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ADVANCED HEART FAILURE RECOGNIZING OPTIONS

John M. Herre, MD, FACC, FACP Director, Advanced Heart Failure Program Sentara Helathcare Professor of Medicine Eastern Virginia Medical School. ADVANCED HEART FAILURE RECOGNIZING OPTIONS. PATIENT 1. Onset heart failure at age 70 Normal coronary arteries Optimal oral medical management

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ADVANCED HEART FAILURE RECOGNIZING OPTIONS

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  1. John M. Herre, MD, FACC, FACP Director, Advanced Heart Failure Program Sentara Helathcare Professor of Medicine Eastern Virginia Medical School ADVANCED HEART FAILURERECOGNIZING OPTIONS

  2. 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

  3. 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

  4. WHAT DO YOU RECOMMEND 1. Hospice 2. Bridge to hospice with milrinone 3. Long term home milrinone 4. Heart transplant 5. Mechanical circulatory support

  5. OUTCOMES OF CONTINUOUS HOME MILRINONE THERAPY Muthsusamy, JHLT 2012, 31:S14

  6. TRANSPLANT SURVIVAL BY AGE Figure 12 Source: The Journal of Heart and Lung Transplantation 2012; 31:1052-1064 (DOI:10.1016/j.healun.2012.08.002 )

  7. THE PROBLEM ~240 Million US Population ≥ 20 years old 6.24 Million HF = 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 2000 heart transplants per year Courtesy John O’Connell, MD

  8. DURABLE MECHANICAL CIRCULATORY SUPPORT

  9. ASSESSING THE BENEFITHEARTMATE II RISK SCORE 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

  10. HEARTMATE II RISK SCORE Cowger, JACC, 2013

  11. PATIENT 1

  12. 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

  13. WHAT DO YOU RECOMMEND • Hospice • Bridge to hospice with milrinone • 3. Long term home milrinone • 4. Heart transplant • 5. Mechanical circulatory support

  14. SURVIVAL IN HEART FAILURE 3 2.5 2 1.5 1 0.5 0 Hospitalizations Median Survival (years) 1 2 3 4 No CKD CKD Age 75-85 Age > 85 Setoguchi, Am Heart J 2007

  15. PATIENT 2HEARTMATE II RISK SCORE 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

  16. HEARTMATE II RISK SCORE Cowger, JACC 2013

  17. SURVIVAL TO DISCHARGE Boyle JHLT 2011

  18. LENGTH OF STAY Boyle JHLT 2011

  19. RISK FACTORS FOR EARLY DEATH Kirklin, JHLT 2012, 31:117

  20. 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

  21. 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

  22. 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

  23. HOSPITALIST ASSESSMENT 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.

  24. 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

  25. WHAT DO YOU DO 1. Continue medical management 2. Intraaortic balloon pump 3. Temporary mechanical circulatory support 4. Durable mechanical circulatory support 5. Palliative care

  26. SHOCK II

  27. 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

  28. Saturday, May 22, 201019 days post transplant

  29. 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

  30. 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

  31. MANAGEMENT OPTIONS 1. Continue medical management 2. Intraaortic balloon pump 3. Temporary mechanical circulatory support 4. Durable mechanical circulatory support 5. Palliative care

  32. 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

  33. WHAT’S THE DIFFERENCE • Same heart • Same age • Case 4 • Late presentation • Later referral • Irreversible end-organ damage • Where do you draw the line?

  34. 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

  35. WHO HAS THE VAD?

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