Current Approaches to the Diagnosis & Management of Heart ...€¦ · Diagnosis of Heart Failure...
Transcript of Current Approaches to the Diagnosis & Management of Heart ...€¦ · Diagnosis of Heart Failure...
Current Approaches to the
Diagnosis & Management of
Heart Failure
J. Bradley Gibson, D.O.
Cardiology Specialists of Dayton
Which of the Following have been considered
therapies for advanced heart failure refractory to
medical therapy?
A. B. C. D. E.
20% 20% 20%20%20%
A. Heart Transplantaion
B. Ventricular Assist Device Placement
C. Biventricular Pacing
D. Ventricular Reduction Surgery
E. All of the Above
Countdown
10
Introduction
• The rapidly increasing prevalence and
economic burden of HF represents a
worldwide epidemic and one of the most
important current public health concerns in
cardiovascular medicine today.
Introduction
• The mainstay of HF therapy today remains
reactive treatment for established and
symptomatic disease.
• However, the burden of HF on our society
will continue to grow until effective primary
and secondary prevention strategies are
adopted and employed, as well as
increased awareness of lifestyle choices
that can modify risk factors for developing
HF.
Epidemiology
• According to the AHA Heart Disease and
Stroke Statistics-2011 Update, HF affects
approximately 5.7 million Americans, with
the incidence of 670,000 new HF cases in
those ≥45 years of age.
• The prevalence of HF increases by age,
and is more common in men than in
women in those > 40 and <80 years of
age.
Women vs. Men
• Although the incidence of HF is lower, in
general, for women than men, women
comprise about half of the HF burden due
to their longer life expectancy.
• Based on the increasing age of the United
States population and improved survival,
it is projected that an estimated 772,000
new HF cases will be observed in the
year 2040.
Distribution of Types of Heart
Failure
• It is important to recognize that the syndrome of HF includes not only HF with systolic dysfunction, but the increasingly recognized entity of HF with preserved ejection fraction (HFpEF).
• Multiple epidemiological studies have demonstrated that the prevalence of HFpEF is in the range of 50-55%, and is largely predominate in the elderly population.
• Furthermore, HFpEF is more common in women than men in all age groups.
Mortality
• From 1968 to the early 1990s, HF has
increased at least fourfold as the primary
cause of death.
• The degree of HF signs and symptoms
remains the most dismal prognosis for
patients with HF.
• The 10-year survival for patients with
symptomatic HF remains only 20%, with a
median survival of 1.7 years for men and
3.2 years for women.
Hospitalization and Readmission Rates
• HF is the primary reason for 12-15 million
office visits and 6.5 million hospital days
annually.
• According to the Centers for Medicare and
Medicaid Services 2008 statistical report,
HF represents America's largest
diagnosis-related group (DRG) coding
• Readmissions for HF remain disturbingly
common, with significant quality of life and
economic repercussions.
Economic Impact
• More Medicare dollars are spent on HF than on any
other diagnosis.
• An analysis of six countries revealed that 1-2% of
total health care expenditures was for HF, and
approximately 70% was consumed for hospital
costs.
Risk Factors for HF
• The many risk factors for HF may best be
represented by the population attributable
risk (PAR), which may be derived from
large population-based studies, such as
the Framingham and Olmsted County
cohorts.
• PAR takes into account both the hazard
ratio (HR) and the prevalence of the
predisposing condition in a given
population.
•Among the numerous risk factors for HF, the common ones include CAD, hypertension, renal dysfunction,
older age, diabetes mellitus, and obesity, which represent important targets for HF prevention initiatives.
Age and HF
• Increasing age has been consistently shown to be a risk factor for the development of HF and correlates strongly with increasing HF incidence and prevalence.
• The most precipitous rise in HF incidence in recent years has been in individuals >75 years of age.
• Furthermore, these elderly patients generally have three or more comorbid conditions that increase their morbidity and mortality substantially.
CAD and HF • In developed countries today, CAD accounts for
60-75% of all symptomatic HF cases, with a history
of prior MI associated with a fivefold increased
incidence of HF over a 5-year period.
Hypertension and HF
• The incidence of HF can be stratified based on
severity of hypertension.
