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Congestive Heart Failure: Update 2002 Bruce D. Hettleman, MD DHMC December 2, 2002 CASE PRESENTATION • 71 yo retired submarine captain is admitted with pulmonary edema and an elevated troponin. His PMH is notable for advanced CAD and previous MI. He had CABGX3 in 1990. • Echo demonstrated a severely dilated LV with an EF of 20% and 3+/4 mitral regurgitation. • EKG showed sinus rhythm at 52 with first degree AV block and LBBB. • Cardiac Cath revealed a patent IMA to the LAD, patent SVG to the RCA and a severely diseased SVG to the circumflex. What should be done once the patient is initially stabilized? • 1. Perform urgent repeat bypass surgery and mitral valve replacement. • 2.Perform percutaneous intervention (stent) on the SVG to the circumflex. • 3. Put in a dual chamber pacemaker • 4.Maximize medical therapy because he is too high a risk for revascularization. Case Presentation--Continued • After stenting the SVG to the circumflex his pulmonary edema subsequently responded to medical therapy and he was able to ambulate but remained Class III CHF. • Discharge medications consisted of a diuretic,digoxin, beta blocker, ace inhibitor, aspirin, plavix and spironolactone. • He was given dietary and weight-based diuretic adjustment guidelines. • Follow-up in CHF Clinic was scheduled for 1 month. What is the most likely adverse event after adding aldactone in the treatment of CHF? • 1. Hypotension • 2. Breast enlargement • 3. Yellow vision • 4. Hyperkalemia • 5. Worsening CHF After starting aldactone in Class IV CHF, when should electrolytes be rechecked? • 1. No worries, mate • 2. One week ( big worries, mate) • 3. Four weeks • 4. Three months Potassium Level 8 7 6 5 4 Potassium 3 2 1 0 JNRY 15 JNRY 25 20-Feb 1-Apr Drugs that have shown to prolong life in CHF are: • 1. ACE inhibitors • 2. Beta Blockers • 3. Digoxin • 4. Aldactone • 5. 1,2 and 4 DIG Trial: Effect of Digoxin on Survival in CHF • NHLBI sponsored study of 7,788 patients with class II and III CHF and LVEFs < 45% or > 45% • Randomized, controlled, double-blinded • 93% of patients on ACEIs • Superimposable survival curves • 25% reduction with Dig on first CHF hospitalization Weight of Evidence: ACE Inhibitors Approximately 7000 patients evaluated in long-term placebo-controlled clinical trials Improvement in cardiac function, symptoms, and clinical status; equivocal effects on exercise tolerance Decrease in all-cause mortality by 20%-25% (P<.001) and decrease in combined risk of death and hospitalization by 30%-35% (P<.001) - Effect shown in SOLVD Treatment, CONSENSUS, and V-HeFT II trials Garg and Yusuf, 1995. Weight of Evidence: -Blockade Traditionally contraindicated in heart failure, due to impaired inotropy, early lack of tolerability, and worsening heart failure Over 10,000 patients have now been evaluated in long-term placebo-controlled clinical trials; Improvement in cardiac function and NYHA class; and decrease in mortality and morbidity shown in multiple clinical trials Effects shown in patients already receiving ACE inhibitors Improved survival with aldactone in advanced CHF--Rales Trial Will a permanent pacemaker help this man? • 1. No, he has no indication for a pacemaker and if you put one in medicare will send you the bill. • 2. Yes, he should have a VVI back up pacemaker prior to discharge because he has LBBB and may unpredictably develop complete heart block and die. • 3. Yes, the placement of a routine DDD pacemaker will reliably improve his hemodynamics • 4.Yes, he ought to have a brand-spankin new biventricular resynchronization device because he has LBBB. Cardiac Resynchronization Therapy for Heart Failure Mechanisms, Clinical Outcomes, Patient Selection, and Implant Ventricular Dysynchrony and Cardiac Resynchronization • Ventricular Dysynchrony1 – Electrical: Inter- or Intraventricular conduction delays typically manifested as left bundle branch block – Structural: disruption of myocardial collagen matrix impairing electrical conduction and mechanical efficiency – Mechanical: Regional wall motion abnormalities with increased workload and stress—compromising ventricular mechanics • Cardiac Resynchronization – Therapeutic intent of atrial synchronized biventricular pacing • Modification of interventricular, intraventricular, and atrial-ventricular activation sequences in patients with ventricular dysynchrony • Complement to optimal medical therapy 1 Tavazzi L. Eur Heart J 2000;21:1211-1214 Animation – Ventricular Dysynchrony Click to Start/Stop Cardiac Resynchronization Click to Start/Stop Clinical Consequences of Ventricular Dysynchrony • Abnormal interventricular septal wall motion1 • Reduced dP/dt3,4 • Reduced pulse pressure4 • Reduced EF and CO4 • Reduced diastolic filling time1,2,4 • Prolonged MR duration1,2,4 1 Grines CL, Bashore TM, Boudoulas H, et al. Circulation 1989;79:845-853. HB, Lee CH, Gibson DG. Br Heart J 1991;66:443-447. 3 Xiao HB, Brecker SJD, Gibson DG. Br Heart J 1992;68:403-407. 4 Yu C-M, Chau E, Sanderson JE, et al. Circulation. 2002;105:438-445. 2 Xiao, Proposed Mechanisms: Improved Intraventricular Synchrony Improved Intraventricular Synchrony1,2 dP/dt 1,3,4 EF1,5 Pulse Pressure 3,4 SV&CO1, 2 LVESV1 1 Yu MR1 LA Pressure1 C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445 P, Kim W, Jensen H, et al. Cardiology 2001;95:173-182 3 Kass D Chen-Huan C, Curry C, et al. Circulation 1999;99:1567-73 4 Auricchio A, Ding J, Spinelli J, et al. J Am Coll Cardiol 2002;39:1163-1169 5 Stellbrink C, Breithardt O, Franke A, et al. J Am Coll Cardiol 2001;38:1957- 65 2 Søgaard Prevalence of Inter- or Intraventricular Conduction Delay General HF Population1,2 Moderate to Severe HF Population3,4,5 IVCD >30% IVCD 15% 1 2 3 4 5 Havranek E, Masoudi F, Westfall K, et al. Am Heart J 2002;143:412-417 Shenkman H, McKinnon J, Khandelwal A, et al. Circulation 2000;102(18 Suppl II): abstract 2293 Schoeller R, Andresen D, Buttner P, et al. Am J Cardiol. 1993;71:720-726 Aaronson K, Schwartz J, Chen T, et al. Circulation 1997;95:2660-2667 Farwell D, Patel N, Hall A, et al. Eur Heart J 2000;21:1246-1250 Increased Mortality Rate with LBBB • Risk remains significant even after adjusting for age, underlying cardiac disease, indicators of HF severity, and HF medications * HR = Hazard Ratio All patients N=5517 20 HR* 1.70 (1.41-2.05) 1-Year Mortality (%) • Increased 1-year mortality with presence of complete LBBB (QRS > 140 ms) LBBB N=1391 16.1 15 11.9 HR * 1.58 (1.21-2.06) 10 7.3 5 5.5 0 All Cause Sudden Cardiac Cause of Death Baldasseroni S, Opasich C, Gorini M, et al. Am Heart J 2002;143:398-405 Proposed Mechanisms of Cardiac Resynchronization Cardiac Resynchronization Improved Intraventricular Synchrony Improved Atrioventricular Synchrony Yu C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445 Improved Interventricular Synchrony Summary of Proposed Mechanisms Cardiac Resynchronization Intraventricular Synchrony dP/dt, EF, CO ( Pulse Pressure) LVESV Atrioventricular Synchrony MR LA Pressure LV Diastolic Filling LVEDV Reverse Remodeling Yu C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445 Interventricular Synchrony RV Stroke Volume Achieving Cardiac Resynchronization Mechanical Goal: Atrial-synchronized bi-ventricular pacing • Transvenous Approach – Standard pacing lead in RA – Standard pacing or defibrillation lead in RV – Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus Right Atrial Lead Right Ventricular Lead Left Ventricular Lead CRT Improves Quality of Life Score and NYHA Functional Class QoL NYHA PATH-CHF1 (n=41) + + InSync (Europe)2 (n=103) + + InSync ICD (Europe)3 (n=84) + + MUSTIC4 (n=67) + MIRACLE5 (n=453) + + MIRACLE ICD6 (n=364) + + + Blank 1 Auricchio Statistically significant improvement with CRT (p 0.05) Not statistically significant or No statistical analysis performed on data Indicates test neither performed