Other Devices for Heart Failure – Cardiac Contractility Modulation (CCM)

Substantial advances in the medical treatment of HFrEF have improved survival and cardiac function in these patients. However despite the use of optimal medical therapy (OMT) and the use of recommended devices in those in whom they are indicated, persistent symptoms limit activity and adversely affect lifestyle in a substantial number of patients. For these patients newer devices other than ICD and CRT may offer an improvement in symptoms and/or survival. This paper reviews the evidence for the use of CCM and discusses in which patients it may be considered as recommended in the recent guidelines. CCM is an established treatment in the management of moderate to severely symptomatic heart failure with reduced EF and normal QRS duration. CCM impulse delivery is associated with acute improvements in cardiac contractility. Chronic changes include reversion from fetal to adult gene expression profiles in the heart, improved calcium handling, restorative ventricular remodeling, and improved cardiac function. The recent 2016 ESC/HFA guidelines for the management of heart failure considered that most of these newer devices had insufficient clinical trial data for a formal recommendation, but in the case of one, cardiac contractility modulation (CCM) the guidelines describe CCM as being something to be considered in selected patients with HF. This is based on a demonstrated improvement in exercise tolerance (peak VO2) and quality of life (by Minnesota LWHF questionnaire, MLWHFQ) produced by CCM in an individual patient data meta- analysis of all the randomised controlled trials of CCM.