1. Healing the Heart: When Failure is Not an Option
September 12, 2013

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3. Our Panelists Nazanin Moghbeli, MD, MPH, Cardiologist
Salil Shah, MD, Cardiothoracic Surgeon

4. Heart Failure
Nazanin Moghbeli, MD, MPH, FACC
September 10, 2013

5. Overview What is heart failure? Why should I know about it?
What are the causes of heart failure?
What are the signs and symptoms?
How do you treat this disease?
What can I do to prevent worsening heart failure?

6. The heart is pumping with less strength than usual
Definition of Heart Failure
Heart failure: is caused by damage to the heart and can be caused by many different reasons.
i.e. heart attack or uncontrolled high blood pressure.
Heart failure in this case - does not mean the heart has fully stopped.
The heart is pumping with less strength than usual

7. Understanding what is going on with the heart…
Blood moves through the body at a slower rate. As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs.
As a result, the kidneys may respond by causing the body to retain fluid (water) and salt.
Often fluid builds up in the arms, legs, ankles, feet, lungs, or other organs, the body becomes congested (full of fluid); hence the term congestive heart failure to describe the condition.

8. Heart failure affects nearly 5.7 million Americans.
How common is Heart Failure?
Heart failure affects nearly 5.7 million Americans.
Roughly 670,000 people are diagnosed with heart failure each year.
It is the leading cause of hospitalization in people older than 65.
1 in every 5 people will develop heart failure in the US.

9. Mortality Data *
80% of men and 70% of women with less than 65 years of age and HF will die within 8 years
Up to 42% of patients die of HF within 5 years of hospitalization of HF.
Sudden cardiac death is 6 to 9 times more likely in a HF patient as compared to the general population.
fatality rates after hospitalization for chf %, 22%, and 42.3%

10. HF is caused by conditions that damage the heart:
What causes Heart Failure (HF)?
HF is caused by conditions that damage the heart:
Coronary artery disease (CAD)= a disease of the arteries of the heart. If arteries of the heart become blocked or narrowed, the heart can be damaged by lack of oxygen and nutrients.
Heart attack= occurs when the heart arteries become suddenly blocked, stopping the flow of blood to the heart muscle. This damages the heart muscle, resulting in a scarred area that no longer functions well.

11. Heart defects present at birth can all cause heart failure
Other causes of HF:
Alcohol
High blood pressure
Valve disease
Thyroid disease
Heart defects present at birth can all cause heart failure
Preeclampsia

12. Fluid and water retention.
Symptoms associated with CHF:
Congested lungs:
Shortness of breath: at rest, with exercise, or if lying flat
Lung congestion can cause a dry hacking cough/wheezing
Fluid and water retention.
Less blood released by kidneys causes fluid and water retention, resulting in swollen ankles, legs, abdomen (called edema), and weight gain.
May cause an increased need to urinate during the night.
Stomach bloating may cause a loss of appetite or nausea.

13. Dizziness, fatigue, and weakness.
Symptoms often found in HF:
Dizziness, fatigue, and weakness.
Less blood to major organs and muscles can cause fatigue/weakness
Less blood to the brain can cause dizziness or confusion.
Rapid or irregular heartbeats.
The heart beats faster to pump enough blood to the body. This can cause a rapid or irregular heartbeat.

14. How do we treat heart failure
Medications that lower blood pressure and heart rate, thereby decreasing the strain on the heart
Restriction of water and salt
Treating diabetes, high blood pressure, coronary artery disease
Exercise
Smoking cessation

15. Advanced treatment options for HF
Mechanical Devices
Heart transplantation (completely replacing the current nonfunctioning heart with a better functioning heart).

16. Left Ventricular Assist Device (LVAD)

17. 50% of all patients will live at least 9-10 years.
Heart Transplantation *
Heart transplant patients can live a near-normal quality of life and functional capacity.
50% of all patients will live at least 9-10 years.
Gold standard for appropriately selected patients with advanced-stage HF

18. Only 2000 people a year receive transplants in the U.S
Heart Transplantation
Only 2000 people a year receive transplants in the U.S
Over 10% of people on the waiting list die each year waiting on a heart to become available.
Hence additional options must be sought to improve outcomes and avoid deaths for these patients.