• The lifetime risk of developing HF doubles if blood
pressure is >160/90 mm Hg compared with those
with a blood pressure of <140/90 mm Hg.
Staging of Heart Failure
• This is the basis of the staging concept of
HF, as outlined in the American College of
Cardiology Foundation/American Heart
Association (ACCF/AHA) 2009 Focused
Update of the 2005 Guidelines for the
Diagnosis and Management of Heart
Failure in Adults.
Mechanisms of Heart Failure
• Myocardial contraction and relaxation are mediated by
interaction of the proteins that compose the thick and thin
filaments of the sarcomere.
• The troponins are also found in the thin filament. They serve
both structural and regulatory functions that facilitate actin and
myosin interaction.
The Length-Tension Relationship (Frank-
Starling Mechanism)
• Increases in end-diastolic volume lead to stretch of ventricular
myocytes and increased tension generation leading to stronger
contraction. This allows the heart to increase stroke volume
when there is increased venous return.
• However, increasing chamber volume beyond a certain point
does not result in further increases, but rather in decreases in
tension generation.
Heart Failure With Reduced Ejection Fraction
• HF is the clinical syndrome that results
from structural or functional abnormalities
that impair the ability of the heart to fill with
or eject blood.
• All forms of cardiac disease can lead to
heart failure with reduced ejection fraction
(HFREF).
• HFREF typically progresses gradually from
asymptomatic LV systolic dysfunction to a
symptomatic state characterized by
dyspnea, fatigue, and volume overload.
The Role of Neurohormones in Heart Failure
• The earliest response to decreased
cardiac output is activation of the
sympathetic nervous system (SNS).
The Role of Neurohormones in Heart Failure
• While initial effects of SNS activation may be
beneficial by augmenting cardiac output,
unopposed sustained SNS activity has deleterious
effects on the myocardium.
– SNS activity increases MVO2 in circumstances in
which there is negative oxygen balance (greater
demand than supply) such as ischemia and pressure
or volume overload with increased wall stress.
– Sustained SNS activation causes downregulation
and uncoupling of beta-1 adrenergic receptors, which
desensitizes the myocardium to the effects of
norepinephrine.
– Persistent activation of the sympathetic nervous and
RAAS after myocardial injury promotes ventricular
remodeling.
Heart Failure With Preserved Ejection Fraction
• Heart failure with preserved ejection
fraction (HFPEF) is a complex and
multifactorial disorder characterized by
exercise intolerance, resulting from
elevated cardiac filling pressures due to
slow and incomplete ventricular relaxation
and increased chamber and arterial
stiffness.
– It affects primarily elderly patients, and is
particularly prevalent in women, and people
with hypertension, diabetes, and obesity.
Heart Failure With Preserved Ejection Fraction
• In addition to diastolic abnormalities, individuals
with HFPEF have increased myocardial systolic
stiffness, reduced contractile reserve, and show
dramatic blood pressure changes in response to
relatively small changes in afterload.
• These changes result in objectively impaired
cardiopulmonary performance.
• The principal pathologic mechanism considered to
produce symptoms in HFpEF is diastolic
dysfunction, characterized by elevated “passive”
chamber stiffness and/or delayed myocardial
relaxation during early diastole
Prognosis
• Despite advances in pharmacological and device therapies,
heart failure is still associated with a particularly poor prognosis.
• A number of individual risk factors are associated with worse
prognosis
Prognosis
• A number of studies have been performed to help develop predictive models of prognosis in heart failure.
• The two most commonly utilized models are the Heart Failure Survival Score (HFSS) and the Seattle Heart Failure Model (SHFM).
• They allow physicians to discuss prognostic information with individual patients and aid in decision-making with regard to the need for transplant or mechanical circulatory support in heart failure patients.
Heart Failure Survival Score (HFSS)
• Patients are subsequently stratified into low, medium, and high risk.
• These strata correlate to 1-year survival rates of 88%, 60%, and 35%, respectively.
• Thus, those considered medium and high risk might be considered for advanced therapeutic interventions (e.g., heart transplantation).
Seattle Heart Failure Model
• The SHFM is another prospectively validated scoring system that was studied in a much broader patient population than the HFSS.
• The model was validated in multiple studies (totaling nearly 10,000 patients), and it estimates 1-, 2-, and 5-year survival across many diverse populations.