nor reported A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026- 2033 Gras D, Leclercq C, Tang A, et al. Eur J Heart Failure 2002;4:311-320 3 Kuhlkamp V. JACC 2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118 2 5 Abraham W, Fisher W, Smith A, et al. N Engl J Med. 2002;346:1845-1853 6 Leon A. NASPE Scientific Sessions – Late Breaking Clinical Trials. May 2002; Medtronic Inc. data on file CRT Improves Exercise Capacity 6 Min Walk Peak VO2 PATH-CHF1 (n=41) + + InSync (Europe)2 (n=103) + InSync ICD (Europe)3 (n=84) + MUSTIC4 (n=67) + MIRACLE5 (n=453) + + + + + MIRACLE ICD6 (n=364) + Blank 1 Auricchio Statistically significant improvement with CRT (p 0.05) Not statistically significant or No statistical analysis performed on data Indicates test neither performed nor reported A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026- 2033 Gras D, Leclercq C, Tang A, et al. Eur J Heart Failure 2002;4:311-320 3 Kuhlkamp V. JACC 2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118 2 Exercise Time 5 Abraham W, Fisher W, Smith A, et al. N Engl J Med. 2002;346:1845-1853 6 Leon A. NASPE Scientific Sessions – Late Breaking Clinical Trials. May 2002; Medtronic Inc., data on file CRT Improves Cardiac Function/Structure LVEF MR PATH-CHF1 (n=41) + LVEDP + LV dP/dtmax InSync (Europe)2 (n=103) + InSync ICD (Europe)3 (n=84) MUSTIC4 (n=67) + LVEDD,LVESD Filling Time MIRACLE5 (n=453) + + + LVEDD, + LVEDV, LVESV MIRACLE ICD6 (n=362) + + LVESV, + LVEDV + Blank 1 Auricchio + Filling Time + Filling Time Statistically significant improvement with CRT (p 0.05) Not statistically significant or No statistical analysis performed on data Indicates test neither performed nor reported A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026- 2033 Gras D, Leclercq C, Tang A, et al. Eur J Heart Failure 2002;4:311-320 3 Kuhlkamp V. JACC 2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118 2 Other 5 Abraham W, Fisher W, Smith A, et al. N Engl J Med. 2002;346:1845-1853 6 Young J. ACC Scientific Sessions – Late Breaking Clinical Trials III. March 2002; Medtronic Inc., data on file Cardiac Resynchronization Outcomes Sustained for at least 12 months NYHA QoL 6 Minute Peak VO2 Walk InSync European and Canadian Study1 + (n=67, followed to 12 months) + + PATH-CHF Study2 + (n=29, followed to 12 months) + + + + + + MUSTIC Study3 (n=42 in sinus rhythm group, n=33 in atrial fibrillation group followed to 12 months) + Blank 1 Statistically significant improvement with CRT (p 0.05) No statistically significant improvement with CRT Indicates test neither performed nor reported Gras D, Leclercq C, Tang A, et al. Eur J Heart Fail 2002;4:311-320 A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026-2033 3 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118 2 Auricchio Step 1: Cannulate CS Attain LDS Model 6216A • Use extreme care when passing the guide catheter through vessels • Due to the relative stiffness of the catheter, damage to the walls of the vessels may include dissections or perforations Step 2: Perform Venograms Varying Patient Anatomy 1,2,3 1. Potkin et al. Am J Cardiol 1987;60:1418-1421 2. Neri et al. Europace 2000;I :D95 Abstract 88/2 3. Hill et al. Europace 2000;I:D238 Abstract 167/2 Photos Courtesy of Dr. Daniel Gras Step 2: Perform Venograms Great CS Os Middle Posterior Postero-lateral Anterolateral Lateral Anterior Cardiac Venous Anatomy Step 2: Perform Venograms Lead in Lateral Cardiac Vein Step 4: Place Lead Attain OTW Model 4193 Click to Start/Stop Step 4: Place Lead Attain OTW Model 4193 Courtesy of Dr. Daniel Gras Click to Start/Stop LAO View: Tracking Over the Wire Courtesy of Dr. Daniel Gras Click to Start/Stop Step 4: Place Leads Attain LV Model 2187 Video compliments of Dr. Vince Paul Click to Start/Stop Biventricular Pacing is indicated for the reduction of CHF symptoms in patients with: • 1. Stable Class III-IV CHF • 2. QRS> 130 ms • 3.EF <35% • 4. Optimal medical therapy