We are talking about a patient with heart failure with severe LV dysfunction (EF < 35%), LBBB (wide QRS), who is following optimal medical treatment and who remains in advanced functional class despite this. Coronary revascularization does not appear to be of much benefit in this patient at this time. Nor does mitral valve replacement, firstly because mitral regurgitation is most likely the result of mitral annular dilatation, and secondly because we would need an echocardiographic assessment of the mitral valve to determine whether there is any alteration. Intra-aortic balloon counterpulsation implantation would not be indicated in this patient (it is used in situations of cardiogenic shock, in post-AMI mechanical complications, as a bridge to cardiac Tx...). The ventricular assist device would also not be indicated in this patient. What would really benefit him of all the answers is number 5, the resynchronization device. By achieving simultaneous stimulation of both ventricles, a mechanical synergy is achieved that improves cardiac function. The indications for the application of CRT (cardiac resynchronization therapy) are precisely those mentioned at the beginning: severe ventricular dysfunction, asynchrony demonstrated by the presence of wide QRS in the ECG (usually due to LBBB) and advanced functional class (III-IV) despite optimal medical treatment.

We are talking about a patient with heart failure with severe LV dysfunction (EF < 35%), LBBB (wide QRS), who is following optimal medical treatment and who remains in advanced functional class despite this. Coronary revascularization does not appear to be of much benefit in this patient at this time. Nor does mitral valve replacement, firstly because mitral regurgitation is most likely the result of mitral annular dilatation, and secondly because we would need an echocardiographic assessment of the mitral valve to determine whether there is any alteration. Intra-aortic balloon counterpulsation implantation would not be indicated in this patient (it is used in situations of cardiogenic shock, in post-AMI mechanical complications, as a bridge to cardiac Tx...). The ventricular assist device would also not be indicated in this patient. What would really benefit him of all the answers is [HIDDEN], the resynchronization device. By achieving simultaneous stimulation of both ventricles, a mechanical synergy is achieved that improves cardiac function. The indications for the application of CRT (cardiac resynchronization therapy) are precisely those mentioned at the beginning: severe ventricular dysfunction, asynchrony demonstrated by the presence of wide QRS in the ECG (usually due to LBBB) and advanced functional class (III-IV) despite optimal medical treatment.

What therapeutic intervention would you consider in a 67-year-old patient with idiopathic dilated cardiomyopathy, left bundle branch block, left ventricular ejection fraction of 26%, mitral insufficiency grade II-III/IV, undergoing treatment with furosemide, spironolactone, enalapril and bisoprolol and who remains in NYHA functional class III?

Implantation of a ventricular assist device.

Implantation of a cardiac resynchronization system.

Management of heart failure

Devices CRT: People with NYHA class III or IV, left ventricular ejection fraction (LVEF) of 35% or less and a QRS interval of 120 ms or more may benefit from cardiac resynchronization therapy (CRT; pacing both the left and right ventricles), through implantation of a bi-ventricular pacemaker. This treatment modality may alleviate symptoms, improving quality of life, and in some trials has been proven to reduce mortality. The COMPANION trial demonstrated that CRT improved survival in individuals with NYHA class III or IV heart failure with a widened QRS complex on an electrocardiogram. The CARE-HF trial showed that patients receiving CRT and optimal medical therapy benefited from a 36% reduction in all-cause mortality and a reduction in cardiovascular-related hospitalization.

Successful bridge to recovery with VAD implantation for anthracycline-induced cardiomyopathy.

Anthracyclines are effective antineoplastic drugs, but they are known to be cardiotoxic. Recovery of cardiac function is rare. A few studies on implantation of a ventricular assist device (VAD) have been performed for anthracycline-induced cardiomyopathy. Recovery of left ventricular (LV) function with an LVAD is also rare. Recently, several adjunctive therapies were attempted to restore ventricular function. We report a successful bridge to recovery of ventricular function using VAD implantation for anthracycline-induced cardiomyopathy. The patient was a 57-year-old man who had been diagnosed with diffuse large B-cell lymphoma (DLBCL) at age 52. Combination chemotherapy including hydroxydaunorubicin was started. Complete remission was achieved after chemotherapy. Heart failure symptoms such as fatigue, dyspnea on exertion, and weight gain appeared 5 months later. A cardiac resynchronization device was implanted. His heart function deteriorated. He underwent implantation of a Toyobo LVAD and mitral annuloplasty. After implantation, he was prescribed carvedilol with spironolactone. He was weaned from the LVAD on postoperative day (POD) 239 and discharged on POD 37 after weaning. He remained in New York Heart Association classes within the first- to second-degree range, the LV dimention diastolic/systolic ratio was 56/46 mm, ejection fraction 38%, and mitral regurgitation mild at 3 years after weaning from the LVAD. Our patient could be weaned from LVAD probably due to the combination management strategy employing mitral valvuloplasty, use of cardiac resynchronization therapy, and taking carvedilol with spironolactone. Further studies will be needed to clarify the efficacy of these adjunctive therapies.

[Commentary on the 2010 ESC guidelines on device therapy in heart failure ].

As part of the 2010 focused update of ESC guidelines on device therapy in heart failure, the guidelines on pacemakers in the treatment of heart failure were renewed. A new feature is that cardiac resynchronization therapy (CRT) is indicated for New York Heart Association (NYHA) class III and IV irrespective of the presence of left ventricular dilatation and specified for NYHA class IV (patient ambulatory, stable, life expectancy >6 months). Furthermore, NYHA class II (but not class I) has been added when there is left bundle branch block and QRS duration ≥150 ms. CRT is also indicated for patients in NYHA class III-IV with permanent atrial fibrillation and heart failure [left ventricular ejection fraction (LVEF) ≤ 35%] when QRS is ≥ 130 ms and ventricular rate has slowed either spontaneously or by AV node ablation. In patients with heart failure (NYHA class II-IV, LVEF ≤ 35%) who need a pacemaker for AV block, CRT is generally indicated to avoid progression of heart failure caused by right ventricular stimulation, also in cases of intrinsic QRS <120 ms. For patients with terminal heart failure who are not eligible for heart transplantation, treatment with a left ventricular assist device can be performed as destination therapy. The new guidelines expand the indication for device therapy in heart failure based on the newest study findings, particularly for patients in NYHA class II, and specify the old guidelines. There are still uncertainties that must be investigated in randomized trials regarding patients with permanent atrial fibrillation, the indication for CRT in heart block, and the question of CRT with pacemaker or defibrillator.

