Download Acute Decompensated Heart Failure: Medical Management

Acute Decompensated Heart Failure
- Medical Management or Device?
Timothy M. Hoffman, MD, FACC, FAHA
Medical Director, Heart Transplant and Heart Failure Program
Associate Medical Director, Division of Cardiology
Professor of Pediatrics
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Presenter Disclosure Information
Session: Heart Failure/Transplant
Presenter: Timothy M. Hoffman, MD
Title: Acute Decompensated Heart Failure - Medical
Management or Device?
Financial Disclosure:
There are no relationships that exist related to this
presentation
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How Do We Answer the Question?
Describe Acute
Decompensated
Heart Failure in
Pediatrics
Review Adult
and Pediatric
Guidelines
Review Care
Algorithms and
Collective
Experiences
What Don’t We Know
• What are the pathophysiological
differences (if any) between acute
and chronic HF?
• What is the difference (if any)
between acute decompensated HF
versus acute on chronic HF?
Adapted from Gheorghiade M, et al. Circulation 2005;112:3958-3968
What Don’t We Know
• What is the contribution of different
organs or systems to the
pathophysiology of acute HF?
– Kidney
– Liver
– Peripheral vasculature
• What is unique to the pediatric patient
population?
Adapted from Gheorghiade M, et al. Circulation 2005;112:3958-3968
Kantor PF, et al. Can J Cardiol 2013;29:1535-1552
Acute Changes & Incomplete
Compensation
Mancini D, et al. Circulation 2005;112:438-448
Goal of Medical or Device Therapy
Mancini D, et al. Circulation 2005;112:438-448
Adult and Pediatric Guidelines
Yancy CW, et al. Circulation 2013;28:e240-e327
Treatment of Stages A to D
Adult Guidelines
Inotropic Support
Inotropic Support
I IIa IIb III
Until definitive therapy (e.g., coronary revascularization,
MCS, heart transplantation) or resolution of the acute
precipitating problem, patients with cardiogenic shock
should receive temporary intravenous inotropic
support to maintain systemic perfusion and preserve
end-organ performance.
I IIa IIb III
Continuous intravenous inotropic support is
reasonable as “bridge therapy” in patients with stage D
refractory to GDMT and device therapy who are eligible for
and awaiting MCS or cardiac transplantation.
Inotropic Support (cont.)
I IIa IIb III
I IIa IIb III
Short-term, continuous intravenous inotropic support
may be reasonable in those hospitalized patients
presenting with documented severe systolic
dysfunction who present with low blood pressure and
significantly depressed cardiac output to maintain
systemic perfusion and preserve end-organ performance.
Long-term, continuous intravenous inotropic support may
be considered as palliative therapy for symptom control
in select patients with stage D despite optimal GDMT and
device therapy who are not eligible for either MCS or
cardiac transplantation.
Inotropic Support (cont.)
I IIa IIb III
Harm
I IIa IIb III
Harm
Long-term use of either continuous or intermittent,
intravenous parenteral positive inotropic agents, in the
absence of specific indications or for reasons other
than palliative care, is potentially harmful in the patient
with HF.
Use of parenteral inotropic agents in hospitalized patients
without documented severe systolic dysfunction, low
blood pressure, or impaired perfusion, and evidence
of significantly depressed cardiac output, with or
without congestion, is potentially harmful.
All Cause Mortality
Elkayam U, et al. Am Heart J 2007;153:98-104
Treatment of Stages A to D
Adult Guidelines
Mechanical Circulatory
Support
Mechanical Circulatory Support
I IIa IIb III
MCS use is beneficial in carefully selected* patients with
stage D HFrEF in whom definitive management (e.g.,
cardiac transplantation) or cardiac recovery is anticipated
or planned.
I IIa IIb III
Nondurable MCS, including the use of percutaneous
and extracorporeal ventricular assist devices (VADs),
is reasonable as a “bridge to recovery” or a “bridge to
decision” for carefully selected* patients with HFrEF
with acute, profound hemodynamic compromise.
I IIa IIb III
Durable MCS is reasonable to prolong survival for carefully
selected* patients with stage D HFrEF.
McMurray J, et al. Eur J Heart Fail 2012;14:803-869
Pediatric Guidelines
ISHLT Practice Guidelines
Inotropic Support
All recommendations LOE C
• Class I:
– Inotropic support can be used in AHF
presenting as cardiogenic shock (poor
perfusion)
• Class IIa:
– Inotropic support may be temporarily used in
AHF with hypotension and low cardiac output
Kirk R, Dipchand AI, Rosenthal D, et al. ISHLT Monograph Series 2014
ISHLT Practice Guidelines
• Class IIa:
– Inotropic support choice depends on clinical
presentation. Milrinone and/or dobutamine
can be used as first-line rescue therapy with
epinephrine playing a role in refractory
hypotension
• Class IIb:
– Levosimendan may be considered in AHF
unresponsive to traditional inotropic support
Kirk R, Dipchand AI, Rosenthal D, et al. ISHLT Monograph Series 2014
ISHLT Practice Guidelines
Mechanical Circulatory Support
All recommendations LOE C
• Class IIa:
– For a child in cardiac arrest/cardiogenic shock
with pulmonary compromise, ECMO should
be considered
– For a child with AHF that is believed to be
reversible, either ECMO or a temporary VAD
may be considered as a temporizing
measure.
