Current and future use of neuromodulation in heart failure

Abstract

Autonomic imbalance is a common finding in heart failure (HF) with reduced ejection fraction (HFrEF). Addressing different targets within the autonomic nervous systems has been evaluated in patients with HF, including renal sympathetic denervation, vagal nerve stimulation, and baroreceptor activation therapy (BAT). Although all are pathophysiologically plausible and promising, only BAT shows sufficient evidence for implementation into clinical practice in randomized controlled trials. Baroreceptor activation therapy can be used in patients with symptomatic HFrEF despite optimal guideline-directed medication and device therapy. This article reviews the current and future use of neuromodulation in HF and provides an overview on current guideline recommendations and clinical practice.

Neuromodulation in heart failure

“…In this issue of EHJ Supplements, De Ferrari et al ’s 7 and Duncker and Bauersachs’s 8 and Dusi et al . 's 9 excellent overviews examine the available clinical evidence with the neuromodulation therapies under development in HF.…”

Neuromodulation interventions in the management of heart failure

“…Consequently, BAT with the Barostim Neo System was approved by the Food and Drug Administration (FDA) in 2019 for the use in HFrEF with NYHA class II or III, an NT-proBNP of <1600 pg/ml or ineligibility for CRT. 11 The MobiusHD System (Vascular Dynamics) is an endovascular, device-based baroreceptor enhancement system that works by inducing passive activation of the baroreceptors through changes in the geometric shape of the carotid body thereby increasing carotid artery wall stretch while maintaining pulsatility. 60,61 This change in signalling causes a negative feedback response, resulting in decreased sympathetic activity and increased parasympathetic activity.…”

“…Currently, beta‐blockers and RAAS inhibitors are the only available pharmacological HF therapies that target this pathway either at the receptor level or at closely linked signalling pathways 3 . Therefore, non‐pharmacological interventions targeting the autonomic imbalance in HF have been investigated and act at the level of receptors such as beta‐blockers and may potentially reduce heart rate or target‐associated signalling pathways by altering RAAS levels 10,11 . This paper aims to review the physiology, available clinical data, and potential therapeutic role of device‐based neuromodulation in HF ( Figures and ).…”

Device-based therapies for decompensated heart failure

“…However, the pathophysiology of HF is driven by an overactive SNS which exceeds the functions of the PNS and contributes to maladaptation and myocardial remodeling. Therefore, augmentation of the ANS via the stimulation of various nerve beds is under clinical investigation [31].…”

“…However, the pathophysiology of HF is driven by an overactive SNS which exceeds the functions of the PNS and contributes to maladaptation and myocardial remodeling. Therefore, augmentation of the ANS via the stimulation of various nerve beds is under clinical investigation [31]. Electrical stimulation of the carotid bodies via baroreflex activation therapy (BAT) can be used to limit SNS activation and enhance PNS effects.…”