Autologous transplantation of bone marrow adult stem cells for the treatment of idiopathic dilated cardiomyopathy.

Morbimortality in patients with dilated idiopathic cardiomyopathy is high, even under optimal medical treatment. Autologous infusion of bone marrow adult stem cells has shown promising preliminary results in these patients. Determine the effectiveness of autologous transplantation of bone marrow adult stem cells on systolic and diastolic left ventricular function, and on the degree of mitral regurgitation in patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III. We administered 4,54 x 10(8) ± 0,89 x 10(8) bone marrow adult stem cells into the coronary arteries of 24 patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III. Changes in functional class, systolic and diastolic left ventricular function and degree of mitral regurgitation were assessed after 3 months, 6 months and 1 year. During follow-up, six patients (25%) improved functional class and eight (33.3%) kept stable. Left ventricular ejection fraction improved 8.9%, 9.7% e 13.6%, after 3, 6 and 12 months (p = 0.024; 0.017 and 0.018), respectively. There were no significant changes neither in diastolic left ventricular function nor in mitral regurgitation degree. A combined cardiac resynchronization and implantable cardioversion defibrillation was implanted in two patients (8.3%). Four patients (16.6%) had sudden death and four patients died due to terminal cardiac failure. Average survival of these eight patients was 2.6 years. Intracoronary infusion of bone marrow adult stem cells was associated with an improvement or stabilization of functional class and an improvement in left ventricular ejection fraction, suggesting the efficacy of this intervention. There were no significant changes neither in left ventricular diastolic function nor in the degree of mitral regurgitation.

[Treatment results of patients with mitral valve disease in IV functional class of NYHA. II: Conservative treatment].

In the group of 60 patients with mitral valve disease (67% in IV and 33% in III functional class of NYHA) the efficacy of medical treatment was analysed. In all of them clinical, noninvasive and invasive investigations were obtained. The conclusion is that survival during ca 1643 days was 15% of the patients in IV class of NYHA. The death was mostly due to severe heart failure.

Cardiac support device, restrictive mitral valve annuloplasty, and optimized medical treatment: a multimodality approach to nonischemic cardiomyopathy.

Nonischemic dilated cardiomyopathy with functional mitral regurgitation carries a poor prognosis. Mitral valve surgery with implantation of a cardiac support device can treat mitral regurgitation and promote left ventricular reverse remodeling. This observational study evaluates clinical and echocardiographic outcomes of an individualized medico-surgical approach, focusing on mitral regurgitation recurrence and left ventricular reverse remodeling. Sixty-nine consecutive patients with heart failure (New York Heart Association class III/IV) with functional mitral regurgitation (grade 3+/4+) and left ventricular remodeling (end-diastolic volume 227 ± 73 mL, ejection fraction 26% ± 8%) underwent restrictive mitral annuloplasty (median ring size 26), with (n = 41) or without (n = 28) a cardiac support device and optimal postoperative medical treatment. Patients were clinically and echocardiographically evaluated at up to 3.1 years' median follow-up. Early mortality was 5.8%. Actuarial survival at 1, 2, and 5 years was 86% ± 4%, 79% ± 5%, and 63% ± 7%. New York Heart Association class improved from 3.1 ± 0.4 to 2.0 ± 0.5 (P < .01). Cardiac support device implantation in addition to mitral valve surgery, applied in patients with more advanced left ventricular remodeling, resulted in similar clinical outcome, greater left ventricular end-diastolic volume decrease (33% vs 18%; P = .007), and in a trend toward less recurrent mitral regurgitation of grade 2+ or more (actuarial freedom at 3 years 89% ± 8% vs 63% ± 11%; P = .067). An individualized medico-surgical approach to nonischemic cardiomyopathy combining restrictive mitral annuloplasty, cardiac support device implantation, and optimal medical management leads to favorable survival and improved functional status, low incidence of significant recurrent mitral regurgitation, and sustained left ventricular reverse remodeling.

[Treatment results in patients with mitral valve disease in IV functional class of NYHA. I. Surgical treatment].

In the group of 142 patients with mitral valve disease (61% in IV and 39% in III functional class of NYHA) the efficacy of mitral valve replacement (MVR) was analysed. In all of the patients clinical, noninvasive and invasive investigations were obtained and compared before an after surgery. After MVR a statistically significant differences (p < 0.05 or p < 0.01) of RHV, noninvasive and hemodynamic data was observed. The survival during ca 1836 days after surgery of patients in IV class of NYHA was 72%. The improvement of activities correlated well with changes of functional class of NYHA.

Selected ventriculoplasty for idiopathic dilated cardiomyopathy with advanced congestive heart failure: midterm results and risk analysis.

To treat advanced heart failure due to idiopathic dilated cardiomyopathy, surgical ventricular restoration with mitral reconstruction was conducted and evaluated. In 95 patients (81 men, mean age: 54 years), New York Heart Association class III/IV was 44/51, and 33 patients (36%) were inotropic dependent preoperatively. Mitral regurgitation (>or=2+) was noted in all patients. All patients underwent left ventriculoplasty (septal anterior ventricular exclusion in 38, partial left ventriculectomy in 57) and mitral reconstruction (repair 53, replacement 42). Fifty-two patients (55%) had concomitant tricuspid repair. Intra-aortic balloon pumping and left ventricular assist device was used in 24 patients and two patients, respectively. Hospital mortality was 11.6% (11 of 95), with 6.6% (5 of 76) in elective and 31.6% (6 of 19) in emergency operations. The ejection fraction and cardiac index increased from 22.3+/-6.3% to 27.2+/-8.0% and from 2.3+/-0.5 ml/m2/min to 2.8+/-0.5 ml/m2/min, respectively (p<0.001). The endodiastolic volume index, endosystolic volume index and diastolic dimension decreased from 232.9+/-56.1 ml/m2 to 160.0+/-49.8 ml/m2, from 178.9+/-46.7 ml/m2 to 113.8+/-44.7 ml/m2 and from 82.0+/-9.0 mm to 68.9+/-11.6 mm, respectively (p<0.001). Late death occurred in 27 patients with 22 cardiac deaths. The mean NYHA class was 1.7 among the survivors. One-, 3- and 5-year survival rates were 72.8%, 61.4% and 50.5%, respectively. In the 62 patients who were non-inotropic dependent preoperatively, 1-, 3-, and 5-year survival rates (81.8%, 73.7% and 62.9%) were significantly better than the inotropic-dependent group (55.3%, 37.3% and 28.0%). Patients with mitral annuloplasty showed a significantly higher 5-year survival rate than patients with mitral valve replacement (59.6% vs 43.6%) in univariate analysis. By application of the exclusion site selection method, the two different ventriculoplasty procedures did not show significant difference in survival rates. Multivariate analysis showed that preoperative inotropes and old age were significant predictors for postoperative mortality. The selected ventriculoplasty in combination with mitral annuloplasty is a useful option for patients with an extremely dilated left ventricle in idiopathic dilated cardiomyopathy. Surgery should be considered before inotropic dependency occurs when prior medical treatment has failed.

