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ADVANCED HEART FAILURERECOGNIZING OPTIONS

John M. Herre, MD, FACC, FACP

Director, Advanced Heart Failure ProgramSentara Helathcare

Professor of Medicine Eastern Virginia Medical School

PATIENT 1

• Onset heart failure at age 70• Normal coronary arteries• Optimal oral medical management• Resynchronization ICD• Recurrent hospitalizations for heart failure and

VT• EF < 10 %• LVEDD 7.5 cm

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PATIENT 1• Age 72• Improvement with milrinone

– Creatinine 0.9– Albumin 3.7– INR 1.2– RA 12 (2-5)– PCW 22 (5-12)– RVSWI 832 (>600)

• Recurrence of symptoms off milrinone

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WHAT DO YOU RECOMMEND

1. Hospice2. Bridge to hospice with milrinone3. Long term home milrinone4. Heart transplant5. Mechanical circulatory support

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OUTCOMES OF CONTINUOUS HOME MILRINONE THERAPY

Group 1 yr surv Baseline NYHA 6 m NYHA(if alive)

Bridge to TX/VAD 83.3% 3.89 2

Weaning strategy 73.4 3.92 2

Palliative care 11.1 3.76 3

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Muthsusamy, JHLT 2012, 31:S14

Figure 12

Source: The Journal of Heart and Lung Transplantation 2012; 31:1052-1064 (DOI:10.1016/j.healun.2012.08.002 )

TRANSPLANT SURVIVAL BY AGE

~240 MillionUS Population ≥ 20 years old

6.24 MillionHF = 2.6% of the population

3.12 Million Systolic HF = 50% of HF population

124,800 Adv. Stage C / NYHA IIIB

Advanced Stage C = 3-4%

156,000 Stage D / NYHA IV = 0.5-5%

70,200 Potential candidates for transplant

THE PROBLEM

2000 heart transplants per year2000 heart transplants per year

Courtesy John O’Connell, MD

DURABLE MECHANICAL CIRCULATORY SUPPORT

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ASSESSING THE BENEFIT

HEARTMATE II RISK SCORE

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0.0274 x age – 0.723 x albumin + 0.74 x creatinine + 1.136 x INR for centers with > 15 implants per year

1.978 – 2.6751 + 0.66 + 1.3632 = 1.349

Cowger, JACC, 2013

HEARTMATE II RISK SCORE

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Cowger, JACC, 2013

PATIENT 1

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PATIENT 2• 72 years old male• Diabetic• CAD• Prior CABG and mitral valve repair• Recurrent hospitalizations for heart failure• 30 lb weight loss• Creatinine 2.9• Albumin 3.0• INR 1.5

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WHAT DO YOU RECOMMEND

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1. Hospice

2. Bridge to hospice with milrinone

3. Long term home milrinone

4. Heart transplant

5. Mechanical circulatory support

SURVIVAL IN HEART FAILURE

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0

0.5

1

1.5

2

2.5

3

No CKD With CKD Age 75-85 Age > 85

1 hosp

2 hosp

3 hosp

4 hosp

3

2.5

2

1.5

1

0.5

0

No CKD CKD Age 75-85 Age > 85

1

2

3

4

HospitalizationsMedian

Survival

(years)

Setoguchi, Am Heart J 2007

PATIENT 2HEARTMATE II RISK SCORE

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0.0274 x age – 0.723 x albumin + 0.74 x creatinine + 1.136 x INR for centers with > 15 implants per year

1.9728 – 2.169 + 2.146 + 1.704 = 3.6538

HEARTMATE II RISK SCORE

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Cowger, JACC 2013

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Profile Description Time to MCS

1 “Crashing and burning” - critical cardiogenic shock. Within hours

2“Progressive decline” – inotrope dependence with continuing

deterioration.Within a few days

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“Stable but inotrope dependent” - describes clinical stability on mild-

moderate doses of intravenous inotropes. (Patients stable on temporary

circulatory support without inotropes are within this profile).

Within a few weeks

4“Recurrent advanced heart failure” - “recurrent” rather than

“refractory” decompensation.

Within weeks

to months

5“Exertion intolerant” - describes patients who are comfortable at rest

but are exercise intolerant.Variable

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“Exertion limited” – a patient who is able to do some mild activity but

fatigue results within a few minutes or any meaningful physical

exertion.

Variable

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“Advanced ” - describes patients who are clinically stable with a

reasonable level of comfortable activity, despite history of previous

decompensation that is not recent.

