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HEALTH CONDITIONS LOW EJECTION FRACTION (EF) What is it? Ejection fraction (EF) is a measure of the amount of blood pumped out of the left ventricle (one of the two lower chambers of the heart). The term "ejection fraction" is used because it is a measurement of the blood pumped or "ejected" with each heartbeat. Because not all of the blood is ever completely pumped out of the ventricle, this number gives you the "fraction" of the total amount of blood pumped out. Your EF, which is given as a percentage, reveals how well your left ventricle is working. In a sense, it reveals how healthy or unhealthy your heart muscle is. A normal EF is 50% or more— meaning at least 50% of the blood is pumped out of your left ventricle with each heartbeat. Generally a value of less than 40% is considered low. But no single percentage determines a low EF. Your doctor decides what is low for you by looking at your overall health and risk factors. Other names for a low ejection fraction: low EF, low left ventricular ejection fraction (low LVEF). What is the cause? A low ejection fraction (EF) is caused by some type of damage to the heart muscle. Some things that damage the heart muscle include: • Heart attack • Heart failure • Heart muscle disease (cardiomyopathy) • Heart valve disease Managing your risk factors is key to preventing a heart attack, heart failure, and other problems. In particular, the risk factors you can control often make a major difference in your heart's health. To learn more, go to the Risk Factors section. Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 1 of 16 What are the symptoms? Sometimes you can have a low ejection fraction (EF) and yet have no symptoms. Many people with a low EF also have heart failure. So the symptoms of a low EF might actually be heart failure symptoms: • Shortness of breath—this may get worse when you lie down. • Fatigue—this happens because your muscles aren't getting enough oxygen from your blood. • Chronic cough—this is due to fluid buildup in the lungs. • Fluid retention—this happens especially in the legs and feet. In other cases a person might notice symptoms of dyssynchrony when they have a low EF: • A heart murmur (due to valve disease) • Fast, abnormal heartbeats called arrhythmias • Swollen neck veins What tests could I have? To find out if you have a low ejection fraction (EF), your doctor may suggest one or more of the tests listed below. The test results can also help your doctor choose the best treatment(s) for you. In some cases you may be sent to specialists for diagnosis and testing—and sometimes for treatment. To learn more, go to the Your Treatment Team section. Chest X-ray CT Scan Echocardiogram MRI Chest X-ray What is a chest x-ray? A chest x-ray produces an image of your heart, lungs, and nearby blood vessels. It reveals the: • Size and shape of your heart • Presence of fluid around your lungs • Position and shape of your large arteries An x-ray can help diagnose many different conditions, including heart diseases. And if you have a cardiac device like a pacemaker, the x-ray also shows the device and the coated wires (leads) that carry the energy to your heart. What can I expect? When you have a chest x-ray you undress from the waist up and put on a hospital gown. You are partly covered by a shield—a heavy apron made of flexible lead—to protect you from any excess radiation. (X-rays use only a small amount of radiation to create the image.) You stand in front of the x-ray machine Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 2 of 16 and hold your breath while the image is taken. Your doctor usually orders two views: one from the back and one from the side. What are the treatment options? A low ejection fraction is caused by damage to your heart, like that from a heart attack. So part of your treatment may include living a healthier lifestyle to avoid further damage to your heart muscle. For example, if you tend to eat high-fat foods, your doctor or nurse can suggest some ways to help you eat healthier foods. Or they might refer you to a dietitian. To learn more, go to the Risk Factors section. Other types of treatment depend on your test results. Your doctor may recommend one or more of these medications or procedures. Computed Tomography (CT or CAT) Scan What is a CAT scan? A computerized (or computed) tomography (CAT, or CT) scan is a special type of x-ray. Although a CAT scan is used to get images of many parts of the body, let's use the example of the heart. A traditional x-ray shows two-dimensional images of the heart—its length and width. But a CAT scan uses an x-ray machine that moves around your body and takes multiple images of the heart. As small amounts of x-rays pass through your body, different types of tissue