• The model also allows the clinician to add or subtract an assortment of treatment regimens, including medical therapies and devices, to assess how these changes affect mortality.
Seattle Heart Failure Model
• There is a simple, free, online score
calculator that is readily accessible to most
clinicians
• http://depts.washington.edu/shfm/
Prognosis
• The early recognition of subclinical heart failure (Stage B) and at-risk populations (Stage A) represents an opportunity for clinicians to intervene before the development of significant heart failure morbidity and mortality.
• Improved understanding of the prognostic implications of a wide range of variables will assist clinicians in determining which patients truly warrant advanced therapeutics (e.g., transplantation, ventricular assist device).
Establishing the Diagnosis
• The clinical diagnosis of heart failure is often challenging because of the nonspecific nature of the presenting symptoms.
• It is common for patients to receive multiple courses of antibiotics for suspected pneumonia, or to receive bronchodilators for suspected asthma or chronic obstructive pulmonary disease (COPD) before the accurate diagnosis of heart failure is established.
• In other cases, many patients with lower extremity edema are falsely assumed to have heart failure, when in fact there may be an underlying nephrotic syndrome, cirrhosis, chronic venous stasis, or an adverse medication effect (e.g., with calcium channel blockers).
History
• Most symptoms in patients presenting with
heart failure are related to elevated filling
pressures.
• Dyspnea is the most common symptom
and can be abrupt in onset (e.g., acute
pulmonary edema) or may present with
subtle progression with lessening activity.
• It may occur with exertion, at rest, or in the
recumbent position (orthopnea and
paroxysmal nocturnal dyspnea).
History
• Other common symptoms of congestion
relate to the manifestations of tissue
edema.
• Swelling in the lower extremities, abdomen
(ascites), and scrotum are common.
• The presence of nausea/vomiting, early
satiety, or right upper quadrant discomfort
suggests hepatic congestion and can
mimic a variety of other clinical
presentations (e.g., gastritis, hepatitis,
biliary disease).
Echocardiography
• Echocardiography provides extensive
information about the etiology and severity
of heart failure and enables an accurate
assessment of chamber dimensions,
biventricular function, valvular
stenosis/regurgitation, and filling
pressures/patterns (diastolic function).
Cardiac Magnetic Resonance Imaging
• The clinical utility of cardiac magnetic
resonance imaging (cMRI) continues to
expand. In addition to providing
remarkable anatomic detail, cMRI allows
accurate assessment of biventricular
function, quantitation of valvular
regurgitation and/or stenosis, tissue
characterization, and assessment of both
microvascular and epicardial perfusion.
Diagnosis of Heart Failure With Preserved
Ejection Fraction
• Whereas the diagnosis of heart failure with
reduced EF can be made readily through
echocardiography in symptomatic patients,
the diagnosis of heart failure with
preserved EF is more difficult.
• Current data suggest that nearly 50% of
patients with heart failure have preserved
EF. Despite having preserved systolic
function, the prognosis of patients with
HFpEF mirrors that of HFrEF, with similar
mortality rates.
Diagnosis of Heart Failure With Preserved
Ejection Fraction
• Multiple diagnostic criteria have been proposed to define HFpEF; they all generally include the presence of signs and symptoms of heart failure in the setting of preserved EF, when other etiologies have been ruled out (e.g., valvular heart disease, infiltrative diseases).
• A sample algorithm developed by the Heart Failure and Echocardiography Societies of the European Society of Cardiology is available.
Staging of Heart Failure
• In 2005, the American College of Cardiology/American Heart Association (ACC/AHA) heart failure guideline writing committee developed a new staging system for heart failure with the purpose of highlighting that heart failure is a spectrum ranging from asymptomatic patients with risk factors to end-stage disease requiring advanced therapeutics.
• By categorizing patients into one of four categories, the clinician can appropriately tailor recommended therapies.
• The first two stages (A and B) comprise asymptomatic patients.
Stage A is the new target
• Stage A includes only patients with risk
factors for the development of heart failure
• Current estimates suggest that this group
represents as much as 22% of the general
population older than 45 years
• Early preventive strategies targeting this
population could have a significant global
impact.
