Advanced hfref pearls

A M E R I C A N C O L L E G E O F C A R D I O L O G Y 2 0 1 5

Advanced HFrEF

Pearls

M A R C H 1 5 , 2 0 1 5

Sanjiv J. Shah, MD, FACC, FAHA Associate Professor of Medicine

Division of Cardiology, Department of Medicine

N O R T H W E S T E R N U N I V E R S I T Y F E I N B E R G S C H O O L O F M E D I C I N E

Case #1: 62-year-old woman with NICM,

LVEF 25%, diabetes, CKD, s/p

ICD presents with ADHF: Cr 1.8,

NTproBNP 8232, Na+ 136:

undergoes IV diuresis with

furosemide 80 mg PO TID

After 5 days of IV diuresis: net -8L, BP 114/62, and

Cr increased from 1.8 on admission to 2.4 mg/dl.

What would you do next?

A. Stop IV diuresis and re-check labs the

next day

B. Stop IV diuresis and give 250 cc NS bolus

and re-check labs the next day

C. Continue IV diuresis and check albumin,

total protein, and hematocrit

D. Inform the patient that she has a poor

prognosis

After 5 days of IV diuresis: net -8L, BP 114/62, and

Cr increased from 1.8 on admission to 2.4 mg/dl.

What would you do next?

A. Stop IV diuresis and re-check labs the

next day

B. Stop IV diuresis and give 250 cc NS bolus

and re-check labs the next day

C. Continue IV diuresis and check albumin,

total protein, and hematocrit

D. Inform the patient that she has a poor

prognosis

Hemoconcentration in HF

Testani et al.

Circulation 2010

Hemoconcentration in HF

Testani et al.

Circulation 2010

P<0.0001

No hemoconcentration

Hemoconcentration

Right heart catheterization is performed

How would you interpret the PCWP tracing?

A. There is evidence of significant mitral

regurgitation

B. PCWP is no longer elevated

C. The patient is still markedly fluid

overloaded

D. The PA catheter is over-wedged

Right heart catheterization is performed



regurgitation



overloaded




regurgitation



overloaded


Respiratory variation in PCWP

End-expiratory

PCWP = 27 mmHg

62-year-old woman with HFrEF

• The patient is diuresed an additional 5L and then discharged

• 3 months later: worsening breathlessness, no overt fluid overload

• NYHA class III

Cardiopulmonary exercise testing

• Peak respiratory exchange ratio: 1.10

• Peak VO2: 15.8 ml/kg/min

• HR increased from 64 138 bpm

• BP increased from 112/62 138/64 mmHg

How would you interpret this patient’s

cardiopulmonary exercise test?

A. The patient has a poor prognosis

B. The patient did not achieve an adequate

effort for the test

C. There is evidence of pulmonary vascular

disease

D. There is evidence of chronotropic

incompetence

Cardiopulmonary exercise testing

• Peak respiratory exchange ratio: 1.10

• Peak VO2: 15.8 ml/kg/min

• HR increased from 64 138 bpm

• BP increased from 112/62 138/64 mmHg

How would you interpret this patient’s

cardiopulmonary exercise test?

A. The patient has a poor prognosis

B. The patient did not achieve an adequate

effort for the test

C. There is evidence of pulmonary vascular

disease

D. There is evidence of chronotropic

incompetence

Exercise oscillatory breathing in HFrEF

Guazzi et al.

Am Heart J 2007

Exercise oscillatory breathing in HFrEF

Guazzi et al.

Am Heart J 2007

Normal VE/VCO2 Elevated VE/VCO2

No EOB

+EOB

No EOB

+EOB

Calculation of chronotropic incompetence in HF

• %Heart rate reserve = (HRpeak-HRrest)

(220-age-HRrest)

• CI is present if:

» %HRR < 80% (not on beta-blocker)

» %HRR < 62% (on beta-blocker)

• %HRR in this case = (138-64)/(220-age-64)

= 79% (on beta-blocker) = No CI

62-year-old woman, s/p OHT

• 2 months post-op

• Meds: » Tacrolimus

» Prednisone

» Diltiazem

» Pravastatin

• Pt doing well

• Biopsy = 0R



• Presented to ER with fatigue, SOB, abdominal distension




What is the most likely diagnosis?

A. Need more information: check IVRT

B. Need more information: check speckle-

tracking echocardiography

C. Tacrolimus toxicity

D. Coronary allograft vasculopathy

E. Acute cellular rejection

What is the most likely diagnosis?

A. Need more information: check IVRT

B. Need more information: check speckle-

tracking echocardiography

C. Tacrolimus toxicity

D. Coronary allograft vasculopathy

E. Acute cellular rejection




• Right heart cath: » CVP 25 mmHg

» PCWP 30 mmHg

» CO 2 L/min


• Endomyocardial biopsy performed

• Urgently taken to OR for V-A ECMO

• Treated with thymo, plasmapheresis, rituxan, IVIG

• ECMO removed 4 days later


• Endomyocardial biopsy performed

• Urgently taken to OR for V-A ECMO

• Treated with thymo, plasmapheresis, rituxan, IVIG

• ECMO removed 4 days later

Grade 3R rejection


• Doing well 1 month later, taking all medications

Echo 1 month later

BASELINE REJECTION RECOVERY

Grade 3R cellular rejection

BASELINE

s’ = 7.5 cm/s

e’ = 8 cm/s

REJECTION

s’ = 4.2 cm/s

e’ = 5.5 cm/s

RECOVERY

s’ = 7.2 cm/s

e’ = 9 cm/s

Grade 3R cellular rejection

Acute cellular rejection (ACR)

