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Congestive Heart Failure: Update 2002

Congestive Heart Failure: Update 2002. Bruce D. Hettleman, MD DHMC December 2, 2002. CASE PRESENTATION. 71 yo retired submarine captain is admitted with pulmonary edema and an elevated troponin. His PMH is notable for advanced CAD and previous MI. He had CABGX3 in 1990.

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Congestive Heart Failure: Update 2002

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  1. Congestive Heart Failure: Update 2002 Bruce D. Hettleman, MD DHMC December 2, 2002

  2. CASE PRESENTATION • 71 yo retired submarine captain is admitted with pulmonary edema and an elevated troponin. His PMH is notable for advanced CAD and previous MI. He had CABGX3 in 1990. • Echo demonstrated a severely dilated LV with an EF of 20% and 3+/4 mitral regurgitation. • EKG showed sinus rhythm at 52 with first degree AV block and LBBB. • Cardiac Cath revealed a patent IMA to the LAD, patent SVG to the RCA and a severely diseased SVG to the circumflex.

  3. What should be done once the patient is initially stabilized? • 1. Perform urgent repeat bypass surgery and mitral valve replacement. • 2.Perform percutaneous intervention (stent) on the SVG to the circumflex. • 3. Put in a dual chamber pacemaker • 4.Maximize medical therapy because he is too high a risk for revascularization.

  4. Case Presentation--Continued • After stenting the SVG to the circumflex his pulmonary edema subsequently responded to medical therapy and he was able to ambulate but remained Class III CHF. • Discharge medications consisted of a diuretic,digoxin, beta blocker, ace inhibitor, aspirin, plavix and spironolactone. • He was given dietary and weight-based diuretic adjustment guidelines. • Follow-up in CHF Clinic was scheduled for 1 month.

  5. What is the most likely adverse event after adding aldactone in the treatment of CHF? • 1. Hypotension • 2. Breast enlargement • 3. Yellow vision • 4. Hyperkalemia • 5. Worsening CHF

  6. After starting aldactone in Class IV CHF, when should electrolytes be rechecked? • 1. No worries, mate • 2. One week ( big worries, mate) • 3. Four weeks • 4. Three months

  7. Potassium Level

  8. Drugs that have shown to prolong life in CHF are: • 1. ACE inhibitors • 2. Beta Blockers • 3. Digoxin • 4. Aldactone • 5. 1,2 and 4

  9. DIG Trial: Effect of Digoxin on Survival in CHF • NHLBI sponsored study of 7,788 patients with class II and III CHF and LVEFs < 45% or > 45% • Randomized, controlled, double-blinded • 93% of patients on ACEIs • Superimposable survival curves • 25% reduction with Dig on first CHF hospitalization

  10. Weight of Evidence: ACE Inhibitors Approximately 7000 patients evaluated in long-term placebo-controlled clinical trials Improvement in cardiac function, symptoms, and clinical status; equivocal effects on exercise tolerance Decrease in all-cause mortality by 20%-25% (P<.001) and decrease in combined risk of death and hospitalization by 30%-35% (P<.001) - Effect shown in SOLVD Treatment, CONSENSUS, and V-HeFT II trials Garg and Yusuf, 1995.

  11. Weight of Evidence: -Blockade Traditionally contraindicated in heart failure, due to impaired inotropy, early lack of tolerability, and worsening heart failure Over 10,000 patients have now been evaluated in long-term placebo-controlled clinical trials; Improvement in cardiac function and NYHA class; and decrease in mortality and morbidity shown in multiple clinical trials Effects shown in patients already receiving ACE inhibitors

  12. Improved survival with aldactone in advanced CHF--Rales Trial

  13. Will a permanent pacemaker help this man? • 1. No, he has no indication for a pacemaker and if you put one in medicare will send you the bill. • 2. Yes, he should have a VVI back up pacemaker prior to discharge because he has LBBB and may unpredictably develop complete heart block and die. • 3. Yes, the placement of a routine DDD pacemaker will reliably improve his hemodynamics • 4.Yes, he ought to have a brand-spankin new biventricular resynchronization device because he has LBBB.

