM) is a device therapy for patients with heart failure with reduced ejection fraction (HFrEF), most of the data on its programming are concerned patients with narrow QRS and of limited follow up. Our aim was to propose programming approach for Optimizer device in setting of wide QRS complex and fragmented ventricular local activation.Methods. We enrolled 11 patients with HFrEF (median age, 8 males, median NYHA class 3) and LBBB-related wide QRS complex, who underwent Optimizer™ device implantation. Three patients got Optimizer™ IV system and eight patients were implanted Optimizer™ Smart. Ten patients were previously implanted with CRT-D due to HFrEF and LBBB; one patient received CRT-D after Optimizer™ implantation.Results. During the implantation procedure ventricular local sense (LS) channel signal fragmentation was detected in all patients. In five patients signal detection was optimized by lead relocation. In six patients LS signal sensitivity limitations were resolved by programming. At two-year follow-up survival 4 patients died of noncardiac causes (1 intracranial hemorrhage, 1 gastrointestinal bleeding and 2 - terminal kidney failure). At 12-month follow-up we observed a non-significant improvement in 6-minute walking distance (300 vs 305, p=0.093), NYHA class (2.75 vs 2, p=0.085), MLHF score (53 vs 42, p=0.109) and left ventricular ejection fraction (LVEF) (30 vs 33.5, p=0.212).Conclusion. CCM system implantation is feasible and safe in patients with HFrEF and LBBB-related wide QRS complex. Device programming maneuvers can resolve the challenges of ventricular local signal detection in these patients.