Stage B
• Stage B includes patients with evidence of
structural heart disease in the absence of
symptoms.
• Early appropriate therapies such as the
use of beta-blockers and ACE inhibitors in
patients with asymptomatic low EF
reduces mortality and delays the
development of symptomatic disease.
Medical Therapy for HF
• Over the past two decades, medical therapy for HF has transformed from focusing on symptom management and palliation to improving natural history, reducing adverse outcomes, and improving survival.
• Much of this advance has centered on approaches that inhibit neurohormonal activation, particularly the adrenergic nervous system and renin-angiotensin-aldosterone axis, in patients with HF and reduced left ventricular ejection fraction.
ACE Inhibitors
• Multiple clinical trials have demonstrated the ability
of ACE inhibitors to reduce mortality and HF
hospitalizations in patients with reduced LVEF.
ACE Inhibitors
• ACE inhibitors were the first agents shown
to reduce the rate of progression of LV
remodeling, as evidenced by diminishing
or preventing the progressive LV dilation
observed in patients following large MIs,
and in those with reduced LVEF and LV
dilation treated with placebo.
• ACE inhibitors also been demonstrated to
prevent recurrent MIs.
ACE Inhibitors
• The American College of Cardiology
Foundation/American Heart Association
(ACCF/AHA) 2009 Focused Update of the
2005 Guidelines for the Diagnosis and
Management of Heart Failure in Adults, as
well as the Heart Failure Society of
America (HFSA) 2010 comprehensive
heart failure practice guideline both
recommend the routine use of ACE
inhibitors in symptomatic and
asymptomatic patients with HF and LVEF
≤40%.
ACE Inhibitors
• Intolerance due to cough represents an indication to switch to an angiotensin-receptor blocker (ARB).
• Intolerance due to hyperkalemia, hypotension, or renal insufficiency, which does not respond adequately to dose reduction, is likely to be replicated by an ARB, and warrants consideration of switching to the combination of hydralazine and isosorbide dinitrate (ISDN).
• Development of angioedema warrants immediate discontinuation of the ACE inhibitor.
Beta Blockers
• Beta-adrenergic blocking agents, long
considered contraindicated in patients with
HF on the grounds that increased
adrenergic tone represented an
appropriate compensatory mechanism in
this condition, were originally purported to
have salutary effects based on
observational studies in patients with
dilated cardiomyopathy in the 1970s.
Beta Blockers
• The mechanistic basis for those
investigations lay in the assumption that,
despite supporting blood pressure and
cardiac output in patients with HF, chronic,
sustained cardiac adrenergic stimulation
accelerated the progression of myocardial
pathology, as well as being proischemic
and proarrhythmic.
Beta Blockers
• More than any other class of agents, beta-
blockers reduce and even reverse the
progression of LV remodeling, as gauged
by the longitudinal assessment of LV
volumes.
• Based on the COMET and MERTIT-HF
studies, the 2 most appropriate beta
blockers for heart failure are Coreg
(Carvedilol) and Toprol XL (Metoprolol
Succinate).
Angiotensin-Receptor Blockers
Angiotensin-Receptor Blockers
• Comprehensive heart failure practice guidelines recommend ARBs as first-line therapy for symptomatic and asymptomatic patients with HF and LVEF ≤40% who are intolerant for reasons other than hyperkalemia or renal insufficiency.
• ARBs are also considered reasonable alternatives to ACE inhibitors as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially in those patients already receiving ARBs for other indications.
Hydralazine-Isosorbide Dinitrate
• The combination of hydralazine and ISDN was first investigated in the V-HeFT trial, comparing this regimen with prazosin and with placebo.
• With the subsequent V-HeFT-2 (Valsartan Heart Failure Trial-2) study, which demonstrated superiority of enalapril over hydralazine/ISDN, the latter combination became incorporated into clinical recommendations as an alternative to ACE inhibitors when ACE inhibitors were considered contraindicated or were not tolerated.
Hydralazine-Isosorbide Dinitrate
• Post-hoc subset analyses of V-HeFT data
suggested preferential benefit for
hydralazine/ISDN among African-
American patients.
• Clinical adoption of the hydralazine/ISDN
combination has been much lower than
that of other HF treatments, perhaps in
part by the requirement for three times
daily dosing and, in part, by the adverse
effects.