Kirk R, Dipchand AI, Rosenthal D, et al. ISHLT Monograph Series 2014
ISHLT Practice Guidelines
• Class IIa:
– For a child with cardiogenic shock that is not
believed to be due to a reversible underlying
cause, consideration should be given to use
of a temporary VAD or ECMO for resuscitation
of end organ function rather than directly
implanting a chronic VAD system
Kirk R, Dipchand AI, Rosenthal D, et al. ISHLT Monograph Series 2014
Kantor PF, et al. Can J Cardiol 2013;29:1535-1552
Kantor PF, et al. Can J Cardiol 2013;29:1535-1552
Kantor PF, et al. Can J Cardiol 2013;29:1535-1552
∙ Circulatory support
Kantor PF, et al. Can J Cardiol 2013;29:1535-1552
Care Algorithms and Collective
Experiences
Can We Predict the Outcome?
ADHERE Trial Analysis
Yancy CW, et al. J Am Coll Cardiol 2006;47:76-84
Seattle Heart Failure Score
Levy W C et al. Circulation. 2006;113:1424-1433
Copyright © American Heart Association, Inc. All rights reserved.
Seattle Heart Failure Score
Levy W C et al. Circulation. 2006;113:1424-1433
Copyright © American Heart Association, Inc. All rights reserved.
Predicted Effects on Survival
Levy W C et al. Circulation. 2006;113:1424-1433
Copyright © American Heart Association, Inc. All rights reserved.
REMATCH Trial: Subset Analysis
Stevenson L W et al. Circulation. 2004;110:975-981
Copyright © American Heart Association, Inc. All rights reserved.
Improvement in Minnesota
Living with Heart Failure Score
Stevenson L W et al. Circulation. 2004;110:975-981
Copyright © American Heart Association, Inc. All rights reserved.
LVAD survival benefit
Stevenson L W et al. Circulation. 2004;110:975-981
% of Patients with VAD as BTT
Blume E D et al. Circulation. 2006;113:2313-2319
Copyright © American Heart Association, Inc. All rights reserved.
How Many Recovered?
Blume E D et al. Circulation. 2006;113:2313-2319
Copyright © American Heart Association, Inc. All rights reserved.
Device Types
Peura J L et al. Circulation. 2012;126:2648-2667
Copyright © American Heart Association, Inc. All rights reserved.
Device Selection Flow Chart
Peura J L et al. Circulation. 2012;126:2648-2667
Copyright © American Heart Association, Inc. All rights reserved.
Optimal Timing for MCS
Peura J L et al. Circulation. 2012;126:2648-2667
Copyright © American Heart Association, Inc. All rights reserved.
Optimal Timing for MCS
Peura J L et al. Circulation. 2012;126:2648-2667
Copyright © American Heart Association, Inc. All rights reserved.
Optimal Timing for MCS
Peura J L et al. Circulation. 2012;126:2648-2667
Copyright © American Heart Association, Inc. All rights reserved.
Device Types
Peura J L et al. Circulation. 2012;126:2648-2667
Copyright © American Heart Association, Inc. All rights reserved.
Bridge to Recovery
Simon MA, et al. Circulation 2005;112[suppl I]:I-32-I-36
Bridge to Recovery
Simon MA, et al. Circulation 2005;112[suppl I]:I-32-I-36
Ejection Fraction
Bridge to Recovery
= non-ischemic CM
Simon MA, et al. Circulation 2005;112[suppl I]:I-32-I-36
Clinical Scenario
• 8 year old (25 kg, BSA 0.97 m2)
– Bone sarcoma
• Doxorubicin 450 mg/m2 cumulative dose
– SF 15%, EF 25%
• Inotropic and mechanical ventilatory support
• Ongoing deterioration
– 149 device days total
• 90 days in hospital
Cavigelli-Brunner A, et al. Pediatrics
2014;134:e894
Catheterization/Balloon
Occlusion of Outflow Graft
Cavigelli-Brunner A, et al. Pediatrics 2014;134:e894
HeartWare
Cavigelli-Brunner A, et al. Pediatrics 2014;134:e894
Impella Recover LVAD
Siegenthaler MP, et al. J Thorac Cardiovasc Surg 2004;127:812-22
Impella Recover LVAD
Acute Decompensated Heart Failure
- Medical Management or Device?
• Answer is …
– Interpreting the current guidelines and
reviewing the collective experiences…
– Optimal medical management is acceptable
as initial therapy for most patients
– For fulminant myocarditis, early device use is
acceptable as a bridge to decision
Acute Decompensated Heart Failure
- Medical Management or Device?
• The decision to implant a device takes into
account:
– Disease process (reversibility, pathophysiology)
– Patient size
– Available devices
– Program experience and infrastructure
• What works best within the program’s system
Future Directions
• Can we predict outcome in acute heart
failure in children?
• Can device technology improve in
pediatrics for specific clinical scenarios?
• Can we develop practice models for
pediatric heart failure?
Future Directions Paradigm
ISHLT
Workforce
Targeted
Therapies
AHA CVDY
Committee
National
Registry
Develop
practice
models
Link
phenotype
and
genotype
data
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