Therapeutic challenges and management of heart failure during pregnancy (part I).

Therapeutic management in pregnant patients with heart failure still remains a challenge, even though in most pregnant women with cardiac diseases an outcome is good. A 32-year-old woman, 17 weeks pregnant, was admitted to hospital with heart failure (HF) NYHA class III/IV. Echocardiography revealed enlarged LV, LVEF 13%, significant mitral insufficiency and pulmonary hypertension. The patient wished to continue the pregnancy. In a life-threatening condition, metoprolol, enalapril, spironolactone (for 5 days), furosemide, and digitalis were administered. Enalapril was continued for 42 days. Then the patient was switched to a dihydralazine and isosorbide mononitrate regimen. The fetus was controlled ultrasonographically. In the 19th week of pregnancy, the patient's condition improved (NYHA class II, LVEF 23%). The patient experienced 2 more episodes of HF exacerbation. In the 26th week of pregnancy, in a primary prevention of sudden cardiac death and because of 2nd-degree AV block, an ICD was implanted. In the 32nd week of pregnancy a cesarean section was performed. A male infant was delivered. The patient made a good recovery and was discharged on the 7th postoperative day. The newborn was discharged after 4 weeks, in good general condition. At 1-year follow-up the patient presented NYHA class II.<br />

Comparison of benefits from cardiac resynchronization therapy in patients with ischemic cardiomyopathy versus idiopathic dilated cardiomyopathy.

Cardiac resynchronization therapy (CRT) is a recently introduced therapeutic option for patients with severe heart failure and intraventricular conduction disturbances. However, it is estimated that 20% to 30% of patients may not respond to CRT. Patients with ischemic cardiomyopathy (IC) may respond less favorably to CRT compared with patients with idiopathic dilated cardiomyopathy (IDC). Accordingly, the beneficial effects of CRT were evaluated in 2 subsets of patients (IC and IDC). Seventy-four patients with end-stage heart failure, New York Heart Association (NYHA) class III or IV, left ventricular (LV) ejection fraction <35%, QRS >120ms, and left bundle branch block received a biventricular pacemaker. At baseline and 6 months after implantation these parameters were evaluated: NYHA class, Minnesota quality-of-life score, QRS duration, and 6-minute walking distance. LV ejection fraction and severity of mitral regurgitation were assessed before and 6 months after CRT using 2-dimensional echocardiography. Long-term follow-up and hospitalization rates were obtained up to 2 years. Of the 74 patients, 46% (n = 34) had IC and 54% (n = 40) IDC. At 6 months follow-up all clinical parameters, QRS duration, LV ejection fraction, and mitral regurgitation improved significantly in both groups. Long-term (2-year) follow-up showed a survival rate of 87.5% for patients with IDC and 88.3% for patients with IC. The percentages of responders to CRT (defined as an improvement in NYHA class >or=1 grade) were comparable in both groups (65% vs 71%). Therefore, the underlying etiology of heart failure (IC vs IDC) was not related to the response to CRT.

[Guideline satisfying therapy for chronic heart failure].

Chronic heart failure may be caused by systolic pump failure and/or impairment of diastolic filling of the ventricles. The standard pharmacotherapy for systolic heart failure includes an ACE inhibitor, betablocker, diuretics and, in patients with severe symptoms, a low dose aldosterone antagonist. An AT1 receptor blocker is indicated for those patients who do not tolerate ACE inhibitors. If patients remain in the functional class NYHA III-IV despite optimal medication and have cardiac dyssynchrony, biventricular pacing may improve the symptoms and prognosis. While evidence-based treatment significantly reduces morbidity and mortality in systolic heart failure, hardly any results from clinical trials are available for diastolic heart failure. Therefore, therapy in patients with diastolic heart failure remains in most cases empirical.

A case report of balloon-assisted tracking to overcome coronary sinus competent valve: a novel technique in left ventricular lead implantation.

Competent lateral and posterolateral valves showed proximal tortuosity that might hinder left ventricular (LV) lead implantation in cardiac resynchronization therapy (CRT). A 57-year-old woman was diagnosed as non-ischaemic cardiomyopathy, no other comorbidities, complaining of dyspnoea [New York Heart Association (NYHA) class III], and on optimal medical therapy. Electrocardiogram showed left bundle branch block with QRS duration 150 ms. The patient was candidate for CRT. However, during LV lead implantation, a competent posterolateral vein valve and proximal tortuosity hindered LV lead implantation that was overcome by balloon-assisted tracking technique. At 9 months of follow-up, the patient had NYHA class II, ejection fraction improved to 38%, and all implanted leads were still in place. Balloon-assisted tracking technique can be used to cross coronary sinus and smaller veins with competent valves and coronary veins tortuosity.

[The use of beta blockers in heart failure: clinical studies].

Although inhibitors of angiotensin-converting enzyme (ACE) have improved the treatment of chronic heart failure (CHF), mortality related to this disorder remains unacceptably high. Results from studies started more than 25 years ago in Sweden suggested that long-term therapy with beta-blockers could improve hemodynamics and increase survival in patients with CHF; this hypothesis is confirmed by the results of six double-blind, randomized, placebo-controlled trials (MDC, CIBIS, ANZ, US Carvedilol Study, CIBIS II and MERIT-HF) who enrolled about 9000 patients with CHF. In these trials beta-blockers (metoprolol, bisoprolol or carvedilol) where added to the stable usual treatment of each patient (ACE-inhibitors, diuretics, digoxin). Baseline characteristics of patients enrolled into the beta-blocker or placebo arm were similar in all these studies. Specifically the mean patient's age was < 60 years, with a mean left ventricular ejection fraction of 25-26%, 30% of enrolled patients were in NYHA functional class II and 60% in NYHA functional class III, CHF was due to ischemic heart disease in about 60% of patients. The average follow-up for all the trials was 14.5 +/- 5.6 months. On the whole in patients on beta-blocker treatment there is a 33.3% reduction in total mortality rate, a 34.2% reduction in cardiac death rate, a 37.7% reduction in sudden death rate, and a 41.7% reduction in worsening heart failure mortality rate. Moreover, in beta-blocker patients there is a 31.7% reduction in all-cause readmissions to hospital and a 26% reduction in the combined end point (total mortality and hospital readmission). Beta-blockers improved ventricular function but there was no significant improvement in functional capacity. In conclusion, the results of the six trials considered indicate that there is convincing evidence supporting a favorable effect of beta-blockade on the risk of death and readmission to hospital in patients with dilated cardiomyopathy with systolic dysfunction, aged < 70 years, in NYHA functional class II-III. The effects of these drugs in CHF patients a) with normal left ventricular ejection fraction, b) aged > 65-70 years, c) in NYHA functional class IV, and d) with comorbilities such as obstructive lung disease, diabetes, peripheral arterial diseases, require additional study.