Not a candidate

for MCS

SURVIVAL TO DISCHARGE

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70.4

93.5 95.8

0

20

40

60

80

100

% s

urv

ival

Group 1(n=27)

Group 2(n=48)

Group 3 (n=24)

Boyle JHLT 2011

LENGTH OF STAY

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4441

17

0

10

20

30

40

50

60D

ay

s

Group 1(n=27)

Group 2(n=48)

Group 3(n=24)

Boyle JHLT 2011

RISK FACTORS FOR EARLY DEATHRisk Factor Hazard Ratio P-value

Prior stroke 1.74 0.005

Prior CABG 1.84 <0.0001

INTERMACS 1 2.87 0.0001

INTERMACS 2 1.84 0.01

BiVAD 3.27 <0.0001

Prior valve surgery 1.81 0.0007

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Kirklin, JHLT 2012, 31:117

OTHER CONSIDERATIONS• Support system• Understand the risks• Understand the lifestyle• Desire to proceed• Ability to interpret and act on alarms• Understand options including palliative care

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PATIENT 3• 30 years old • ODU graduate• Program Development Director for

Muscular Dystrophy Association• Bought a condo • Acquired a small dog

• Progressive cough and dyspnea for 6 weeks

• Couldn’t carry dog up the steps• Diagnosis – bronchitis, reflux• 2 courses of outpatient antibiotics • Sent to ER by PCP for pneumonia

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1. Bilateral lower lobe air space opacities with effusions, right greater than left. Findings may be related to multifocal pneumonia or aspiration. Recommend radiographic follow-up to clearance.2. Mildly enlarged cardiac silhouette

HOSPITALIST ASSESSMENT

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Assessment:

Patient Active Hospital Problem List:

*Community Acquired Pneumonia (4/13/2010)

GERD (Gastroesophageal Reflux Disease) (4/13/2010)

Fatigue (4/13/2010)

Anxiety (4/13/2010)

Plan:

Treat for CAP. Prn nebulizer treatments.

Prn xanax for anxiety.

Continue home celexa.

Recommend repeat imaging during her hospital course.

HOSPITAL COURSE• Respiratory arrest at 11 AM on 4/14• Cardiac arrest at 12 noon• Ejection fraction – 5-10% by echo• Persistent shock despite norepinephrine, dobutamine

• Creatinine 1.1• INR 1.58• Albumin 3.1• SGOT 1158• Lactate13.6

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WHAT DO YOU DO

1. Continue medical management2. Intraaortic balloon pump3. Temporary mechanical circulatory support4. Durable mechanical circulatory support5. Palliative care

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SHOCK II

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HOSPITAL COURSE

• Referred to Advanced Heart Failure Team at 2:30 PM• Briefly staibilized with intraaortic balloon pump• Progressive deterioration over next 30 min• To OR at 6:30PM for Acute Mechanical Circulatory

Support• Regained consciousness• End organ function recovered• Heart transplant 5/3/2010

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Saturday, May 22, 201019 days post transplant

PATIENT 4• 28 years old male • Air Force veteran• 4-6 month history progressive deterioration• 3 week history of nausea, abdominal pain,

vomiting• Admitted to local hospital on 6/26/2012• INR 6.1• Creatinine 2.7• Albumin 1.9

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PATIENT 4• Diagnosis: acute liver failure, acute renal

failure• Vitamin K, FFP• Considered urgent referral for liver

transplant• Cardiopulmonary arrest 6/27• EF 5-10%• Medical management• Transferred to SNGH 6/28/2012 for acute

mechanical circulatory support

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MANAGEMENT OPTIONS

1. Continue medical management2. Intraaortic balloon pump3. Temporary mechanical circulatory support4. Durable mechanical circulatory support5. Palliative care

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PATIENT 4• CentriMag temporary support

device• Restoration of circulation• Changout to durable device• Fungal device infection• Recovery of cardiac function• Device explant• Death from multiorgan failure

and heart failure• Family asks if earlier transfer

would have changed outcome

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WHAT’S THE DIFFERENCE• Same heart• Same age

• Case 4– Late presentation– Later referral– Irreversible end-organ damage

• Where do you draw the line?

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SUMMARY• Durable mechanical circulatory

– Referral before progressive renal or liver dysfunction– Referral before pressors are required– Referral before cardiac cachexia develops

• Acute, temporary mechanical circulatory support – Early recognition before irreversible end-organ damage– Early referral– Early initiation of mechanical support– Families of young, healthy patients who die are

litiginous

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WHO HAS THE VAD?

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