2016: Lynne Warner Stevenson, Boston, USA

”Taking the congestion out of heart failure”

Lynne Warner Stevenson was raised in a mathematical household with a large blackboard for solving problems, which had to begin with clear articulation of the question. She was in the third class of women at Princeton University, where she helped to launch the first women’s a cappella ensemble. Attending Stanford University School of Medicine, she watched cardiac transplants performed by Norman Shumway and managed by Sharon Hunt. During cardiology fellowship at University of California Los Angeles, she initiated the heart transplant program there in 1984 with Hillel Laks as surgeon. Much of her academic career can be traced back to two fundamental questions that she faced with the first patients referred for transplantation: 1) How can we relieve the congestion of heart failure and 2) How should decisions be approached with patients throughout the heart failure journey? We recognized the dominance of clinical congestion in patients waiting or rejected for heart transplantation, which challenged us to discover how and how far to relieve the severely elevated cardiac filling pressures. Our early work disproved the previous assumption that severely elevated filling pressures were necessary to support cardiac output from the failing heart. Tailoring therapy to lower filling pressures relieved congestion for many patients evaluated for cardiac transplantation, some of whom regained sufficient cardiac reserve to leave the transplant waiting list. The major mechanism through which unloading therapies decrease filling pressures and enhance forward cardiac output was reduction of secondary mitral regurgitation. Translation of these hemodynamic principles re-focused bedside clinical assessment according to wet/ dry and warm/cold, further refined by “matching and mismatching” for right and left-sided pressures. The ability to sustain relief of congestion after discharge was hindered by the inability to follow filling pressures out of the hospital. Over 20 years of investigation, including pioneering work by Dr. Braunschweig and colleagues at Karolinska, has finally resulted in an effective pre-emptive strategy of heart failure management aimed at “Optivolemia” as guided by ambulatory pulmonary artery pressure measurement. For heart failure patients with reduced ejection fraction and even more for heart failure with preserved ejection fraction, this strategy decreases all-cause hospitalizations as well as hospitalizations from heart failure and pulmonary disease. The new information opens a new window into ambulatory heart failure physiology and provides hope that earlier intervention to avoid pulmonary hypertension may postpone or even prevent the right heart failure that often heralds terminal disease. Dr. Stevenson is currently Director of the Cardiomyopathy and Heart Failure Program at Brigham and Women’s Hospital in Boston and Professor of Medicine at Harvard Medical School, where she has been for 23 years. She is an author on over 250 original research publications, and a key contributor to national guidelines addressing heart failure, cardiac transplantation, ventricular assist devices VAD, arrhythmia devices, and decision-making in advanced heart failure, particularly with regard to ICDs, transplantation, VADs, and end of life care. She has played leadership roles in NHLBI-sponsored studies for strategies in advanced heart failure, including REMATCH, ESCAPE, and more recently the National Heart Failure Network and the INTERMACS Registry of ventricular assist devices. Over 25 years before Heart Failure became an official specialty in the US, she established principles and training in this growing field, in which she has founded 2 active networks of NHLBI young investigators. Strong commitments for her remain training the next generation to sustain the spirit of challenge and the patient-doctor connection, and to ensure that care is individualized not only to hemodynamic and poly- “nomic” profiles, but also to individual goals for life and quality of life.