Determinants of mortality in patients undergoing cardiac resynchronization therapy: baseline clinical, echocardiographic, and angioscintigraphic evaluation prior to resynchronization.

In dilated cardiomyopathy (DCM) patients (pts) with cardiac resynchronization therapy (CRT) for ventricular dyssynchrony, long-term predictors of mortality and morbidity remain poorly investigated. We reviewed data of 102 pts, 68 +/- 10 years, NYHA Class II-IV (14 Class II, 67 Class III, 21 Class IV), who benefited from CRT (69 CRT, 33 CRT-ICD). Fifty-two patients had an ischemic DCM, 36 a previously implanted conventional PM/ICD, 29 a permanent atrial fibrillation, and 19 needed dobutamine in the month preceding implant. QRS duration was 187 +/- 35 ms, left ventricular end-diastolic diameter 72 +/- 10 mm, mitral regurgitation severity 1.9 +/- 0.8, echographic aorto-pulmonary electromechanical delay 61.5 +/- 25 ms and septo-lateral left intraventricular delay 86 +/- 56 ms, pulmonary artery pressure (PAP) 43 +/- 11 mmHg, angioscintigraphic left ventricular ejection fraction (EF) 20 +/- 9%, and right ventricular EF 30.5 +/- 14%. Over a mean follow-up of 23 +/- 20 months, 26 pts died (18 heart failures (HFs), 1 arrhythmic storm, 7 noncardiac deaths). Positive univariate predictors of death from any cause were NYHA Class IV (P < 0.001), and need for dobutamine the month preceding CRT (P < 0.008), while use of beta-blocking agents (P < 0.08) and left ventricular EF (P < 0.09) were negative ones. NYHA Class IV was the only independent predictor at multivariate analysis (P < 0.01). Survival at 24 months was 85% in Class II, 80% in Class III, and 37% in Class IV (II vs III, P = ns; III vs IV, P < 0.001). When using a composite endpoint of death from any cause and unplanned rehospitalization for a major cardiovascular event, there were 48 events (14 HF deaths, 3 noncardiac deaths, 26 HF rehospitalizations, 2 paroxysmal atrial fibrillation, 2 sustained ventricular tachycardia, 1 nonfatal pulmonary embolism). Predictors of death from any cause/unplanned rehospitalization for a major cardiovascular event in the follow-up were NYHA Class IV (P < 0.001), need for dobutamine during the month preceding CRT (P < 0.002), and PAP (<0.02). NYHA Class IV was the only independent predictor at multivariate analysis (P < 0.05). Event-free proportion at 24 months was 70% in Class II, 64% in Class III, and 37% in Class IV (II vs III, P = ns; III vs IV, P < 0.01). When considering determinants of mortality only in NYHA Class IV patients, no variable was significantly correlated to mortality. Need for dobutamine during the last month preceding CRT did not add an adjunctive mortality risk. Baseline NYHA Class IV at implantation appears as the most important determinant of a poor clinical outcome in terms of both mortality and morbidity. No predictive criteria seem available for NYHA Class IV patients, in order to discriminate who will die after CRT and who will not. NYHA Class IV strongly influences the clinical outcome, suggesting that, in future studies planned on mortality and rehospitalization as major endpoints, baseline NYHA Class IV should be separately taken into account.

Cardiac resynchronization therapy in NYHA class IV heart failure.

Clinical practice guidelines recommend cardiac resynchronization therapy (CRT) for ambulatory New York Heart Association (NYHA) class IV patients with a QRS duration >or= 120 ms and a left ventricular ejection fraction <or= 35%. Only two prospective, randomized trials have compared outcomes after CRT in NYHA class III and IV patients. CRT improved mortality, exercise capacity, and quality of life in class IV patients, but the 1-year mortality remained high. Patients in these trials were in sinus rhythm at randomization and most patients had a left bundle branch block. Less data are available for NYHA class IV patients with atrial fibrillation, right bundle branch block, and previous ventricular pacing. No prospective randomized data are available for the use of CRT as rescue therapy in inotrope-dependent patients, but several case series have reported promising results. It is likely that "rescue therapy" with CRT will be most beneficial when patients improve enough with CRT to allow reinstitution of angiotensin-converting enzyme inhibitors and beta blockers.

Early and intermediate results of left ventricular reduction surgery.

Left ventricular reduction surgery is a new surgical option for treatment of end-stage cardiac dysfunction, and little is known about hemodynamics and outcome in the European heart failure population. We present our early results with this operation. From January 1995 to September 1997, 30 patients (25 men, 5 women; mean age 61.2 years) underwent partial left ventriculectomy. The underlying disease was ischemic in 18 patients and idiopathic dilated cardiomyopathy in 12 patients. Preoperatively 23 patients were in New York Heart Association functional class IV and 7 were in class III. Mean cardiac index, stroke index and ejection fraction were 1.8 +/- 0.3 l/m2 per min, 23.5 +/- 5.1 ml/m2 and 19.3% +/- 6.8%, respectively. Associated procedures were coronary bypass in 18 patients, mitral valvuloplasty in one, aortic or mitral valve replacement in three, dynamic cardiomyoplasty in two, and left ventricular assist device implantation in 1. There were two early deaths: one from bleeding and one from anticoagulant-related cerebral hemorrhage. Regarding late deaths, one patient died from pneumonia 3 months after the operation and two died from dysrhythmia 4 and 17 months postoperatively. The estimated 1-year survival rate calculated by the Kaplan-Meier log-rank method was 85%. Mean cardiac index, stroke index, and ejection fraction rose significantly (P = 0.0001) to 2.9 +/- 0.51/m2 per min, 36.9 +/- 6.2 ml/m2 and 37.8% +/- 9.2%, respectively. Currently 26 patients are in New York Heart Association functional class I or II. Left ventricular reduction surgery improves objective and subjective parameters of cardiac performance significantly in early and intermediate follow-up. Randomized studies and carefully documented long-term results seem to be necessary to define the role of left ventricular reduction surgery.

