From the Guidelines
Baroreflex activation therapy (BAT) is a treatment approach for heart failure that involves electrically stimulating the baroreceptors in the carotid artery to improve symptoms, exercise capacity, and quality of life, as evidenced by a prospective, multicenter, RCT with 408 patients showing improvements in QOL, exercise capacity, and NT-proBNP levels 1.
Mechanism of Action
The therapy works by reducing sympathetic nervous system activity while increasing parasympathetic tone, creating a more balanced autonomic nervous system. This leads to decreased heart rate, reduced vascular resistance, improved cardiac contractility, and enhanced kidney function.
Clinical Evidence
The 2022 AHA/ACC/HFSA guideline for the management of heart failure mentions that an implantable device that electrically stimulates the baroreceptors of the carotid artery has been approved by the FDA for the improvement of symptoms in patients with advanced HF who are unsuited for treatment with other HF devices including CRT 1.
Key Points
- BAT has shown promise in clinical trials for reducing heart failure symptoms and improving exercise capacity in patients with reduced ejection fraction who remain symptomatic despite optimal medical therapy.
- The therapy addresses the underlying autonomic imbalance in heart failure rather than just treating symptoms.
- While there are no mortality or hospitalization rates results available with this device, the improvements in QOL, exercise capacity, and NT-proBNP levels are significant benefits for patients with advanced HF.
Patient Selection
Patients with current or recent NYHA class III HF, LVEF ≤35%, and who are unsuited for treatment with other HF devices including CRT may be suitable candidates for BAT.
Procedure
The procedure involves surgically implanting electrodes near the carotid sinus and connecting them to a pulse generator placed under the skin in the chest area. Patients typically undergo programming sessions after implantation to optimize the stimulation parameters for their specific condition.
From the Research
Definition and Mechanism of Baroreflex Activation Therapy
- Baroreflex activation therapy is a medical device-based treatment that activates the carotid baroreflex to suppress central sympathetic outflow in a controlled manner 2.
- The therapy works by generating a centrally mediated reduction of sympathetic outflow and increasing parasympathetic activity to the heart via a physiological reflex pathway 3.
- This approach aims to rebalance the autonomic nervous system, which is often deranged in patients with heart failure, leading to excessive sympathetic nervous system activation 3.
Clinical Applications and Efficacy
- Baroreflex activation therapy has been investigated as a potential treatment for heart failure with reduced ejection fraction (HFrEF) 3, 4, 5.
- Studies have shown that the therapy can provide safe and effective improvements in functional status, exercise capacity, and quality of life for patients with HFrEF 4, 5.
- However, the therapy's effect on cardiovascular mortality and heart failure morbidity is still being researched, with some studies yielding neutral results 4.
Safety and Adverse Effects
- Baroreflex activation therapy has been found to be safe, with a low rate of major adverse neurological and cardiovascular events 4, 5.
- Early concerns about facial nerve injury during surgical implantation have been addressed with the development of a miniaturized second-generation pacing electrode 6.
Patient Selection and Rationale
- Patient selection for baroreflex activation therapy is critical, with factors such as NYHA functional class, ejection fraction, and NT-proBNP levels being considered 3, 5.
- The therapy may be considered for patients with advanced heart failure who are not responding to guideline-directed medical therapy 3.