Hydralazine-Isosorbide Dinitrate
• Comprehensive heart failure practice guidelines recommend hydralazine/ISDN to improve outcomes in African Americans with moderate to severe HF symptoms and reduced LVEF or LV dilation, on top of optimal ACE inhibitor/ARB, beta-blocker, and diuretic treatment.
• This combination is considered "reasonable" (though not firmly evidence-based) for non-African Americans with persistent symptoms despite standard treatment and for those intolerant of ACE inhibitors or ARBs.
Aldosterone-Receptor Blockers
• Circulating levels of aldosterone are
markedly increased in patients with HF.
• ACE inhibition and angiotensin-receptor
blockade diminish, but do not abolish,
aldosterone secretion, which tends to
"escape" over time following institution of
renin-angiotensin system inhibition.
Aldosterone-Receptor Blockers
• Comprehensive heart failure practice guidelines recommend aldosterone-receptor blockers for patients with HF (NYHA class IV or class III with prior class IV symptoms) and LVEF ≤35% and consideration of this therapy in patients post-MI with clinical HF and LVEF <40%.
• This therapy is not recommended for patients with serum creatinine >2.5 mg/dl (or estimated glomerular filtration rate of <30 ml/min) or serum potassium >5.0 mmol/L, or in those receiving other potassium-sparing diuretics.
Aldosterone-Receptor Blockers
• The principal side effect of aldosterone-
receptor blockers is hyperkalemia.
Gynecomastia is an additional side effect
with spironolactone, reported in
approximately 9% of men.
Digoxin
• Digoxin, an age-old remedy for HF, and a
long-time mainstay of its treatment
regimen, is now far from universally-
prescribed, yet remains an effective form
of therapy.
• Clinical trial evidence supports the efficacy
of digoxin, although this evidence falls
short of that available for ACE inhibitors,
ARBs, beta-blockers, and aldosterone-
receptor blockers.
Digoxin
• Comprehensive heart failure practice guidelines recommend consideration of the addition of digoxin to standard therapy for patients with LVEF ≤40% who have current or prior HF symptoms and who are receiving standard therapy, to improve symptoms and reduce HF hospitalizations.
• Dosing should be based on lean body mass, renal function, and concomitant medications. The majority of patients should be treated with 0.125 mg daily, targeting a level <1.0 ng/ml.
Digoxin
Diuretics
• Diuretics are a mainstay of treatment for
patients with HF and evidence of volume
overload.
• Although thiazide diuretics alone may be
considered in patients with minimal fluid
excess, the vast majority of patients are
better-treated with loop diuretics, such as
furosemide, bumetanide, or torsemide.
Diuretics
• Treatment approaches to refractoriness to
loop diuretics include increased dose,
dividing into multiple daily doses, switching
from furosemide to torsemide, and adding
a thiazide diuretic, such as chorthiazides
or metolazone (recognizing the greater
potential for electrolyte perturbation with
daily metolazone use).
Key Points
• In general, all patients with HF and
reduced LVEF should have ACE inhibitors
and beta-blockers instituted and titrated to
the target doses used in clinical trials.
• ARBs should be prescribed in the event of
ACE inhibitor intolerance due to cough or
angioedema. ARBs do not provide any
particular benefit over ACE inhibitors if
cardiorenal limitations (e.g., hypotension,
renal insufficiency, hyperkalemia) are the
reason for ACE inhibitor intolerance.
Key Points
• Digoxin may have symptomatic benefits in
patients with HF, but effective serum levels
rarely require doses >0.125 mg daily.
• Diuretics should be used in the lowest
doses tolerated to maintain a stable
compensated volume status.
• Aldosterone antagonists should be
considered in patients with symptomatic
HF, as long as serum creatinine is <2.5
mg/dl and potassium levels are <5.0
mEq/dl.
Key Points
• Hydralazine and ISDN in combination
should be considered, particularly in
African-American populations, if advanced
symptoms (e.g., HF of NYHA class III-IV)
persist.
• To avoid complications of polypharmacy,
close, frequent surveillance of symptoms,
clinical status, and laboratories is required.