The management of heart failure--an overview.

National and international societies have issued guidelines on the management of heart failure: The European Society of Cardiology, WHO, ACC/AHA Task Force Report, US Department of Health and Human Services, German Society of Cardiology. The therapeutic approaches to heart failure have undergone considerable changes during the last few years. The guidelines have to be updated almost yearly due to new results from prospective randomized studies. Although an agreement could be reached with respect to general measures and drug treatment, no agreement on mechanical devices, pacemakers and surgical interventions has been reached. The basis for medical treatment of chronic heart failure depends on diuretics, digitalis, ACE inhibitors, and beta-blockers. Calcium antagonists and other positive inotropic drugs, other than digitalis, should be avoided as far as possible. Thiazides, loop diuretics and aldosterone antagonists are needed for acute and chronic treatment of heart failure, alone or in combination (diuretic resistant heart failure!). Digitalis glycosides are needed in patients with atrial fibrillation with a fast ventricular rate or atrial flutter and in patients with systolic dysfunction, large hearts and symptomatic failure class NYHA III and IV. However, digitalis does not convert atrial fibrillation to sinus rhythm. Today there is no question that ACE inhibitors improve the prognosis of all patients with heart failure in all stages, if ejection fraction is reduced. Therefore, most patients after myocardial infarction or after having experienced pump failure due to myocarditis or cardiomyopathy are treated with ACE inhibitors and diuretics. The beneficial effects of ACE inhibitors seem to be most pronounced the worse the situation is. Relative risk reductions (mortality!) between 10% and 40% have been published depending on the severity of symptomatic left ventricular dysfunction. Those patients with high absolute risk have more to gain than those with low risk for any given "risk reduction", of course. Recent studies also indicate that most high risk cardiac patients profit from ACE inhibitors even if pump function is normal (i.e., patients with coronary heart disease, diabetes mellitus, cerebral vascular disease, hypertension) (15). AT1 antagonists can substitute for ACE inhibitors, if the latter are not tolerated due to cough. Up to now, beta-blocking agents apart from diuretics seem to be the best investigated drugs in heart failure. Large controlled studies with bisoprolol, carvedilol and metoprolol in addition to diuretics, digitalis and ACE inhibitors convincingly yielded positive results in chronic left ventricular failure patients. Reduction of mortality by 35% and even of sudden cardiac deaths by 40% have been proven beyond doubt. Thus, heart failure patients today should also receive beta-blocking agents in all stages of the disease. In the era of controlled prospective studies (evidence-based medicine), physicians are well advised to use only drugs that have been proven beneficial in large controlled studies.

[Recent advances and limitations of medical treatment on heart failure].

Main part of the management of chronic heart failure is pharmaceutical therapy. In patients with chronic heart failure due to left ventricular systolic dysfunction, enhanced activation of neurohormonal systems including sympathetic nerve and renin-angiotensin-aldosterone system plays the most important role in its progression and poor prognosis. Therefore, principle of treatment of chronic heart failure is inhibition of the elevated neurohormonal activity. Angiotensin converting enzyme inhibitors and beta blockers are class I drugs of choice. In patients who can not tolerate angiotensin converting enzyme inhibitors, angiotensin II receptor blockers are used as replacement. In patients with severe heart failure [New York Heart Association (NYHA) class > III], aldosterone antagonists are added. Diuretics are also class I drug necessary for an improvement of symptoms of heart failure. Recently, implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) are implanted more frequently, because volume of evidence indicates benefits of these non-pharmacological treatments. In this paper, recent advance in medical therapy for patients with heart failure and its limitation is discussed.

Valvular heart disease

Mitral regurgitation Surgery is recommended for chronic severe mitral regurgitation in symptomatic patients with left ventricular ejection fraction (LVEF) of greater than 30%, and asymptomatic patients with LVEF of 30-60% or left ventricular end diastolic volume (LVEDV) > 40%. Surgical repair of the leaflets is preferred to mitral valve replacement as long as the repair is feasible. Mitral regurgitation may be treated medically with vasodilators, diuretics, digoxin, antiarrhythmics, and chronic anticoagulation. Mild to moderate mitral regurgitation should be followed with echocardiography and cardiac stress test every 1–3 years. Severe mitral regurgitation should be followed with echocardiography every 3–6 months.

Two-year experience of the Batista operation for non-ischemic cardiomyopathy.

The Batista operation was performed in 30 patients (25 men and 5 women, mean age 47 years) to treat cardiac failure due to non-ischemic cardiomyopathy, mostly idiopathic dilated cardiomyopathy, from December 1996 to June 1998. Preoperative New York Heart Association (NYHA) class was IV in 21 patients including 17 receiving inotropic support, and class III in 9 patients. Seven patients required emergency surgery because of on-going shock and 23 patients were operated electively. Combined cardiac procedures were; mitral valve reconstruction in 26 patients (19 replacements, 7 repairs), tricuspid annuloplasty in 15, aortic valve replacement in 3 and one each of maze and coronary artery bypass grafting. All patients successfully weaned from cardiopulmonary bypass. Intraaortic balloon pump was used in 6 patients but no left ventricular assist device was used. Two of 23 patients (8.7%) who underwent elective operation died during hospitalization and 3 patients (13.0%) died in the late period. Six of 7 patients (85.7%) with emergency operation died in the hospital and only one survived. Sixteen of 19 survivors returned to NYHA class I-II, and 3 were in class III. Mean ejection fraction increased from 18 +/- 6% to 31 +/- 5%. Diastolic dimension decreased from 79 +/- 8 to 60 +/- 8 mm. End-diastolic and systolic volume indices decreased from 203 +/- 43 to 103 +/- 25 ml/m2 and from 164 +/- 39 to 70 +/- 25 ml/m2, respectively, at the second postoperative week. Six patients had ventriculography at one year after the operation, and no redilation was noted. Increased thickness of left ventricular wall was observed postoperatively. The Batista operation can be performed with relatively low risk and clinical improvement was obvious in elective operation, wheras risk is very high in emergency cases. Therefore, proper guidelines for patient selection and choice of procedure are critically important to achieve a successful outcome in the Batista operation.

[Therapeutic perspectives in heart failure]].