  14. Cardiac Resynchronization Therapy for Heart FailureMechanisms, Clinical Outcomes,Patient Selection, and Implant

  15. Ventricular Dysynchrony and Cardiac Resynchronization • Ventricular Dysynchrony1 • Electrical: Inter- or Intraventricular conduction delays typically manifested as left bundle branch block • Structural: disruption of myocardial collagen matrix impairing electrical conduction and mechanical efficiency • Mechanical: Regional wall motion abnormalities with increased workload and stress—compromising ventricular mechanics • Cardiac Resynchronization • Therapeutic intent of atrial synchronized biventricular pacing • Modification of interventricular, intraventricular, and atrial-ventricular activation sequences in patients with ventricular dysynchrony • Complement to optimal medical therapy 1 Tavazzi L. Eur Heart J 2000;21:1211-1214

  16. Animation – Ventricular Dysynchrony Click to Start/Stop

  17. Cardiac Resynchronization Click to Start/Stop

  18. Clinical Consequences of Ventricular Dysynchrony • Abnormal interventricular septal wall motion1 • Reduced dP/dt3,4 • Reduced pulse pressure4 • Reduced EF and CO4 • Reduced diastolic filling time1,2,4 • Prolonged MR duration1,2,4 1 Grines CL, Bashore TM, Boudoulas H, et al. Circulation 1989;79:845-853. 2 Xiao, HB, Lee CH, Gibson DG. Br Heart J 1991;66:443-447. 3 Xiao HB, Brecker SJD, Gibson DG. Br Heart J 1992;68:403-407. 4 Yu C-M, Chau E, Sanderson JE, et al. Circulation. 2002;105:438-445.

  19. Proposed Mechanisms: Improved Intraventricular Synchrony Improved Intraventricular Synchrony1,2  dP/dt 1,3,4 EF1,5  Pulse Pressure 3,4  SV&CO1, 2  MR1  LVESV1  LA Pressure1 1Yu C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445 2 Søgaard P, Kim W, Jensen H, et al. Cardiology 2001;95:173-182 3 Kass D Chen-Huan C, Curry C, et al. Circulation 1999;99:1567-73 4 Auricchio A, Ding J, Spinelli J, et al. J Am Coll Cardiol 2002;39:1163-1169 5 Stellbrink C, Breithardt O, Franke A, et al. J Am Coll Cardiol 2001;38:1957- 65

  20. Prevalence of Inter- or Intraventricular Conduction Delay Moderate to Severe HF Population3,4,5 General HF Population1,2 IVCD >30% IVCD 15% 1 Havranek E, Masoudi F, Westfall K, et al. Am Heart J 2002;143:412-417 2 Shenkman H, McKinnon J, Khandelwal A, et al. Circulation 2000;102(18 Suppl II): abstract 2293 3 Schoeller R, Andresen D, Buttner P, et al. Am J Cardiol. 1993;71:720-726 4 Aaronson K, Schwartz J, Chen T, et al. Circulation 1997;95:2660-2667 5 Farwell D, Patel N, Hall A, et al. Eur Heart J 2000;21:1246-1250

  21. Increased Mortality Rate with LBBB • Increased 1-year mortality with presence of complete LBBB (QRS > 140 ms) • Risk remains significant even after adjusting for age, underlying cardiac disease, indicators of HF severity, and HF medications All patients N=5517 20 LBBB N=1391 HR* 1.70 (1.41-2.05) 16.1 15 11.9 HR * 1.58 (1.21-2.06) 1-Year Mortality (%) 10 7.3 5 5.5 * HR = Hazard Ratio 0 All Cause Sudden Cardiac Cause of Death Baldasseroni S, Opasich C, Gorini M, et al. Am Heart J 2002;143:398-405

  22. Proposed Mechanisms of Cardiac Resynchronization Cardiac Resynchronization Improved Intraventricular Synchrony Improved Atrioventricular Synchrony Improved Interventricular Synchrony Yu C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445

  23. Summary of Proposed Mechanisms Cardiac Resynchronization Intraventricular Synchrony Atrioventricular Synchrony Interventricular Synchrony  RV Stroke Volume  dP/dt,  EF,  CO ( Pulse Pressure)  LA Pressure  LV Diastolic Filling  MR  LVESV  LVEDV Reverse Remodeling Yu C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445

  24. Achieving Cardiac ResynchronizationMechanical Goal: Atrial-synchronized bi-ventricular pacing • Transvenous Approach • Standard pacing lead in RA • Standard pacing or defibrillation lead in RV • Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus Right AtrialLead Left VentricularLead Right VentricularLead

