Download Management of End Stage Heart Failure

Ali Valika, MD, FACC
Advanced Heart Failure & Transplant Cardiologist
Advocate Medical Group
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No disclosures
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Survival statistics….
estimates of prognosis
Over 100 different variables that have been
looked at that can give prognostic evaluation
for the HF patient.
CHARM data: LVEF
Solomon et al. Circ 2005
Lee et al., AJC 1993
Anand et al. Circ 2003
Gheorgiade et al. Eur Heart J 2007 
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Refractory Symptoms
Intolerance to cardiac medications
Worsening renal function
Low blood pressure
Hyponatremia
Elevated cardiac biomarkers (eg. BNP, Troponin)
Need for inotropes
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Cardiopulmonary Exercise Stress Test
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Heart Failure Survival Score
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Standard. Objective evaluation of functional capacity
Has certain limitations
Model drafted prior to device therapy and wide-spread
beta-blocker use.
Seattle Heart Failure Model
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Complex calculation.
calculation (Overestimates survival)
Mancini, DM et al Circulation 1991; 83:778
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Provides the most objective assessment of functional
capacity in patients with HF.
Value of VO2 for optimal timing of cardiac transplantation
in ambulatory patients with HF was illustrated by
Mancini,et al, circulation 1991;83:778.
Patients with VO2<=12ml/kg/min are likely to experience
maximum improvement in survival with transplantation.
Patients with VO2 12-14 ml/kg/min, remain optimal
candidates for transplantation, provided they are on
maximal medical therapy.
Limitations
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Predictive value of a severely reduced peak VO2 only
applies when it is caused by HF
Factors that prematurely terminate the test and prevent
patients from achieving VO2 will confound the results.
It is a continuous parameter affected by age, gender,
degree of conditioning. It should also be interpreted as a
percent of the expected value for a specific patient
Several studies have suggested that a peak VO2<50%of
predicted is a significant predictor of cardiac death within
1-3 years
Figure 1. Kaplan-Meier survival curves for group 1 (VO2 ≥12 ml/min/kg, CI ≥1.8
L/min/m2), group 2 (VO2 ≥12 ml/min/kg, CI <1.8 L/min/m2), group 3 (VO2 <12
ml/min/kg, CI ≥1.8 L/min/m2), and group 4 (VO2 <12 ml/min/kg, CI <1.8
L/min/m2).
Am J Card. 105: 9 May 2010, 1353–1355
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Cardiac Transplantation
Ventricular Assist Devices
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Heart transplantation survival is on the rise thanks to
improved therapy.
About half the patients now live for more than 11 years, and
about one quarter for 17 or more years.
Taylor DO et al. J Heart Lung Transplant 2003;22:616–624
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There are currently about 20,000 pts living with a
transplanted heart in the US.
Prolonged survival stresses the need for awareness of drug
therapy, drug-drug interactions and common co-morbid
conditions
2000 Annual Report of the U.S. Scientific Registry of Transplant Recipients and the Organ Procurement and Transplantation Network:
Transplant Data 1989–1998. Rockville, Md, and Richmond, Va:HHS/HRSA/OSP/DOT and UNOS; 2001
J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
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Absolute or Relative Contra-indications
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Fixed pulmonary hypertension
Severe, chronic disabling diseases
Severe, irreversible, chronic impairment of other vital organs, such as kidneys,
intestines, liver, lungs or central nervous system
Recent (<5yrs) or uncontrolled malignancy
Symptomatic, severe peripheral, visceral, carotid or cerebrovascular disease
that cannot be corrected
Inability to discontinue recreational drug, tobacco or alcohol use
Active mental illness that interferes with medical treatment compliance
Psychosocial instability, lack of social or family support, ongoing noncompliance
with medical treatment
70 years old or older
Pulmonary infarction within the past six weeks
Very brittle diabetes or diabetes with end organ damage
Major chronic disabling diseases, such as arthritis, stroke, neurological disease,
severe inflammatory or collagen vascular disease
Active, but treatable infection (temporary)
Morbid obesity
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Cardio-pulmonary stress testing
Role of right heart catheterization
Co-morbidities: Age, Obesity, cancer, diabetes,
renal dysfunction and peripheral vascular
disease
Tobacco, substance abuse and psychosocial
evaluation
Baseline screening – Malignancy, Infections, etc.
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Wait list for Heart Transplant
Status 1A
 Status 1B
 Status 2
 Status 7
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Priority on Waiting List
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Based on status level
Duration of time in that status level
No credit given for time at a lower status level
No advantage for being hospitalized (required for 1A status
however)
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Pulsatile
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Continuous Flow
Axial Flow
 Centrifugal Flow
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Pump (VAD)
 Internal or external
placement
Wearable or portable control
system
Power source
 AC power or battery power
that is outside of the body
The pump can vary in method of
operation, size and placement
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Bridge to Transplant
Non-reversible left heart failure
 Imminent risk of death
 Candidate for cardiac transplantation
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Destination Therapy
NYHA Class IIIB or IV heart failure
— Optimal medical therapy 45 of last 60 days
— Not candidate for cardiac transplantation
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Bridge to Recovery
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Ability to tolerate / allergy toward
anticoagulation
Social support
Nonreversible end organ failure
Surgical Risk
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HeartMate II—Improvement in BTT Outcomes
Miller LW, Pagani FD, Russell SD, et al. NEJM. 2007;357:885-96.
Pagani FD, Miller LW, Russell SD, et al. JACC. 2009;54:312-21.
Starling, Naka, Boyle, et al. JACC. 2011;57:19.
HeartMate II—Improvement in DT Outcomes
Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuouscontinuous-flow
left ventricular assist device. N Engl J Med. 2009;361:22412009;361:2241-51.
Park SJ. AHA Scientific Sessions, November 2010.
HeartMate II—Actuarial Survival
Post-Approval Study
Starling, Naka, Boyle, et al. JACC. 2011;57:19.
INTERMACS Profiles
Starling, Naka, Boyle, et al. JACC. 2011;57:19.
Clinical Outcomes Based on INTERMACS Profile
Length of Stay Post-VAD
Actuarial Survival Post-VAD
Less acutely ill, ambulatory patients in INTERMACS profiles 4–7 had better survival and
reduced length of stay compared to patients who were more accurately ill in profiles 1–3.
Group 1: INTERMACS 1
Group 2: INTERMACS 2–
2–3
Group 3: INTERMACS 4–
4–7
Boyle, Ascheim, Russo, et al. JHLT. 2011;30:4.
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Significant improvement in survival.
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Dramatic improvements in QoL.
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Factors contributing to improving trends:
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Improved timing of patient referral
Better patient selection
Enhanced implantation techniques
Improved post-op patient management
Increased knowledge and team training
Higher surgery volume
More dedicated coordinators and experienced patient care
teams
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End Stage HF is a treatable condition if
diagnosed early.
Objective assessment of a patient’s HF status
can be interpreted with CPX stress testing
Heart Transplantation remains the gold
standard for management of stage D HF
Left Ventricular Assist devices have brought a
new paradigm of therapy to this subgroup,
and will continue to expand the patient
population eligible for treatment