Many different diseases may lead to heart failure. Nevertheless, the symptoms and pathophysiological changes in heart failure are uniform as are the basic principles of treatment. Although significant progress has been achieved in understanding the biology of heart failure and the therapeutic options, the quality of life of heart failure patients and their survival are often poor. Since cardiac transplantation as a final therapeutic option is limited by the availability of donor organs, new strategies and technologies need to be explored to treat the failing heart effectively. Approaches to improve the medical therapy of heart failure mainly focus on strategies to escape the vicious circle of decreased contractility and neurohumoral activation. Substances with promising experimental and clinical results include neutral endopeptidase inhibitors, endothelin antagonists or cytokine inhibitors, e.g. TNF antagonists. Mechanical and electrical devices are under development such as left ventricular assist devices (LVADs), biventricular pacemakers and artificial hearts, which may become valuable alternative therapies. Gene therapy approaches aim to improve the vascularization of the heart, the Ca-homeostasis of the myocytes or the survival of cardiac cells in disease. Finally, cellular cardiomyoplasty is a relatively novel approach to replace or support the cardiomyocytes of the diseased heart by implanting new ones. Which cell type under which conditions will turn out to be the most suitable is still unknown and subject to debate. Ongoing clinical studies will only help to demonstrate the safety and feasibility of this technique but not determine its long-term efficacy. It is highly desirable that one of these new therapeutic strategies or a combination of them will have a significant impact on the future management of heart failure. Currently, our main clinical focus must be to treat as many patients as possible with drugs that are known to improve symptoms and survival, like ACE inhibitors, beta-blockers, cardiac glycosides, diuretics and spironolactone.

Left ventricular reconstruction: Early and late results.

In patients with coronary disease and poor left ventricular function, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. This study reports results achieved with ventricular reconstruction in 285 patients who had akinesia or dyskinesia associated with relative wall thinning. Data were prospectively collected. Reconstruction on the beating heart was accomplished by a modified linear closure plus septoplasty, when indicated, (dyskinetic septum). Preoperatively, 237 (83%) were in symptom class III or IV with congestive heart failure (n =174; 61%), angina (n = 157; 55%), or ventricular tachycardia (n = 107; 38%). Average ejection fraction was 24% +/- 11%, and 144 (51%) had preoperative grade 2+ mitral regurgitation. Operative procedures included coronary artery bypass grafting in 262 (92%), septoplasty in 64 (22%), ablation of ventricular tachycardia in 118 (41%), and a mitral valve procedure in 6 (2%). Operating room mortality was 2.8%. Perioperative support included intra-aortic balloon pumping in 49 (17%) and inotropic drugs in 154 (54%). During a mean follow-up of 63 +/- 48 months, 8 patients required transplantation (interval of 49 +/- 41 months), 2 needed mitral valve replacement, and 9 required use of an implantable cardioverter-defibrillator for ventricular tachycardia. At 1, 5, and 10 years actuarial survivals were 92%, 82%, and 62%. Freedom from sudden death was 99%, 97%, and 94%. Among survivors, symptom class improved in 140 of 208 patients (67%), mean improvement 1.3 +/- 1.1 functional class per patient. Average increase in ejection fraction postoperatively was 10% +/- 9%. Using wall thinning as a criterion for patient selection, left ventricular reconstruction can be performed with low operative mortality, provides good control of symptoms, excellent long-term survival, and freedom from sudden death. This approach should be considered in all patients with coronary disease, poor left ventricular function, and relative wall thinning.

Debate: Do all patients with heart failure require automatic implantable defibrillators for the prevention of sudden death?

Recent clinical trials indicate that approximately two-thirds of patients in New York Heart Association (NYHA) class II and III, who comprise almost 90% of patients with heart failure, die suddenly. Patients in NYHA class IV usually die of progressive heart failure. Implantation of implantable cardioverters defibrillators (ICDs) in this population would represent a huge logistic problem and economic expense. Clinical trials have recently demonstrated that beta-blocker therapy with carvedilol, bisoprolol, and toprol XL decrease the sudden death rate by almost 50%, in addition to impacting significantly on death due to worsening heart failure. This medical approach is beneficial to all patients, and should be our major therapy. However, it is reasonable to attempt to identify that subpopulations of heart failure patients who could benefit from an ICD.

The clinical benefit of cardiac resynchronization therapy optimization using a device-based hemodynamic sensor in a patient with dilated cardiomyopathy: a case report.

Results on the evolution of the clinical status of patients undergoing cardiac resynchronization therapy with a defibrillator after automatic optimization of their cardiac resynchronization therapy are scarce. We observed a rapid and important change in the clinical status of our non-responding patient following activation of a sensor capable of weekly atrioventricular and interventricular delays' optimization. A 78-year-old Caucasian man presented with dilated cardiomyopathy, left bundle branch block, a left ventricular ejection fraction of 35 %, New York Heart Association class III/IV heart failure, and paroxysmal atrial fibrillation. Our patient was implanted with a cardiac resynchronization device with a defibrillator and the SonRtip atrial lead. Right ventricular and left ventricular leads were also implanted. Because of the recurrence of atrial fibrillation, the automatic optimization was set off at discharge. Consequently, the device did not optimize atrioventricular and interventricular delays (programming at discharge: 125 ms for the atrioventricular delay and 0 ms for the interventriculardelay). Our patient was treated with an anti-arrhythmic drug. Five months after implantation, his clinical status remained impaired (left ventricular ejection fraction = 30 %). The SonR signal amplitude had also decreased from 0.52 g to 0.29 g. Nevertheless, because our patient was no longer presenting with atrial fibrillation, the anti-arrhythmic treatment was stopped and the SonR optimization system was activated. After 2 months of automatic cardiac resynchronization therapy with defibrillator optimization, our patient's clinical status had significantly improved (left ventricular ejection fraction = 60 %, New York Heart Association class II) and the SonR signal amplitude had doubled shortly after the first weekly automatic optimization. In this non-responding patient, device-based automatic cardiac resynchronization therapy optimization was shown to significantly improve his clinical status.

The Treatment of Heart Failure with Reduced Ejection Fraction.