absorb different amounts of the x-rays. This helps provide a more precise image compared to a traditional x-ray. The CAT scan images are viewed together on a video monitor, offering a threedimensional view—length, width, and depth. Because it is a three-dimensional image, a CAT scan offers a much better picture of the entire heart than a traditional two-dimensional x-ray can. A CAT scan is used to detect many health conditions—tumors, for example, or bone problems like osteoporosis. As it relates to heart and blood vessel disease, a CAT scan is often used to identify: Some types of heart disease, such as heart failure A blood vessel blockage or blood clot What can I expect? When you have a computed tomography (CAT) scan, you typically undress and put on a hospital gown or sheet. You lie on an exam table. As the test begins, the table slowly moves inside a doughnut-shaped machine. Sometimes you receive a contrast dye—usually through an intravenous (IV) line that is put into your arm. The dye allows your heart or blood vessels to show up as images on a monitor. For instance, if the test is being done to look at your blood vessels, the dye makes them visible—almost like roads on a map. You might notice some effects from the dye: • Warm flushing feeling, and maybe nausea, for a minute or so Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 3 of 16 • Metallic taste when the dye reaches the blood vessels in your mouth The technician asks you to hold your body still during the scan. Sometimes pillows and/or straps help you stay in the same position. As the x-ray tube rotates around your body, the table slowly moves through the machine. You might be asked to hold your breath at certain times during the scan. Although the CAT scan is generally not a painful test, you may feel uncomfortable from having to lie in one position during the test—anywhere from 15 to 60 minutes. Echocardiogram What is an echocardiogram? An echocardiogram (also called an echo) is a three-dimensional, moving image of your heart. An echo uses Doppler ultrasound technology. It is similar to the ultrasound test done on pregnant women. The echo machine emits sound waves at a frequency that people can't hear. The waves pass over the chest and through the heart. The waves reflect or "echo" off the heart, showing: • The shape and size of your heart • How well the heart valves are working • How well the heart chambers are contracting • The ejection fraction (EF), or how much blood your heart pumps with each beat What can I expect? When you have an echocardiogram, you undress from the waist up, put on a hospital gown, and lie on an exam table. The technician spreads gel on your chest and side to help transmit the sound waves. The technician then moves a pen-like instrument (called a transducer) around on your chest or side. The transducer records the echoes of the sound waves. At the same time, a moving picture of your heart is shown on a special monitor. You may be asked to lie on your back or your side during different parts of the test. You may also be asked to hold your breath briefly so that the technician can get a good image of your heart. An echo is a painless test. You feel only light pressure on your skin as the transducer moves back and forth. Magnetic Resonance Imaging (MRI) What is magnetic resonance imaging (MRI)? Magnetic resonance imaging (MRI) uses magnets, radio waves, and computer technology to create images of different parts of your body. MRI is especially useful in creating clear images of soft tissues. For instance, many people have an MRI to check their heart and/or blood vessels. MRI is done in a large, tube-shaped machine. Coils inside the machine's walls produce a strong magnetic field. Other coils inside the machine's walls send and receive radio waves. In response to the radio waves, your body produces faint signals. As the machine senses the faint signals, a computer creates threedimensional images of the inside of your body. Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 4 of 16 The images can reveal: • Blockages in blood vessels • The size and thickness of your heart's chambers • Damaged muscle from a heart attack • How your heart valves are working What can I expect? Before your magnetic resonance imaging (MRI) you undress and put on a hospital gown or sheet. Before entering the MRI room, it's important to remove any jewelry, hearing aids, or anything else with metal in it. The magnets in the MRI machine are very strong, and if you have metal on your body you could possibly be injured. Most people with a cardiac device—a pacemaker, implantable defibrillator, or heart failure device—should typically avoid an MRI. All cardiac device patients should check with their doctor before scheduling an MRI. Once in the MRI room, you lie on a moveable