Treatment of Heart Failure: Beyond Medical Therapy Veronica Franco, MD Assistant Professor – Clinical Division of Cardiovascular Medicine Veronica.Franco@osumc.edu Set B1 – Title Slide

Stage A Heart Failure J Am Coll Cardiol 2005;46:1116-1143 We will focus on therapies other than medications that can reduced morbidity and mortality in HF patients. These therapies are focus on Stages C and D heart failure patients. J Am Coll Cardiol 2005;46:1116-1143

Sudden Death in Heart Failure Not all patients with HF die with decompensated HF. An important group have sudden death, presumably due to VT or VF. NYHA Class 2 NYHA Class 3 NYHA Class 4 MERIT-HF Lancet 1999

BiV Pacemaker/CRT This slide shows a CRT-D device, meaning that it has the capability of a defibrillator in addition to cardiac resynchronization. Placement of the 3 leads is demonstrated, along with the sub-pectoral positioning of the device. Battery life is over 5 years. Implanted with conscious sedation. Average time for implanting this device is about 70-90 minutes. Clinical evidence accumulated over the past 10 years provide support for the use this therapy. An ICD is indicated for patients with a reduced LVEF < 35% despite optimal therapy for ~ 9 months in non-ischemic cardiomyopathy and ~ 3 months in ischemic cardiomyopathy than can’t be revascularized (stents or bypass). If there have been revascularization then ICD can be placed if LVEF remain low after 40 days. A biventricular pacemaker (3 leads – including one in LV) is indicated if there is also the presence of LBBB.

Effects of Medical Education on Mortality

Device Placement Left BBB RV pacing Right BBB LV pacing V1 V1 6 6 It is important to verify if the biventricular pacemaker is working, in other words, that is pacing the LV 1st and RV second (to improve synchronization). If a patient has a BIV-ICD, they should have RBBB morphology on their EKG. If the QRS is very wide or there is a LBBB on EKG, the ICD should be interrogated to assure there is biventricular pacing. 6 6

AHA/ACC/HRS 2008 guidelines for device therapy Cardiac Resynchronization Therapy I IIa IIb III For patients that have a LVEF ≤ 35%, QRS ≥ 120 ms and sinus rhythm, CRT with or without ICD is recommended for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy For patients that have a LVEF ≤ 35%, QRS ≥ 120 ms and atrial fibrillation, CRT with or without ICD is reasonable for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy For patients that have a LVEF ≤ 35%, CRT with or without ICD is reasonable for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy and expected frequent pacing post CRT implantation A I IIa IIb III B I IIa IIb III This are the guidelines for implantation of an ICD or BIV_pacemaker. A BIV-ICD is indicated only if there is wide QRS, more than 120 ms and LBBB morphology. BIV-ICD has better results if a patient is on sinus rhythm and not atrial fibrillation. C 7 7

AHA/ACC/HRS 2008 guidelines for device therapy Cardiac Resynchronization Therapy I IIa IIb III For patients that have a LVEF ≤ 35%, QRS ≥ 120 ms and sinus rhythm, CRT with or without ICD is recommended for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy For patients that have a LVEF ≤ 35%, QRS ≥ 120 ms and atrial fibrillation, CRT with or without ICD is reasonable for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy For patients that have a LVEF ≤ 35%, CRT with or without ICD is reasonable for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy and expected frequent pacing post CRT implantation A I IIa IIb III B I IIa IIb III Is important to point out that these recommendations are for patients that have persistently low LVEF despite being on optimal medical therapy C 8 8

Device Placement – RAFT Pts w/ QRS > 120 ms + LBBB + LVEF<30% This slide shows that a CRT-D device have shown to reduce mortality in patients with NYHA class II as well and are being use in those patients. The new guidelines should reflect these new studies. Tang et al. Engl J Med 2010; 363:2385-2395 9 9

Mitral Valve Repair Mitral valve surgery to reduce severe mitral regurgitation has been used in some cases of heart failure. Westaby S: Heart 2000; 83: 603

DOR Procedure Left ventricular restoration by endoventricular patch repair (the Dor procedure) as opposed to simple linear aneurysmectomy Left ventricular restoration by endoventricular patch repair (the Dor procedure) as opposed to simple linear aneurysmectomy Westaby S: Heart 2000; 83: 603

LVAD another procedure, more commonly used but reserved for end-staged HF patients is a LVAD. They are reserved for those patients where medical and surgical therapies have failed. They can be use as a bridge to transplant or as destination therapy (in patients that are not transplant candidates). In involves placing a cannula in the apex of the LV and another in the aorta. The blood gets to the Aorta at a prederminate rate, irrespective of the LVEF. There is a driveline connected to batteries outside of the body and devices can not be removed unless patient undergoes a heart transplant.  

Total Artificial Heart (TAH-t) One-year survival rate following human heart transplant for patients receiving the CardioWest temporary Total Artificial Heart was 70%, compared to 31% for control patients who did not receive the device: NEJM 2004                          <> A total artificial heart can be use only in patients as a bridge to transplantation. Its use remains investigational. CardioWest

Cardiac Transplantation

Indications for Cardiac Transplantation or LVAD therapy Recurrent admissions Peak VO2 < 14 mL/kg/min NYHA class IIIb or IV symptoms despite optimal therapy Cardiorenal syndrome Low cardiac output symptoms

Contraindications for Transplantation Age > 70 yo BMI > 35 Active infection or cancer Severe renal failure or pulmonary hypertension Severe complications of DM – retinopathy or neuropathy Social concerns: active smoking or drug/alcohol abuse, lack of social support.

Contraindications for LVAD Severe RV failure Bleeding diathesis Severe renal failure Active infection Social concerns, active drug abuse, lack of social support. Life expectancy < one year for other reasons than HF

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