Chronic congestive heart failure is a common condition that, if untreated, markedly impairs the quality of life and is associated with a high risk of recurrent hospitalization and death. This review is based on articles retrieved by a selective search in PubMed, as well as on relevant guidelines. Evidence-based treatment options are available only for congestive heart failure with a low ejection fraction. Pharma - cotherapy is based on neurohumoral inhibition of the renin-angiotensin-aldosterone system and the adrenergic system. The prognosis of patients with this condition has been further improved recently through the introduction of combined angiotensin receptor antagonists and neprilysin inhibitors. Modern implantable devices are a further component of treatment. Implantable defibrillators and special pacemakers for cardiac resynchronization are well established; the utility of alternative devices (baroreflex modulation or cardiac contractility modulation) needs to be investigated in further studies. It was recently shown that the catheter-based treatment of secondary mitral regurgitation with a MitraClip improves the outcome of selected patients. The treatment of chronic systolic heart failure as recommended in the relevant guidelines, with drugs and implanted devices if indicated, can significantly improve the clinical outcome.

Resynchronization of mitral valve annular segments reduces functional mitral regurgitation in cardiac resynchronization therapy.

Cardiac resynchronization therapy (CRT) reduces the severity of functional mitral regurgitation (FMR) in patients with heart failure and left bundle branch block. Our hypothesis was that the induction of a more synchronous mitral valve anulus contraction can be a mechanism of FMR reduction in CRT patients. An echo tissue Doppler imaging (TDI) examination was performed at baseline and 6 months after biventricular pacing system implant in 30 patients (4 females and 26 males, 74.1+/-6.1 years) with dilatative or ischemic chronic heart failure, NYHA class = or >III, ejection fraction (EF) = or <35% and QRS = or >140 ms. EF, Myocardial Performance Index (MPI), left end-diastolic and systolic volumes (LVEDV, LVESV), mitral regurgitation jet area/left atrial area (JA/LAA), effective regurgitant orifice area (EROA), mitral anulus contraction (MAC) were evaluated. Using TDI, at the 6 left ventricle (LV) basal segments the time to the peak myocardial sustained systolic velocity (Ts) and the standard deviation (SD) of TS were evaluated. At 6 months follow-up NYHA class, EF, MPI were significantly improved, LV volumes were reduced. FMR degree, evaluated both as JA/LAA and EROA, was significantly reduced. This effect was associated with the 6 basal segments resynchronization and with a more effective annular contraction. Our data show that CRT by resynchronizing left ventricular basal segments produces a more effective mitral valve annulus contraction and contributes to FMR improvement. Further studies need to evaluate if this could be taken into account as new therapeutic perspective of functional mitral valve regurgitation.

Meta-Analysis on Drug and Device Therapy of New York Heart Association Functional Class IV Heart Failure With Reduced Ejection Fraction.

Heart failure with reduced ejection fraction (HFrEF) is associated with significant morbidity and mortality, particularly in patients with New York Heart Association (NYHA) functional class IV symptoms. Decades of discovery have heralded significant advancements in the pharmacologic management of HFrEF. However, patients with NYHA IV symptoms remain an under-represented population in almost every clinical trial to date, leaving clinicians with limited evidence with which to guide drug treatment decisions in this patient group with severe heart failure. Randomized controlled trials of adult patients with NYHA IV symptoms of HFrEF randomized to current guideline-recommended medical therapy were included in this systematic review and meta-analysis. The outcomes of interest included the rate of all-cause mortality, cardiovascular mortality, and heart failure hospitalization. A total of 39 randomized controlled trials were included. A total of 6 studies examined angiotensin converting enzyme inhibitors, with meta-analyses of 2 demonstrating a reduced risk of all-cause mortality (relative risk (RR) 0.76, 95% confidence interval 0.59 to 0.97, p = 0.03). A total of 11 studies examined β blockers, with meta-analysis of 6 demonstrating a reduced risk of all-cause mortality (risk ratio 0.74, 95% confidence interval 0.60 to 0.92, p = 0.008). A study examined the mineralocorticoid antagonist spironolactone, reporting a reduced risk of all-cause mortality in the NYHA IV subgroup. A total of 6 studies examined device therapy, demonstrating the benefit of cardiac resynchronization therapy with or without an implantable cardiac defibrillator in reducing hospitalization in the NYHA IV subgroup. Although trial evidence exists for angiotensin converting enzyme inhibitors, β-blockers, and mineralocorticoid antagonist therapy in the NYHA IV population, the role of angiotensin receptor blockers is unclear. Ivabradine, angiotensin receptor neprilysin inhibitors, and sodium-glucose transport protein 2 inhibitors remain underinvestigated and have not been proved to provide any benefit above standard heart failure therapy in patients with HFrEF and NYHA IV symptoms.

Management of heart failure

AICD: Patients with NYHA class II, III or IV, and LVEF of 35% (without a QRS requirement) may also benefit from an implantable cardioverter-defibrillator (ICD), a device that is proven to reduce all-cause mortality by 23% compared to placebo in patients who were already optimally managed on drug therapy. Patients with severe cardiomyopathy are at high risk for sudden cardiac death due to ventricular dysrhythmias. Although ICDs deliver electrical shocks to resynchronize heart rhythm which are potentially distressing to the patient, they have not been shown to affect quality of life. The number of (appropriate and inappropriate) shocks seems to be associated with a worse outcome. Although they are expensive, ICDs are potentially cost-effective in this setting.

[Results of aortic valve replacement surgery in patients over 75 years of age].

The increase in the mean populational age has increased the number of elderly people eligible for cardiac surgery. The aortic pathology represents the most common valvular pathology, mainly of degenerative etiology. The efficiency of the aortic valve replacement in people aged over 75 years was studied, with evaluation of hospital mortality, survival and functional class (NYHA). A total of 51 patients (25 males and 26 females, mean age 76.4 years [range: 75-83]) underwent aortic valve replacement from October 1989 to February 1997. The most common condition was aortic stenosis (62.7%), followed by aortic insufficiency (19%) and double aortic lesion (17%). Moreover, 31.3% of patients required also coronary surgery with a mean of 1.1 grafts per patient. In 13.7% of cases surgery on mitral valve was performed (1 commissurotomy, 1 mitral prosthesis, 5 valve prostheses). In 10% of patients the procedure had to be performed on an emergency basis. The functional class of patients prior to surgery was NYHA grade III for 37% and grade IV for 10% of cases. The clinical symptoms corresponded to angor in 15 cases (29.4%) and syncope in four cases (7.8%). In nine patients the left ventricular ejection fraction prior to surgery was below 50%. Aortic bioprostheses were implanted in 86.2% of cases. The hospital fatality rate was 13.7% (7 cases). In the univariate analysis the following mortality risk factors reached statistical significance: left ventricular ejection fraction prior to surgery below 50%, associated surgery and size of aortic prosthesis. In the multivariate analysis the following risk factors were significant: left ventricular ejection fraction prior to surgery below 50% and associated mitral surgery. The follow-up was performed in 100% of patients, with a mean time of 29.6 months. One patient died during follow-up. The functional class was NYHA grade I in 95.2% of cases. The actuarial survival, including hospital mortality, was 84.2% at 5 years. Despite a higher mortality in the aortic valve replacement surgery in patients aged over 75 years compared with general population, results, long-term survival and life quality of patients, renders surgery a non refusable first option as therapy for aortic valve pathology in this age group. Nevertheless, avoiding the deterioration of preoperative left ventricular function is imperative, mainly in those cases with concomitant mitral pathology, as both factors significantly contribute to an increase in mortality in this group.

