Transcript Heart Failure - Vanderbilt University Medical Center

• These patients live in your community.
Hospitalization
$20.9
Total Cost
$39.2 billion
53.3%
11.9%
6.4%
10.5%
Lost Productivity/
Mortality*
$4.1
Nursing Home
$4.7
9.7%
Home Healthcare
$3.8
Physicians/Other
Professionals
$2.5
Drugs/Other
Medical Durables
$3.2
8.2%
Heart Disease and Stroke Statistics—
2010 Update: A Report From the AHA
Circulation, Feb 2010; 121: e46 - e215
• Ischemic cardiomyopathy
• Non-ischemic cardiomyopathy
New York Heart Association Functional Classification of Heart Failure
Increasing Severity
Class I
Class II
Class IIIa and IIIb
Class IV
• Cardiac disease
• No symptoms
• No limitation in
ordinary physical
activity
• Mild symptoms
(mild shortness of
breath and/or
angina)
• Slight limitation
during ordinary
activity
• Marked
limitation in
activity due to
symptoms
• Comfortable only
at rest
• Severe
limitations
• Symptoms even
while at rest
• Mostly bedbound
patients
Katz AM
Heart Failure
(Strength of Evidence = A)
• ACE inhibitors
• Beta Blockers
• ARBs
• Aldosterone Antagonists
• Hydralazine and Isosorbide
Dinitrate
• Warfarin
• In patients with atrial fibrillation,
pulmonary embolism, or TIA
• Loop Diuretics
Lindenfeld, J, et al.
J Card Failure
2010; 6, 486-491
Strength of Evidence = B
Strength of Evidence = C
• Antiplatelet agents (Aspirin)
• Digoxin
• Ischemic etiology of HF
• Digoxin
• In stage IV HF
• Metalazone
• In stage II and III HF
• Thiazide diuretics
• Warfarin
• MI patients with LV thrombus
Lindenfeld, J, et al.
J Card Failure
2010; 6, 486-491
Inotropes
• Commonly used on an outpatient basis for stage IIIb – IV heart failure
• Milrinone and Dobutamine are the only FDA approved drugs for
outpatient use
• Not recommended for acute heart failure exacerbations in ischemic
patients
• Probable benefit in non-ischemic exacerbations
• OPTIME-CHF JAMA
2002; 287:1541-7
Cardiac Resynchronization Therapy (CRT)
• LVEF <35%
• NYHA class III – IV
• QRS > 120 ms
• Optimal medical therapy
Implantable Cardiac Defibrillators
• Ischemic Etiology
• (Strength of Evidence = A)
• Non-ischemic Etiology
• (Strength of Evidence = B)
• Primary prevention of ventricular
arrhythmias
• LVEF <35%
Lindenfeld, J, et al.
J Card Failure
2010; 6, 486-491
Decreased end organ perfusion
• Renal function
• Liver function
• Pulmonary function
We need more support!
A mechanical circulatory device used to partially or completely
replace the function of either the left ventricle (LVAD); the right
ventricle (RVAD); or both ventricles (BiVAD)
Long-Term LVAD
Short-Term LVAD
ANY
• Are there any contraindications to VAD support?
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End-stage lung, liver, or renal disease
Metastatic disease
Medical non-adherence or active drug addiction
Active infectious disease
Inability to tolerate systemic anticoagulation (recent CVA, GI bleed, etc.,)
Moderate to severe RV dysfunction for some LVADs
• What are our other issues in this particular patient?
• What are the patient’s goals? What are our goals?
• What happens if we don’t meet our goals?
INTERMACS SCORE
Interagency Registry for Mechanically Assisted Circulatory Support
Long-Term LVAD
Ideal candidates are
INTERMACS classes 3-4
Short-Term LVAD
Candidates are
INTERMACS classes 1-2
Not a LVAD Candidate
INTERMACS 1 or those with
multisystem organ failure
Lietz and Miller
Curr Opin Cardiol
2009, 24:246–251
Long-term placement
Bridge to Transplantation (BTT)
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Patient is approved and currently
listed for transplant
NYHA IV
Failed maximized medical therapy
Destination Therapy (DT)
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http://www.cms.gov/medicarecoverage-database
Not a heart transplant candidate
NYHA IV
LVEF <25%
Maximized medical therapy >45
of 60 days; IABP for 7 days; OR
14 days
Functional limitation with a peak
oxygen consumption of less than
or equal to 14 ml/kg/min
Life expectancy < 2 years
Bridge to Transplantation (BTT)
Destination Therapy (DT)
HeartMate II (Thoratec)
Pump Speed (RPM) – How quickly
the pump rotates
Pump Power (Watts) – Measure of
motor voltage and current
Pump Flow (L/min) - Estimated
value of the volume running
through the pump
Pulsitility Index – The measure of
the left ventricular pressure during
systole
VS
Outflow graft (kink , leak)
Inflow cannula (poor position,
obstruction)
Drive line infection / fracture
Pump/rotor dysfunction
(thrombus)
Controller malfunction
Battery dysfunction
Winston Churchill
Rose, EA; et al
NEJM 2001;
345:1435-1443
Kirkland, JK, et. al
JHLT 2013; 32:141-156
Kirkland, JK, et. al
JHLT 2013; 32:141-156
• Shock Team Evaluation for
mechanical circulatory
support (MCS)
• Try to avoid the bridge to
decision or the bridge to
nowhere
• Utilized for LV support only; not appropriate to
use with RV failure
• Impella 2.5 can be inserted through the femoral
artery during a standard catheterization
procedure; provides up to 2.5 L of flow
• Impella 5.0 inserted via femoral or axillary
artery cut down; provides up to 5L of flow
• The catheter is advanced through the
ascending aorta into the left ventricle
• Pulls blood from an inlet near the tip of the
catheter and expels blood into the ascending
aorta
• FDA approved for support of up to 6 hours
• Used for LV support; not
appropriate in RV failure
• Cannulas are inserted
percutaneously through the
femoral vein and advanced across
the intraatrial septum into the left
atrium
• The pump withdraws oxygenated
blood from the left atrium and
returns it to the femoral arteries
via arterial cannulas
• Provides up to 5L/min of flow
• Can be used for up to 14 days
• Can be used for LV and/or
RV support
• Cannula are typically
inserted via a midline
sternotomy
• Capable of delivering flows
up to 9.9 L/min
• Can be used for up to 30
days
• Used for patients with a
combination of acute cardiac
and respiratory failure
• A cannula takes deoxygenated
blood from a central vein or the
right atrium, pumps it past the
oxygenator, and then returns
the oxygenated blood, under
pressure, to the arterial side of
the circulation
• Can be used for days to weeks