  25. CRT Improves Quality of Life Score and NYHA Functional Class 1Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026- 2033 2 Gras D, Leclercq C, Tang A, et al. Eur J Heart Failure 2002;4:311-320 3 Kuhlkamp V. JACC 2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118 5Abraham W, Fisher W, Smith A, et al.N Engl J Med. 2002;346:1845-1853 6 Leon A. NASPE Scientific Sessions – Late Breaking Clinical Trials. May 2002; Medtronic Inc. data on file QoL NYHA PATH-CHF1 (n=41) ++ InSync (Europe)2 (n=103) ++ InSync ICD (Europe)3 (n=84) ++ MUSTIC4 (n=67) + MIRACLE5 (n=453) ++ MIRACLE ICD6 (n=364) ++ +Statistically significant improvement with CRT (p  0.05)  Not statistically significant or No statistical analysis performed on dataBlank Indicates test neither performed nor reported

  26. CRT Improves Exercise Capacity 6 Min Walk Peak VO2 Exercise Time PATH-CHF1 (n=41) ++ InSync (Europe)2 (n=103) + InSync ICD (Europe)3 (n=84) + MUSTIC4 (n=67) + MIRACLE5 (n=453) +++ MIRACLE ICD6 (n=364) ++ +Statistically significant improvement with CRT (p  0.05)  Not statistically significant or No statistical analysis performed on dataBlank Indicates test neither performed nor reported 1Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026- 2033 2 Gras D, Leclercq C, Tang A, et al. Eur J Heart Failure 2002;4:311-320 3 Kuhlkamp V. JACC 2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118 5Abraham W, Fisher W, Smith A, et al.N Engl J Med. 2002;346:1845-1853 6 Leon A. NASPE Scientific Sessions – Late Breaking Clinical Trials. May 2002; Medtronic Inc., data on file

  27. CRT Improves Cardiac Function/Structure LVEF MR Other PATH-CHF1 (n=41) +LVEDP + LV dP/dtmax InSync (Europe)2 (n=103) + + Filling Time InSync ICD (Europe)3 (n=84) + + Filling Time MUSTIC4 (n=67)    LVEDD,LVESD Filling Time MIRACLE5 (n=453) + + + LVEDD, + LVEDV, LVESV MIRACLE ICD6 (n=362)  + + LVESV, + LVEDV +Statistically significant improvement with CRT (p  0.05)  Not statistically significant or No statistical analysis performed on dataBlank Indicates test neither performed nor reported 1Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026- 2033 2 Gras D, Leclercq C, Tang A, et al. Eur J Heart Failure 2002;4:311-320 3 Kuhlkamp V. JACC 2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118 5Abraham W, Fisher W, Smith A, et al.N Engl J Med. 2002;346:1845-1853 6 Young J. ACC Scientific Sessions – Late Breaking Clinical Trials III. March 2002; Medtronic Inc., data on file

  28. Cardiac Resynchronization OutcomesSustained for at least 12 months +Statistically significant improvement with CRT (p  0.05) No statistically significant improvement with CRTBlank Indicates test neither performed nor reported 1 Gras D, Leclercq C, Tang A, et al. Eur J Heart Fail 2002;4:311-320 2Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026-2033 3 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118

  29. Step 1: Cannulate CSAttain LDS Model 6216A • Use extreme care when passing the guide catheter through vessels • Due to the relative stiffness of the catheter, damage to the walls of the vessels may include dissections or perforations

  30. Step 2: Perform Venograms Varying Patient Anatomy 1,2,3 1. Potkin et al. Am J Cardiol 1987;60:1418-1421 2. Neri et al. Europace 2000;I :D95 Abstract 88/2 3. Hill et al.Europace2000;I:D238 Abstract 167/2 Photos Courtesy of Dr. Daniel Gras

  31. Cardiac Venous Anatomy Step 2: Perform Venograms Great Postero-lateral CS Os Antero- lateral Lateral Middle Anterior Posterior

  32. Lead in Lateral Cardiac Vein Step 2: Perform Venograms

  33. Step 4: Place LeadAttain OTW Model 4193 Click to Start/Stop

  34. Step 4: Place LeadAttain OTW Model 4193 Courtesy ofDr. Daniel Gras Click to Start/Stop

  35. LAO View: Tracking Over the Wire Courtesy ofDr. Daniel Gras Click to Start/Stop

  36. Step 4: Place Leads Attain LV Model 2187 Video compliments of Dr. Vince Paul Click to Start/Stop

  37. Biventricular Pacing is indicated for the reduction of CHF symptoms in patients with: • 1. Stable Class III-IV CHF • 2. QRS> 130 ms • 3.EF <35% • 4. Optimal medical therapy

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