[Contemporary approaches to the treatment of chronic heart failure in adults (after materials of recommendations of American College of Cardiology and American Heart Association, 2005)].

Detailed and critical analysis of a novel version of the "Updated Guideline for the Diagnosis and Management of Chronic Heart Failure (CHF) in the Adult" prepared by experts of American College of Cardiology and American Heart Association is given. The novel version contains somewhat modified recommendations on the management of patients with CHF. In particular this relates to the place of various classes of drugs in the treatment of CHF due to systolic left ventricular dysfunction. For the first time recommendations on the treatment of patients with CHF and normal left ventricular ejection fraction are presented in detail. Among statements of the updated guideline the following are considered controversial or deserving special discussion. Perindopril is mentioned among recommended ACE inhibitors despite the fact that it has never been studied in long term trials. Results of SENIORS trial are ignored and nebivolol is not included in the number of beta-blockers with proven efficacy. Despite multiple proofs of beneficial effects of aldosterone receptor blockers on clinical course of CHF wide use of spironolactone and eplerenone is not recommended because of multiple communications about life threatening hyperkalemia. Inherent dangers of digoxin therapy are disregarded and the use of cardiac glycosides in patients with sinus rhythm is not prohibited.

[Clinical experience of surgical treatment on hypertrophic obstructive cardiomyopathy].

To evaluate the surgical outcome of hypertrophic obstructive cardiomyopathy (HOCM). From October 1996 to December 2007, 54 HOCM patients underwent surgical treatment. There were 37 males and 17 females ranging from 6 to 68 years old (36 +/- 16) with body weight 27-83 (60 +/- 14) kg. Operation was performed under general anesthesia and cardiopulmonary bypass (CPB) with the moderate systemic temperature and low volume blood flow. The concomitant operations included coronary artery bypass grafting in 5 cases, mitral valve plasty in 5 cases, mitral valve replacement in 9 cases, tricuspid valve plasty in 2 cases, aortic valve replacement in 4 cases and closure of patent ductus arteriosus in 2 cases. Preoperative and postoperative left ventricular (LV), left ventricular outflow tract (LVOT), left atrium (LA), mitral valve function and value of LVEF were evaluated by transesophageal echocardiograph examination. The time of CPB and aortic occlusion were 40 to 290 minutes (107 +/- 52) and 27 to 195 min (70 +/- 36 min) respectively. The endotracheal intubation durations were 5 to 21 hours (14 +/- 15) and ICU duration 11 to 183 hours (45 +/- 34). Comparing with the pre-operative echocardiographic parameters, the size of left atrium (42 +/- 8 vs 35 +/- 7), pressure gradients through LVOT (106 +/- 44 mm Hg vs 24 +/- 19 mm Hg), the thickness of septum (27 +/- 6 mm vs 19 +/- 5 mm) and the value of EF (70 +/- 10 vs 61 +/- 9) obviously decreased postoperatively (P < 0.05). The surviving patients had either no mitral valve regurgitation or only mild mitral valve regurgitation. Four (7.4%) patients died during the perioperative period. The cause of death included severe low cardiac output, heart failure, severe ventricular arrhythmias and severe acute renal failure. There were 4 patients with a complete AV block postoperatively and 3 were implanted permanent pacemakers. The left bundle branch block or left anterior hemiblock were found in 26 cases, intraventricular conduction defect in 6 cases and type I AV block in 4 cases. All surviving patients were in NYHA functional class I/II during the follow-up of 1 month to 10 years. Surgical outcome for HOCM patients is satisfactory. Most HOCM patients achieve such a satisfactory relief of LV outflow tract obstruction as to lead a better life.

[Effect of long-term treatment with enalapril, losartan and their combination on the quality of life of patients with congestive heart failure].

To study the effect a combination of enalapril and losartan on life quality in patients with congestive heart failure (HF). One hundred and eighty six patients with NYHA functional classes II to IV HF were examined. The study inclusion criteria were as follows: a left ventricular (LV) end-diastolic volume of > 160 ml, a LV ejection fraction of < 35%, sinus rhythm, a cardiothoracic index of > 0.55, no history data on prior treatment with an angiotensin-converting enzyme inhibitor (ACEI) and/or an AT1-antagonist, a patient's written free-will consent to participate in the study. The exclusion criteria were as follows: pacemaker migration, an artificial pacemaker, high-degree block, atrial fibrillation, cerebral circulatory disorders. All the patients were divided into 4 groups and received basic therapy with cardicet, 60-120 mg/day, aspirin, 250 mg/day, furosemide, 80-440 mg/week, and digoxin, 0.25-0.5 mg/day. Group 1 comprised 60 patients who refused therapy with ACEI and/or AT1-antagonist despite that they had indications for their use and they had been convinced many times. In Group 2 (n = 82) enalapril, an ACEI, was added to the basic therapy. Its initial dose of 2.5 mg/day was given once and slowly incremented to the therapeutical one (10-20 mg/day). Group 3 patients (n = 56) on the basic therapy were additionally treated with the AT1-antagonist losartan in a daily dose of 25-50 mg. They were started on 12.5 mg a day. In group 4 the basic therapy was added by a combination of enalapril and losartan in the same doses. The follow-up was 48 weeks. The efficiency of the treatments was controlled by the personal questionnaires SF-36, Life with Heart Failure, by evaluating the magnitude of clinical HF manifestations and by estimating the total life quality inxed. The data were analyzed by assuming that all the patients received the treatments. As compared with the conventional therapy and the use of each drug alone, a combination of the ACEI enalapril and the AT1-antagonist losartan promotes a more significant increase in the satisfaction of the patients with their vital activity, in the critical rate of their self-assessment of the "internal picture" of disease, and leads to a greater improvement of the quality of their life as a whole. The ICAE-AT1-antagonist combination exerts a positive impact on life quality in patients with heart failure.