When the myocardium is subjected to abnormal mechanical and neurohormonal stresses, left ventricular remodeling ensues with a progression of structural, cellular, molecular, metabolic, and functional changes.
In chronic heart failure with reduced ejection fraction, this remodeling affects the left ventricle with consequences that include ventricular dilation, transition of the chamber shape from elliptical to spherical, and the shifting of papillary muscles and mitral valve apparatus into abnormal positions. Ironically, while remodeling is an outgrowth of the initial hemodynamic and metabolic insults that lead to heart failure, it is also self-propagating, contributing to the progressive loss of ventricular function over time.
In the July 20 online issue of Structural Heart, heart failure specialists at Columbia University Vagelos College of Physicians and Surgeons present a comprehensive review of treatment options that focus on restoring the normal ventricular size and preventing the remodeling process from continuing. But can preventing or limiting left ventricular remodeling following an insult or reversing it once it is present reduce cardiovascular morbidity?
Their article provides insight into this question with a view toward better understanding the impact of remodeling on ventricular dysfunction and an in-depth look at therapeutic approaches, including those that are well-established, several that are currently under investigation, as well as those that have been invalidated and no longer used. The authors focus on two fundamental therapeutic approaches – those that rely primarily on biological mechanisms to induce responses in the myocardium and improve myocardial function, and physical mechanisms, involving procedures where a portion of the heart is either removed or excluded and devices to reduce myocardial wall stress through ventricular constraint or reshaping.