Feng Lina, Su Lina, Ren Jingyi
Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
Department of Cardiology, Heart Failure Center, China-Japan Friendship Hospital, Beijing, China.
Front Cardiovasc Med. 2025 Jun 6;12:1577680. doi: 10.3389/fcvm.2025.1577680. eCollection 2025.
Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) has been demonstrated to significantly reduce morbidity and mortality. However, many patients, especially those with advanced HFrEF, are unable to tolerate optimal GDMT due to hypotension. Cardiac contractility modulation (CCM) is a novel therapeutic approach that enhances myocardial contractility and reverses cardiac remodeling, thereby improving cardiac function and quality of life in patients with HFrEF. However, whether CCM can bridge the hemodynamic vulnerability phase to facilitate GDMT optimization and improve patient prognosis remains unclear.
A 56-year-old man with dilated cardiomyopathy and HFrEF (YHA functional class III) had recurrent hospitalizations for HF over the past 4 years. Due to hypotension (systolic blood pressure ≤90 mmHg), the patient was unable to tolerate full-dose GDMT, with sacubitril-valsartan limited to 25 mg twice daily, metoprolol succinate to 23.75 mg once daily, and spironolactone to 20 mg once daily. After a comprehensive evaluation, a CCM device was implanted as the most effective and evidence-based option. Postoperatively, the patient's blood pressure gradually improved, allowing initiation of the four major therapeutic drug classes, which were uptitrated to the maximum tolerated doses. With regular follow-up for 12 months, the patient showed dramatic improvements in exercise capacity and quality of life. More surprisingly, there was significant improvement in cardiac structural and functional remodeling. Echocardiography revealed that left atrioventricular dimensions returned to normal, left ventricular ejection fraction (LVEF) increased from 15% to 48%, and left ventricular global longitudinal strain (GLS) improved from -3.3% to -16.2%. NT-proBNP levels also decreased from 6,553 pg/ml to within the normal range.
This case suggests that CCM may serve as a promising strategy to address the issue of poor GDMT tolerance due to hypotension, thereby facilitating GDMT optimization and improving cardiac remodeling patients with HFrEF.
射血分数降低的心力衰竭（HFrEF）的指南导向药物治疗（GDMT）已被证明可显著降低发病率和死亡率。然而，许多患者，尤其是晚期HFrEF患者，由于低血压而无法耐受最佳的GDMT。心脏收缩力调制（CCM）是一种新型治疗方法，可增强心肌收缩力并逆转心脏重塑，从而改善HFrEF患者的心脏功能和生活质量。然而，CCM是否能跨越血流动力学脆弱期以促进GDMT优化并改善患者预后仍不清楚。
一名56岁男性，患有扩张型心肌病和HFrEF（纽约心脏协会功能分级III级），在过去4年中因心力衰竭反复住院。由于低血压（收缩压≤90mmHg），患者无法耐受全剂量GDMT，沙库巴曲缬沙坦限制为每日两次25mg，琥珀酸美托洛尔为每日一次23.75mg，螺内酯为每日一次20mg。经过全面评估，植入CCM设备作为最有效且基于证据的选择。术后，患者血压逐渐改善，开始使用四大类治疗药物，并逐渐滴定至最大耐受剂量。经过12个月的定期随访，患者的运动能力和生活质量有了显著改善。更令人惊讶的是，心脏结构和功能重塑有了显著改善。超声心动图显示左房室尺寸恢复正常，左心室射血分数（LVEF）从15%增加到48%，左心室整体纵向应变（GLS）从-3.3%改善到-16.2%。NT-proBNP水平也从6553pg/ml降至正常范围内。
该病例表明，CCM可能是解决因低血压导致GDMT耐受性差问题的一种有前景的策略，从而促进GDMT优化并改善HFrEF患者的心脏重塑。