LV RemodelingLV Remodeling
•• ACE InhibitorsACE Inhibitors
•• ARBsARBs
•• Beta BlockersBeta Blockers
SurvivalSurvival
•• ACE InhibitorsACE Inhibitors
•• Beta BlockersBeta Blockers
•• HydralazineHydralazine//IsordilIsordil
•• AldactoneAldactone (Class II(Class II--IV)IV)
SymptomsSymptoms
•• DiureticsDiuretics
•• DigoxinDigoxin
•• ACE InhibitorsACE Inhibitors
•• ARBsARBs
•• Beta BlockersBeta Blockers
Advanced Therapies
• Recent studies have demonstrated that more than 6 million people are living with HF and that >1 million hospitalizations occur for a primary diagnosis of HF each year in the United States.
• Most HF-related hospitalizations and deaths occur in a subgroup of patients who are refractory to guideline-based medical management, a group commonly categorized as having advanced HF.
• Studies have estimated that >200,000 Americans are living with end-stage HF, with a 1-year mortality rate of 70-90%.
Advanced Therapies
• Beyond evidence-based medications,
device therapy in the form of defibrillators
(e.g., implantable cardioverter-defibrillators
[ICDs]) and cardiac resynchronization
therapy have demonstrated clear mortality
benefits in patients with advanced HF.
• Referral of patients with refractory HF to a
HF program with the expertise in the
management of end-stage HF may also be
useful.
Heart Transplantation
• Within years of the first human heart
transplantation performed in South Africa
by Christiaan Barnard in 1967, enthusiasm
for the procedure waned, as few patients
survived even 1 year after surgery.
• Currently, with the 1-year survival rate
approaching 90%, the 5-year survival rate
of 70%, and the 10-year survival rate of
50%, heart transplantation is established
as a valuable option for acceptable
patients with advanced HF.
Heart Transplantation
• Determination of transplantation candidacy
requires that two basic questions be
answered: 1) Is the patient sick enough
that the prognosis would benefit
significantly from heart transplantation?
and 2) Is there some characteristic of this
particular patient that would make a poor
transplant outcome?
Causes of Death in Heart Transplantation
• The causes of death are dependent on the time
period after transplantation.
CAV=Cardiac Allograft Vasculopathy
Transplant Centers in Ohio
• Childrens Hospital Medical Center
Cincinnati – Transplant
• The Cleveland Clinic Foundation
• Nationwide Children’s Hospital
• The Ohio State University Medical Center
Mechanical Circulatory Support
• While heart transplantation has become
the accepted form of treatment for
selected patients with end-stage HF,
limited donor hearts dictate that
transplantation is a treatment for a minority
of these patients.
• MCS has attracted increased interest as
an option for patients waiting for transplant
(bridge to transplant [BTT]) and for
patients who are not transplant candidates
(destination therapy [DT]).
Mechanical Circulatory Support
• Incremental improvements in the design of
LVADs and management of patients with
MCS have made its wider use a reality.
• VADs can be divided into two main
categories: 1) pulsatile-flow pumps, and 2)
continuous-flow pumps.
LVADs
• Currently used pulsatile-flow LVADs
include the Thoratec HeartMate XVE and
Thoratec IVAD.
• Currently, the FDA has approved the use
of the Thoratec HeartMate II (axial-flow
pump) and the MicroMedDeBakey VAD
(axial-flow pump, approved by the FDA for
use in children).
Bridge to Transplantation
• Both of the following criteria must be fulfilled in order for Medicare coverage to be provided for a VAD used as a BTT: 1) The patient is approved and listed as a candidate for heart transplantation by a Medicare-approved heart transplant center, and 2) the implanting site, if different than the Medicare-approved transplant center, must receive written permission from the Medicare-approved heart transplant center under which the patient is listed prior to implantation of the VAD.
Destination Therapy
• The current criteria established by the
CMS for DT include: 1) NYHA functional
class IV symptoms in patients ineligible for
heart transplantation; 2) failure to respond
to optimal medical therapy for at least 45
of the last 60 days, or being balloon pump
dependent for 7 days, or intravenous-
inotrope dependent for 14 days; 3) LVEF
<25%; and 4) demonstrated function
limitation with a peak oxygen consumption
of 14 ml/kg/min.