table and an intravenous (IV) line is put into your arm. The IV delivers fluids and medications during the procedure. For instance, the technician may put contrast dye into the IV. Patches called electrodes are put on your chest. The electrodes connect to wires on an electrocardiogram (ECG). The electrodes and ECG monitor your heart's activity during the procedure. Often a blood pressure cuff on your arm also regularly takes your blood pressure. The table you are lying on slides into the MRI scanner, but there are no moving parts inside the machine. You wear headphones or earplugs to muffle some of the noises from the machine, which makes thumping sounds. The technician might ask you to lie very still or hold your breath for parts of the test. However, you may feel muscles twitching in your fingers or toes. Medications ACE Inhibitors Beta Blockers Diuretics Inotropes Vasodilators Procedures Defibrillator Implant Heart Failure Device Implant Heart Transplant MEDICATIONS Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 5 of 16 Tips for Taking Heart Medications If you have a heart or blood vessel condition, you might want to know more about some of the medications you take. The information in this section describes some medications commonly prescribed for heart or blood vessel conditions. It also includes some tips to help you take your medications as ordered. Make sure you tell your doctor—or any new doctor who prescribes medication for you—about all the medications and dietary supplements you take. Your doctor can then help make sure you get the most benefit from your medications. Telling your doctor this information also helps avoid harmful interactions between medications and supplements. You may also want to discuss these topics with your doctor or nurse each time you get a new medication: • The reason you're taking the medication, its expected benefits, and its possible side effects • How and when to take your medications • If you take other medicines, vitamins, supplements, or other over-the-counter products In some cases, your heart needs several months to adjust to new medications. So you may not notice any improvement right away. It also may take time for your doctor to determine the correct dosage. Blood tests are sometimes necessary for people who take heart medications. The blood tests help your doctor determine the correct dosage—and therefore help avoid harmful side effects. Never stop taking your medication or change the dosage on your own because you don't believe you need it anymore, don't think it's working properly, or feel fine without it. Be sure to talk to your doctor or nurse if you have: • Questions about how your medications work • Unpleasant side effects • Trouble remembering to take your pills • Trouble paying for your medications • Other factors that prevent you from taking your medications as needed • Questions about taking any of your medications And don't hesitate to ask your pharmacist if you have questions about how and when to take your medications. ACE Inhibitors “ACE” is short for “angiotensin-converting enzyme." ACE inhibitors are medications that help prevent your body from producing too much of a natural chemical called angiotensin II. Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 6 of 16 Some generic (and Brand) names All medications are approved by the Food and Drug Administration (FDA) for a specific patient group or condition. Only your doctor knows which medications are appropriate for you. benazepril (Lotensin) captopril (Capoten) enalapril (Vasotec) fosinopril (Monopril) lisinopril (Prinivil, Zestril) moexipril (Univasc) perindopril erbumine (Aceon) quinapril (Accupril) ramipril (Altace) trandolapril (Mavik) What they're used for To treat high blood pressure To treat heart failure and related conditions, such as low ejection fraction (EF) To reduce damage after a heart attack and to help reduce the chance for further heart attacks How they work ACE inhibitors block an enzyme that is needed to produce angiotensin II. The body uses angiotensin II to maintain proper blood pressure and fluid balance. But angiotensin II can have harmful long-term effects on your heart and blood vessels. It can cause blood vessels to narrow and can also raise blood pressure. Taking ACE inhibitors can: Relax the arteries Lower blood pressure Help the heart work more effectively Beta Blockers Beta blockers get their name because they "block" the effects of substances like adrenaline on your body's "beta receptors." Some generic (and brand) names All medications are approved by the Food and Drug Administration (FDA) for a specific patient group or condition. Only your doctor knows which medications are appropriate for you. acebutolol (Sectral) atenolol (Tenormin) betaxolol (Kerlone) bisoprolol (Zebeta) Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 7 of 16 carvedilol (Coreg) labetalol (Trandate) metoprolol (Lopressor, Toprol) nadolol (Corgard) penbutolol (Levatol) pindolol (Visken) propranolol (Inderal) sotalol (Betapace, Sorine) timolol (Blocadren) What they're used for To treat high blood pressure To slow fast arrhythmias (abnormal heartbeats, or heart rhythms) To prevent angina (chest pain due to blocked blood flow to parts of the heart) To prevent long-term damage after a heart attack To treat heart failure and related conditions, such as low ejection fraction (EF) How they work These medications block activity of your sympathetic nervous system. The sympathetic nervous system reacts when you are stressed or when you have certain health conditions. When your system responds, your heart beats faster and with more force. Your blood pressure also goes up. Beta blockers block signals from the sympathetic nervous system. This slows your heart rate and keeps your blood vessels from narrowing. These two actions can result in: Lower heart rate Lower blood pressure Less angina (chest pain related to the heart) Fewer arrhythmias (abnormal heartbeats, or heart rhythms) Diuretics (Water Pills) Diuretics remove excess water from your body. Some generic (and brand) names All medications are approved by the Food and Drug Administration (FDA) for a specific patient group or condition. Only your doctor knows which medications are appropriate for you. amiloride (Midamor) bendroflumethiazide (Naturetin) bumetanide (Bumex) chlorothiazide (Diuril) chlorthalidone (Hygroton, Thalitone) eplerenone (Inspra) ethacrynic acid (Edecrin) furosemide (Lasix) Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 8 of 16 hydrochlorothiazide (Microzide, Oretic) indapamide (Lozol) methyclothiazide (Enduron) metolazone (Zaroxolyn) polythiazide (Renese) spironolactone (Aldactone) torsemide (Demadex) triamterene (Dyrenium) What they're used for To lower blood pressure To reduce edema (swelling caused by excess fluid in your body—often in the legs and feet) associated with conditions such as heart failure How they work Some diuretics work by causing the kidneys to release more sodium (salt) into urine. Sodium helps draw water out of the blood. With less fluid in your blood, your blood pressure decreases. Diuretics also relieve symptoms like shortness of breath. That's because excess fluid in your lungs can cause these symptoms. Inotropes The word "inotrope" refers to the strength of the heart muscle's pumping action, or contractions. Some generic (and Brand) names All medications are approved by the Food and Drug Administration (FDA) for a specific patient group or condition. Only your doctor knows which medications are appropriate for you. digoxin (Digitek, Lanoxicaps, Lanoxin) What they're used for To improve symptoms of heart failure and related conditions, such as low ejection fraction (EF) To slow the heart rate in response to atrial fibrillation (fast rhythm in the heart's upper chambers) How they work The term "inotrope" describes the strength and force of the heartbeat. Taking inotropic medications can: Make the heart beat more strongly and efficiently Help slow and control the heart rate for certain arrhythmias Vasodilators Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 9 of 16 One purpose of vasodilators is to lower blood pressure. To understand how vasodilators work, imagine the same amount of water moving through a 1-inch diameter hose versus a 2-inch diameter hose. The bigger the hose, the less pressure on the walls of the hose. Medications such as vasodilators can help relax and dilate blood vessels that have become narrowed (constricted). Some generic (and Brand) names All medications are approved by the Food and Drug Administration (FDA) for a specific patient group or condition. Only your doctor knows which medications are appropriate for you. doxazosin (Cardura) guanabenz (Wytensin) guanfacine (Tenex) hydralazine (Apresoline) isosorbide dinitrate (Dilatrate, Isordil, Isochon) isosorbide mononitrate (Imdur, ISMO, Monoket) methyldopa (Aldomet) minoxidil (Loniten) nitroglycerin (Minitran, Nitro-Bid, Nitro-Dur, Nitrogard, Nitrolingual, NitroQuick, Nitrostat) prazosin (Minipress) reserpine (Serpalan) terazosin (Hytrin) You may have heard of other types of vasodilators. Beta blockers, which are a common heart and blood vessel medication, are one type of vasodilator. Another type is calcium channel blockers. What they're used for To treat high blood pressure To treat/prevent angina (chest pain related to the heart) which can result from atherosclerosis (blocked blood vessels) and coronary artery disease (CAD) How they work Vasodilators help relax and dilate the blood vessels, so blood moves through them more easily. This helps to: Lower blood