Download Advanced Heart Failure Care

Advanced Therapies
Lee R. Goldberg, MD, MPH
Medical Director, Heart Failure and
Cardiac Transplant Program
University of Pennsylvania
What Are Advanced Therapies?
• Heart Transplant
• Ventricular Assisted Devices (VAD)
– Mechanical Circulatory Support (MCS)
The Paradox
Desperately sick and otherwise healthy at the same
time!
Sick enough to
need transplant or VAD
without any other
threatment options
Well enough to survive VAD
and/or transplant and have
good quality of life
For Transplant, limited organ availability creates a
societal responsibility to carefully select recipients most
likely to survive and have a good quality of life
The Evaluation – Three Components
• The Heart
– There are no other therapies that will improve the status of the
heart, survival or quality of life
• The rest of you
– All the organs except the heart are healthy and can survive the
surgery and the effects of either the VAD or the medications
after transplant
• Everything outside of you
–
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“Family” support
Psychosocial
Transportation
Finances, insurance, disability, prescription coverage
Timing
• Move forward with VAD or Transplant before
irreversible organ damage, malnutrition, muscle
weakness or infection
• Avoid going “too soon”
– “Up front risk” – can shorten life
– New therapies always being developed and improved
• Can use VAD as bridge to heart transplant
– Correct heart failure
– Better candidate when it comes time to transplant
Transplant Wait List
• The current UNOS system divides the waiting list
by “risk of death”
– Status 1A – On IV medications at high dose with a
monitoring (PA) catheter, VAD complication, 30 days
following VAD
– Status 1B – On IV medication or VAD
– Status 2 – Not on IV medications or VAD
– Status 7 – Inactive
• Body Size
• Blood Group
• Antibodies (PRA)
Heart Transplant
• Rejection versus infection
• Immunosuppression
– Calcineurin inhibitor (Tacrolimus, Cyclosporine)
– Anti-proliferative (Mycophenolate mofetil, azathiprine
– Steroid (Prednisone)
• Immunosupporession issues
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Must take for life
Increases risk of infection
Increases risk for cancers
Toxicity to kidneys
Other side effects – tremor, GI, weight gain, diabetes
• Frequent visits
– Weekly, biweekly, monthly in first year
– Heart biopsies, blood draws, frequent adjustment of medications
Ventricular Assist Device
• Need to take anticoagulation (blood thinners) for
life
– Risk of clot in VAD
– Risk of bleeding especially in GI tract
– Risk of stroke – clots and bleeding
• Infection
– Drive line infections
• Blood pressure control
– Challenging – No pulse!
• Tethered to batteries
– Can impact travel – need to plan ahead
Palliative Care
• For people who are not candidates or who do
not want advanced therapies
– Focus on quality of life and symptom control
– Define wishes for heroic therapies – CPR, Shocks
from ICD device, admission to hospital
• For people who have had advanced therapies
– Define goals of care
– When to deactivate VAD
Conclusion
• Advanced therapies include ventricular assist
devices and heart transplants
• You need to be “sick” and “healthy” at the same
time to really benefit from these therapies
• A comprehensive evaluation is necessary to
determine who is a good candidate
• Each therapy has advantages and disadvantages
• Communicating your wishes and goals to your
family and clinical team is critical