Heart failure with reduced ejection fraction (HFrEF) is a rapidly growing cardiovascular problem with ongoing research for optimal solutions. Congestive heart failure is the final common pathway for most cardiovascular illnesses. The number of adults in the U.S. living with heart failure rose by approximately 800,000 from 5.7 million to 6.5 million between 2009 and 2014, and is projected to rise 46% by 2130, according to the American Heart Association 2017 Heart Disease and Stroke Statistics Update.

There are several causes for HFrEF. The underlying etiology for deterioration of LV function and complications in HFrEF patients is secondary neurohormonal derangement. The morbidity and healthcare costs for HFrEF are on the rise despite optimal medical therapy and device therapies.

At RENU-CA research Institute we have identified dysautonomia as the crux problem underlying neurohormonal derangement in HFrEF. We have developed novel treatment protocols based on dysautonomia assessment and regulation for a comprehensive approach in the management of HFrEF both in ischemic and non-ischemic cardiomyopathy patients with ejection fractions <30%. In our experience of 108 patients between 2010 and 2018 we have successfully recovered LV systolic functions from <25% to > 45% range and avoided device therapy (ICD/CRT) or CABG in ischemic cardiomyopathy patients with adjuvant complex high-risk coronary revascularization. All patients remained clinically free from heart failure, arrhythmias and repeated hospitalizations for decompensation which are the common causes for increased morbidity and mortality in these patients. We were also successful in minimizing polypharmacy and drug intolerance that are common problems during medical therapy of HFrEF patients. We believe this was possible due to regulation of dysautonomia that is the underlying dysfunction for neurohormonal derangement and negative myocardial remodeling. Extended percutaneous hemodynamic support (PVAD) with Impella augments faster recovery of LV systolic function with optimization of hemodynamics and unloading the left ventricle in both ischemic and non-ischemic patients. Impella support also improves organ perfusion and low out-put state.

Future directions in this approach would warrant randomizing HFrEF patients between current optimal medical therapy and device therapy and therapy based on autonomic neurohormonal modulation with extended Impella (PVAD) augmentation. This approach is a proactive rather than conventional reactive approach in management of chronic severe left ventricular dysfunction and heart failure.