• Major cause of 1-year mortality, highest

risk in first 6 months

• Effector T cells mediate inflammatory

response myocardial edema/damage

• Routine surveillance currently performed

with cardiac bx works well but invasive

• Problems with cardiac bx:

» Sampling error, interobserver variability,

wide variability in frequency and duration

Acute cellular rejection (ACR)

• Grade 2R or higher rejection considered

clinically significant:

» Rx with high-dose corticosteroids

» Add lymphocyte-depleting agents if

hemodynamic compromise is present

Echo for diagnosis of ACR

• Increased LV wall thickness and LV mass:

» Indicative of myocardial edema

• Pericardial effusion:

» 49% sensitivity, 74% specificity

• Diastolic function:

» Influenced by donor age, heart rate

(increased due to cardiac denervation),

loading conditions, dissociation of atria

Echo for diagnosis of ACR

• Mena et al. (JASE 2006) performed a

systematic review of the published

literature between 1967-2005:

» E, A velocities: did not predict ACR

» PHT: sensitivity 23-87%, specificity 76-98%

» IVRT: sensitivity 28-85%, specificity 80-98%

» Conclusions: inconsistent quality, low

sensitivity

• Newer modalities (e.g., speckle-

tracking): conflicting results

Acute cellular rejection: imaging algorithm

Estep JD et al. JACC Imaging 2009

62-year-old woman, s/p OHT now 3 years post-transplant with dyspnea, syncope

• Prior work-up for dyspnea:

» RHC: normal hemodynamics

» RV biopsy: Grade 0R

» V/Q scan: low probability for PE

» CT chest: no abnormalities

» Event monitor: sinus brady with occasional

junctional escape during episodes of

dyspnea, lightheadedness

• On night of admission, had 30-second

syncopal episode

Electrocardiogram

Chest Radiography

• Right heart catheterization:

» RA 0-1, RV 20/0, PA 20/3 (11), PCWP 5

» Ao 110/67 (85); CO 4.2 (TD), 4.54 (Fick)

» Sats: Ao 98%, PA 68%

62 y.o. woman s/p OHT with syncope

Coronary Angiography



Left Heart Catheterization

• Just after the contrast injection into the

left main coronary artery…

» Patient became progressively bradycardic

» ST elevations seen on monitor

Left Heart Catheterization

What is the most likely coronary

pathophysiology?

A. Plaque rupture

B. Allograft vasculopathy

C. Coronary vasospasm

D. Cellular rejection

What is the most likely coronary

pathophysiology?

A. Plaque rupture

B. Allograft vasculopathy

C. Coronary vasospasm

D. Cellular rejection

A diagnostic procedure was performed…


PRE POST


PRE POST

Event Monitor

presyncope, dizzy, sweaty (just prior to syncope)

Event Monitor

“felt like passing out” “chest tightness”

Coronary vasospasm s/p OHT

• Rare: occurs in <5%

• Usually begins 1-3 years post-transplant

• “Triple-vessel” spasm very rare

• Spasm carries a poor prognosis

• Possibly associated with accelerated

arteriosclerosis and diffuse lymphocytic

coronary endothelialitis

Cardiac allograft vasculopathy (CAV)

• Prevalence ~54% in survivors at 10 years

after OHT:

» Diffuse intimal hyperplasia, likely results

from cumulative endothelial injury

• Early diagnosis of CAV is challenging:

» Typical symptoms of ischemia lacking

» Coronary angiography can underestimate

» Early recognition important:

—Rapid CAV progression can occur bad outcomes

• Associated with traditional cardiac RFs

• Other risk factors:

» Acute rejection, anti-HLA antibodies

» Cytomegalovirus (CMV)

» Nephrotoxicity post-transplant

» New-onset diabetes post-transplant

• Typically affects distal coronary arteries


• Diagnosis:

» Coronary angiography, IVUS,

dobutamine stress echocardiography

• Prevention/Treatment:

» Everolimus, sirolimus

» Lipid-lowering

» Percutaneous coronary intervention

» Re-transplantation


Case #2: 74-year-old man with history of CAD s/p CABG, HFrEF,

progressively worsening dyspnea, and exertional dizziness

74-year-old man with HFrEF

• ACE-I and beta-blocker stopped

• Diuresed 5L, feels much better

• Attending switches on day of discharge

» “Start guideline-directed medical therapy”

» Low-dose ACE-I and beta-blocker started

» Pt has syncope while walking in room, develops

subdural hematoma…

Case #2: 74-year-old man with history of CAD s/p CABG, HFrEF,

progressively worsening dyspnea, and exertional dizziness

74-year-old man with HFrEF

• Constrictive pericarditis diagnosed

• Underwent pericardial stripping

• Still with mild HFrEF but now NYHA class II

and no further syncopal events

1. If creatinine goes up during IV diuresis,

differentiate hemoconcentration from

worsening renal function

2. Remember to measure hemodynamics

(especially PCWP) at end-expiration

3. Exercise oscillatory breathing: poor

prognostic sign in HF

Advanced HFrEF pearls

5. Echo: cannot yet replace routine biopsy

surveillance for transplant rejection

6. Coronary vasospasm in the setting of

cardiac transplantation: consider

coronary allograft vasculopathy

7. When treating HFrEF: get with the

guidelines, but don’t stop using your

noggin’!

Advanced HFrEF pearls

thank you!

Health & Medicine

Advanced hfref pearls