LVADs
• Patients are at risk for development of von
Willebrand syndrome type 2, so assessment for
bleeding risk and bleeding history prior to surgery is
mandatory.
• Oral anticoagulation and antiplatelet therapy are
necessary for patients undergoing LVAD
placement, due to the potential for thrombus
formation in the device and subsequent risk for
thromboembolic complications. Data from the
second INTERMACS annual report demonstrate
that stroke (14.1%) and bleeding (6.7%) are
accountable for more than one-fifth of the deaths
that occur after MCS surgery.
Infection
• Infection accounts for 15% of the deaths in
patients on LVAD therapy, the
transcutaneous drive line increases the
likelihood that bacteria will enter the body,
and the position of the mechanical pump
hardware makes it difficult to successfully
treat a device infection. Patients with an
infection on LVAD support have
significantly prolonged hospital stays and
tend to have a higher risk of mortality.
Ventricular Reduction Surgery
• In the setting of ischemic heart disease, ventricular reconstruction in the form of endoventricular patch plasty repair, as described by Dor, has generated a great deal of recent interest.
• Initial series demonstrated that surgical ventricular reconstruction was associated with reduced ventricular volumes, increased EF, and improved ventricular function.
• A substudy of the STICH (Surgical Treatment for Ischemic Heart Failure) trial showed no benefits demonstrated with respect to symptoms, exercise tolerance, hospitalizations, or deaths.
Biventricular Pacing (Cardiac
Resynchronization Therapy)
• As Ventricular dilation and LV function worsens, conduction often worsens.
• Many patient develop conduction delay and Bundle Branch Blocks.
• Biventricular pacing improves LV contraction by ensuring a delayed yet synchronous contraction and thereby improving intraventricular synchrony.
• Improved synchrony results in more effective systolic function, and therefore, improvement in EF, stroke volume, and cardiac output.
The LV lead
• The implantation of an LV lead is most often performed transvenously into a branch vessel of the coronary sinus.
• In approximately 7% of cases, transvenous LV lead implantation is unsuccessful. This may be due to patient anatomy, inability to access the coronary sinus, inadequate target vessels, high capture threshold, or phrenic nerve stimulation. In these cases, the patient can consider epicardial lead placement via surgical approach.
CRT
• CRT improves mortality, hospitalizations,
and reverse remodeling in HF with systolic
dysfunction and wide QRS.
• Two thirds of appropriately selected
patients respond to CRT.
• Recently, evidence has supported the use
of CRT in mild HF as well as moderate to
severe HF.
Key points on Advanced Therapies
• Consideration of advanced HF therapies
should be entertained when either HF
symptoms become refractory to
conventional medical, surgical, and device
interventions or when end-organ
dysfunction becomes apparent.
• Heart transplantation is the treatment of
choice for end-stage HF, but remains
limited by donor organs and comorbidities
in potential candidates.
Key points on Advanced Therapies
• Survival following heart transplantation is >85% at 1 year, 70% at 5 years, and 50% at 10 years.
• Complications following transplantation include rejection, infection, renal insufficiency, malignancy, and cardiac allograft vasculopathy.
• The continuous flow LVAD is now an established therapeutic option as a permanent solution for advanced HF, as well as a "bridge" to transplantation, myocardial recovery, and/or further consideration of long-term options (e.g., "bridge to decision").
Key points on Advanced Therapies
• Myocardial recovery after VAD support
remains uncommon, but will likely evolve
over time as VAD support will be used as
a platform for direct myocardial therapies.
• Current evidence does not support
surgical ventricular remodeling or mitral
valve repair for most patients with severe
systolic HF.
Which of the Following have been considered
therapies for advanced heart failure refractory
to medical therapy?
A. B. C. D. E.
20% 20% 20%20%20%A. Heart Transplantation
B. Ventricular Assist
Device Placement
C. Biventricular Pacing
D. Ventricular Reduction
Surgery
E. All of the Above
Countdown
10
Which of the Following have been considered therapies
for advanced heart failure refractory to me...
20%
20%
20%
20%
20%
20%
20%
20%
20%
20%
Heart Transplantation
Ventricular Assist Device
Placement
Biventricular Pacing
Ventricular Reduction
Surgery
All of the Above
First Slide Second Slide
Questions?
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