Download Management of End Stage Heart Failure

Ali Valika, MD, FACC
Advanced Heart Failure & Transplant Cardiologist
Midwest Heart Advocate Medical Group
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No disclosures relevant to this topic.
Broad definition
“You’ll Know it when you see it”
Normal heart
Chronic heart failure
5 million in the US
10 million in Europe
Initial
myocardial
injury
Heart Viability
Death
>60% mortality within 5 years
after diagnosis
First ADHF episode:
Pulmonary edema
ER admission
Later ADHF episodes:
Rescue therapy
ICU admission
Initial phase
Gheorghiade M. Am J Cardiol. 2005;96(suppl 6A):1-4G.
Last year
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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.
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Dyspnea and fatigue
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Weight
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Rapid and recurrent gains
Eventually weight loss (cachexia)
Signs of hypoperfusion
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Narrow Pulse Pressure
Congestion at Rest
NO
NO
Low Perfusion
at Rest
YES
A
YES
B
Warm &
Dry
Warm &
Wet
(Low
Profile)
(Complex)
Cold & Dry
Cold & Wet
L
Possible Evidence of Low Perfusion:
Narrow pulse pressure
Sleepy / obtunded
Low serum sodium
C
Signs/Symptoms of
Congestion:
Orthopnea / PND
JV Distension
Hepatomegaly
Edema
Rales (rare in chronic heart
failure)
Elevated est. PA systolic
Cool extremities
Hypotension with ACE inhibitor
Renal Dysfunction (one cause)
R. Bourge, UAB (adpt from L. Stevenson)Stevenson LW. Eur J Heart Failure 1999
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Pulmonary hypertension
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Pulmonary venous congestion
PAH: Arterial remodeling  elevated TPG (MPAPCWP)
Cardiorenal syndrome
RV enlargement/dysfunction
Hepatic or bowel congestion
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Early satiety, nausea
Diuretic resistance
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
30% cumulative incremental
risk associated with discharge
from a second or third HF
hospitalization
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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. (Overestimates survival)
www.SeattleHeartFailureModel.org
Free App
Mancini, DM et al Circulation 1991; 83:778
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Provides the most objective assessment of functional
capacity in patients with HF.
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Value of VO2 for optimal timing of cardiac transplantation
in ambulatory patients with HF was illustrated by
Mancini,et al, circulation 1991;83:778.
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Patients with VO2<=12ml/kg/min are likely to experience
maximum improvement in survival with transplantation.
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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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Refractory Symptoms
Intolerance to cardiac medications
Worsening renal function
Low blood pressure
Hyponatremia
Elevated cardiac biomarkers (eg. BNP, Troponin)
Need for inotropes
Reduced Cardiac Index / Reduced pVO2
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Cardiac Transplantation
Ventricular Assist Devices
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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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
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Destination Therapy
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Non-reversible left heart failure
Imminent risk of death
Candidate for cardiac transplantation
NYHA Class IV heart failure
Optimal medical therapy 45 of last 60 days
Not candidate for cardiac transplantation
Bridge to Recovery
30
HeartMate II—Actuarial Survival
Post-Approval Study
Starling, Naka, Boyle, et al. JACC. 2011;57:19.
PROFILE-LEVEL
PRIMARY
LVADs
12-09
Official Shorthand
(after Lynne Stevenson)
NYHA
CLASS
Modifier option
INTERMACS
LEVEL 1
633
“Crash and burn”
IV
INTERMACS
LEVEL 2
841
“Sliding fast” on ino
IV
INTERMACS
LEVEL 3
284
Stable but Ino-Dependent
Can be hosp or home
IV ish
INTERMACS
LEVEL 4
185
Resting symptoms on
oral therapy at home.
ambul
IV
+FF frequent flyer
A for arrhythmia
INTERMACS
LEVEL 5
“Housebound”,
Comfortable at rest,
symptoms with minimum
activity ADL
ambuI
IV
+ FF
A
INTERMACS
LEVEL 6
“Walking wounded”-ADL
possible but meaningful
activity limited
IIIB
+FF
A
Advanced Class III
III
INTERMACS
LEVEL 7
(5,6,7 =
119)
CURRENT VAD
INDICATIONS
ROADMAP TRIAL
A only
Lietz, Curr Opin Cardiol; 09:246
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 2–3
Group 3: INTERMACS 4–7
Boyle, Ascheim, Russo, et al. JHLT. 2011;30:4.
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2 admits in the last year for CHF
LVEF < 25%
Diuretic dose > 1.5 mg/kg/day
Intolerance to ACE I and Beta blockers due to
hypotension and CKD
Serum Na < 134 mmol/L
BUN > 50
Serum Cr > 2 mg/dL or GFR < 40
Use of any intravenous inotrope:
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milrinone, dobutamine, dopamine
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Don’t wait for progressive renal dysfunction
and recurrent ascites
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Don’t wait till multiple pressors are required
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Don’t wait for cardiac cachexia
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Refractory VT/ ICD shocks as persistent
elevation of LVEDP
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not just scar mediated VT/VF
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Patients who require inotrope therapy to
reverse/manage renal dysfunction or pulmonary
hypertension are VERY high risk patients despite
symptoms (inotrope dependence: Intermacs 3)
Patients with significant secondary pulmonary
hypertension
 Pre-operative pulmonary hypertension
contraindication to OHT
 a good sign RV can pump effectively (protective
with VAD)
 Worry about the dilated RV, low PA pressures and
high CVP
Hospital admission – 34% risk of death at 1 year
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End Stage HF is a treatable condition if diagnosed early. There are
patients in our community with subtle clues of a very sick heart
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Patients are at greater risk of treatment failure, complications, or
absolute contraindications for advanced therapies when they are
critically ill
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Patients should be evaluated by an advanced heart failure team
early in the course of the disease to determine optimal timing of
advanced therapies
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MCS or Transplantation is superior to medical therapy in patients
with advanced heart failure and can provide excellent
improvements in both quantity and quality of life