pressure Allow the heart to work with less effort Decrease the amount of angina (chest pain) PROCEDURES Defibrillator Implant (ICD Device Implant) Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 10 of 16 What is a defibrillator (ICD device)? An implantable cardioverter defibrillator (ICD) is a small device that treats abnormal heart rhythms called arrhythmias. Specifically, an ICD treats fast arrhythmias in the heart's lower chambers (ventricles). Two such arrhythmias are ventricular tachycardia (VT) and ventricular fibrillation (VF). Arrhythmias result from a problem in your heart's electrical system. Normal electrical signals follow a certain path through the heart. It is the movement of these signals that causes your heart to contract. To learn more about your heart's electrical system, go to the Heart & Blood Vessel Basics section. During VT or VF, however, far too many signals are present in the ventricles. In addition, the signals often do not travel down the proper pathways. The heart tries to beat in response to the signals, but it cannot pump enough blood out to your body. If you have either VT or VF, you are at high risk of sudden cardiac arrest (SCA). If not treated immediately with defibrillation, SCA can result in sudden cardiac death (SCD). An ICD can treat VT and VF and restore your heart to a normal rhythm. So it reduces your risk of SCD. The device can deliver several types of treatment: • Anti-tachycardia pacing (ATP) delivers very small amounts of energy to your heart—so small that you can't feel the treatment. • Cardioversion is a low-energy shock that treats fast but regular arrhythmias. • Defibrillation is a high-energy shock that treats fast and chaotic (irregular) rhythms. Defibrillation is painful for an instant, but it can also save your life. A device implant is a procedure that uses local numbing. General anesthesia is usually not needed. An implanted device needs to be checked regularly to review information that is stored in the device and to monitor settings. These checks can happen in the clinic or from the comfort of the patient’s home using remote monitoring. Remote monitoring uses a small piece of equipment that can sit on a bedside table to collect data from the cardiac device. Data is collected on a daily or weekly basis depending upon how the system is programmed and the type of device implanted. It sends information through a regular landline phone to a secure website that only the patient’s healthcare support team can access. In many cases, remote monitoring means that the patient needs to make fewer trips to the doctor's office for device follow-up visits. Not all devices can be checked using remote monitoring, and not all doctors use remote monitoring. How is the implant procedure done? An Implantable cardioverter defibrillator (ICD) system has two parts. Device—the device is quite small and easily fits in the palm of your hand. It contains small computerized parts that run on a battery. Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 11 of 16 Leads—the leads are thin, insulated wires that connect the device to your heart. The leads carry electrical signals back and forth between your heart and your device. Your doctor inserts the leads through a small incision, usually near your collarbone. Your doctor gently steers the leads through your blood vessels and into your heart. Your doctor can see where the leads are going by watching a video screen with real-time, moving x-rays called fluoroscopy. The doctor connects the leads to the device and tests to make sure both work together to deliver treatment. Your doctor then places the device just under your skin near your collarbone and stitches the incision closed. What can I expect? Usually you are told not to eat or drink anything for a number of hours before the procedure. You undress and put on a hospital gown or sheet. Your procedure will be performed in a ”cath lab." You lie on an exam table and an intravenous (IV) line is put into your arm. The IV delivers fluids and medications during the procedure. The medication makes you groggy, but not unconscious. The doctor makes a small incision near your collarbone to insert the leads. The area will be numbed so you shouldn't feel pain, but you may feel some pressure as the leads are inserted. You may be sedated when the device is tested, since it delivers a shock to your heart. You may be in the hospital overnight, and there may be tenderness at the incision site. Afterwards most people have a fairly quick recovery. Heart Failure Device Implant (CRT Device Implant) What is a heart failure device (CRT device)? A heart failure device, also called a CRT device, treats certain types of heart failure. When the heart's lower chambers (ventricles) pump or contract in an uncoordinated way, it is called dyssynchrony. The CRT device treats dyssynchrony. CRT stands for cardiac resynchronization therapy. It gets its name because the device helps “resynchronize,” or re-coordinate, the pumping of the ventricles. A device implant is a procedure that uses local numbing. General anesthesia usually is not needed. There are two types of CRT devices: • A CRT-P device is a special kind of pacemaker. A regular pacemaker sends tiny amounts of energy to one side of the heart. This electrical treatment is called pacing therapy. A CRT device delivers pacing to both ventricles—both sides of the heart. This is why the CRT-P device is sometimes called a biventricular pacemaker. • A CRT-D device offers the same type of pacing therapy described as a CRT- Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 12 of 16 P device. But it also has a built-in implantable cardioverter defibrillator (ICD). In the CRT-D device, the ICD can treat dangerously fast abnormal heart rhythms (arrhythmias). Fast arrhythmias, like ventricular tachycardia (VT) or ventricular fibrillation (VF), put people at risk of sudden cardiac arrest (SCA). If not treated immediately with defibrillation, SCA can result in sudden cardiac death (SCD). And in people with heart failure, SCD occurs at 6-9 times the rate of the general population. Many people benefit from a CRT device because it helps relieve symptoms of heart failure. However, the device is not effective for everyone with heart failure. An implanted device needs to be checked regularly to review information that is stored in the device and to monitor settings. These checks can happen in the clinic or from the comfort of the patient’s home using remote monitoring. Remote monitoring uses a small piece of equipment that can sit on a bedside table to collect data from the cardiac device. Data is collected on a daily or weekly basis depending upon how the system is programmed and the type of device implanted. It sends information through a a standard analog phone line to a secure website that only the patient’s healthcare support team can access. In many cases, remote monitoring means that the patient needs to make fewer trips to the doctor's office for device follow-up visits. Not all devices can be checked using remote monitoring. How is the implant procedure done? A CRT-P or CRT-D system has two parts. Device—the device is quite small and easily fits in the palm of your hand. It contains small computerized parts that run on a battery. Leads—the leads are thin, insulated wires that connect the device to your heart. The leads carry electrical signals back and forth between your heart and your device. Your doctor inserts the leads through a small incision, usually near your collarbone. Your doctor gently steers the leads through your blood vessels and into your heart. Your doctor can see where the leads are going by watching a video screen with real-time, moving x-rays called fluoroscopy. The doctor connects the leads to the device and tests to make sure both work together to deliver treatment. Your doctor then places the device just under the skin near your collarbone and stitches the incision closed. What can I expect? Usually you are told not to eat or drink anything for a number of hours before the procedure. You undress and put on a hospital gown or sheet. Your procedure will be performed in a ”cath lab." You lie on an exam table and an intravenous (IV) Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 13 of 16 line is put into your arm. The IV delivers fluids and medications during the procedure. The medication makes you groggy, but not unconscious. The doctor makes a small incision near your collarbone to insert the leads. The area will be numbed so you shouldn't feel pain, but you may feel some pressure as the leads are inserted. If you have a CRT-D device implant, you may be sedated when the device is tested, since it delivers a shock to your heart. Most people do not need to be sedated if they have a CRT-P device implanted. You may be in the hospital overnight, and there may be tenderness at the incision site. Most people have a fairly quick recovery. Heart Transplant What is a heart transplant? A heart transplant is the surgical replacement of a diseased heart with a healthy heart from a donor. A heart transplant can prolong the life of a person with lifethreatening heart disease. Heart transplants are typically done in people who have advanced heart failure that can’t be successfully treated with other procedures or medications. The transplant involves transferring a healthy heart from a donor to the recipient. The donor is usually someone who has suffered brain death but whose heart is healthy. The donor must be a similar height and weight as the recipient, and the two must have the same blood type. However, the age, sex, and race of the two individuals can differ. A transplant must take place within 4 hours of the time the healthy heart is removed from the donor. That’s why time—and location of the donor and recipient—are such critical factors. People on the transplant waiting list usually carry a pager at all times. They must be at the hospital shortly after being paged. A heart transplant is a major surgery that involves general anesthesia and a fairly long recovery period. In the United States, just over 2200 heart transplants are done every year. Doctors could save many more lives if more people were willing to be donors. Left ventricular assist device (LVAD) Sometimes a person has a surgery before the heart transplant. This initial surgery is the implantation of a device called a left ventricular assist device (LVAD). The LVAD is necessary because the left ventricle (lower heart chamber) can become very weak from damage to the heart muscle. In some people the weakened heart is increasingly unable to pump enough blood out to the body. A LVAD helps by taking over the work of the left ventricle. A tube on the LVAD takes blood entering the left ventricle and sends it to the LVAD pump. The LVAD uses the right amount of force to pump the blood in a blood vessel, which then Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 14 of 16 sends blood throughout the body. The LVAD is removed during the heart transplant surgery. An LVAD is most often used for people who are on a waiting list for a heart transplant. So an LVAD is called a “bridge to transplant”. Until a heart is available for the person on the list, the LVAD can help keep the heart working properly. How is the surgery done? Your heart transplant surgery begins with an incision in the breastbone (sternum). Your doctor needs to operate on a completely still heart. So you receive medications to stop your heart. A heart-lung machine then does the job of both the heart and the lungs: • It adds oxygen to your blood—as your lungs would do • It pumps the blood back into, and throughout, your body—as your heart would do The doctor then removes your diseased heart and attaches the donor heart to your blood vessels. What can I expect? Usually you are told not to eat or drink anything for a number of hours before your surgery. You lie on an exam table and an intravenous (IV) line is put into your arm. The IV delivers fluids and medications during the surgery. You are then wheeled into the operating room, where you receive medication that makes you unconscious during the surgery. After surgery you will be in the intensive care unit (ICU) for several days. You stay in the hospital a total of about 2 weeks. People often have pain at the incision site for several weeks, but medication is provided for pain. At home, recovery usually takes another several months. Heart transplants are associated with major risks, including infection and organ rejection. After the transplant, you'll need to take many medications to stop your body from "rejecting" the new heart. Your immune system will likely never get used to the new organ. So you usually need to take some anti-rejection medications for the rest of your life. Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 15 of 16 Important Safety Information Medications, procedures and tests can have some risks and possible side effects. Results may vary from patient to patient. This information is not meant to replace advice from your doctor. Be sure to talk to your doctor about these risks and possible side effects. Cardiac resynchronization therapy pacemakers (CRT-P) and defibrillators (CRT-D) are used to treat heart failure patients who have symptoms despite the best available drug therapy. These patients also have an electrical condition in which the lower chambers of the heart contract in an uncoordinated way and a mechanical condition in which the heart pumps less blood than normal. CRT-Ps and CRT-Ds are not for everyone including people with separate implantable cardioverter-defibrillators (CRT-P only) or certain steroid allergies. Procedure risks include infection, tissue damage, and kidney failure. In some cases, the device may be unable to respond to your heart rhythm (CRT-P only) or may be unable to respond to irregular heartbeats or may deliver inappropriate shocks (CRT-D only). In rare cases severe complications or device failure can occur. Electrical or magnetic fields can affect the device. Only your doctor knows what is right for you. Boston Scientific is a trademark and HEARTISTRY is a service mark of Boston Scientific Corporation. All other brand names mentioned are used for identification purposes only and are trademarks of their respective owners. Low Ejection Fraction (EF) HEARTISTRY brought to you by Boston Scientific Corporation Page 16 of 16