19. What can I do? Exercise Cholesterol control Weight management
Medications as needed
Avoid over the counter medications such as Motrin, decongestants
Avoid alcohol excess

20. Diagnosis and workup of heart failure:
Einstein Heart Failure Services
Diagnosis and workup of heart failure:
Treatment, including careful monitoring of heart failure medications
Education
Team approach: PCP, patient, heart failure team
Mechanical support, transplant evaluation and referral

21. Surgical Treatment of Heart Failure
September 12, 2013

22. Objectives Differentiate between acute and chronic heart failure
Surgical management of acute heart failure
Device options and efficacy
Surgical Management of Chronic Heart Failure
Ventricular Remodeling
Device placement and management
The Future

23. Acute vs Chronic Heart Failure
A sudden change in heart function related to some new event that has caused damage to the heart.
Chronic
A gradual decline of heart function over a period of time. (Often the body compensates slowly for the loss of heart function).

24. Causes of Acute Heart Failure:
Myocardial Infarction (aka Heart attack)
Pulmonary Embolism (Blood clot in the lungs)
Myocarditis (Inflammation)
Post-partum Cardiomyopathy (Enlarged heart after pregnancy)
Chronic heart failure with acute (new) flare
Trauma (i.e. direct injury to the heart)
Acute Heart Transplant Rejection

25. Management
Most importantly, treatment is to prevent or stop the failure of other organs that are dependent on blood flow from the heart.
This can be done medically or with mechanical devices.

26. Intra-Aortic Balloon pump
Device placed via the femoral artery (in the leg) to increase heart blood flow.
Pros:
Can be placed and removed by a catheter.
Will allow increased heart and brain blood flow
Cons:
Does not increase the amount of blood pumped by the heart
Has never been shown to improve survival.

27. Tandem Heart Centrifugal flow pump placed percutaneously
Designed to augment left ventricular output and rest left ventricle
Can augment cardiac output up to 5 LPM
Pros: Can fully augment left ventricular cardiac output
Placed and removed percutaneously
Cons: Must have skilled person to place the cannula trans-septal
Cannula position is difficult to control and cannula can migrate

28. Tandem Heart
Many case studies and retrospective reviews to show efficacy, but no PRCT to show efficacy versus convertional therapy.
Theoretical advantage to allowing the left ventricle to rest and provide the body with support.
No mechanism to deal with right ventricular failure.
Trial starting now to determine efficacy versus other devices

29. Impella Axial flow device 2.5- 5.0 L/min Active forward flow
Single Vascular access
5 Minute setup\
Percutaneous or surgical cut-down for placement
Multiple configurations possible
Operation independent of cardiac function or rhythm

30. Impella New Technology Investigational Console Pumps Implantation
Impella LP2.5
Impella LD/LP 5.0
Impella CP
Impella CP
Pumps
Implantation
Impella RP
Investigational

31. Myocardial Protection Hemodynamic Support
Physiology of Impella 31
Myocardial Protection Hemodynamic Support
Inflow
(ventricle)
Outflow
(aortic root)
aortic
valve
EDV, EDP
AOP
Flow
O2 Demand
O2 Supply
Cardiac Power Output
Myocardial Protection
Systemic Hemodynamic Support

32. Impella Unloading Effect

33. ECMO Extracorporeal Membraneous Oxygenation
Blood is removed from the venous system either peripherally via cannulation of a femoral vein or centrally via cannulation of the right atrium,
Oxygenate
Extract carbon dioxide
Blood is then returned back to the body either peripherally via a femoral artery or centrally via the ascending aorta.

34. ECMO Cadillac of mechanical support Full cardiopulmonary bypass
Provides body with oxygenated blood
Provides body with full cardiac output
Allows heart and lungs to rest as body recovers from injury and insult

35. ECMO Pros: Can be placed percutaneously anywhere
Provides full heart and lung support
Allows for bridge to decision
Cons: Must be removed surgically
Need trained staff to monitor and adjust 24 hrs/day while on support
Have increased bleeding and vascular complications

36. Bottomline
All therapies have their place
If chosen and used correctly will take an almost uniformly deadly situation and provide a chance for recovery
There are indications for each device and all devices are approved to be used in acute cardiogenic shock situations.

37. Chronic Heart Failure
Decline of heart function over a period of time where the body compensates slowly for the decrement in heart function.
Treatment:
Medication-Ionotropes, afterload reduction
Ventricular Remodeling
Mechanical Support-LVAD/RVAD
Heart Transplantation

38. Heartmate II Continuous axial flow pump Connects LV apex to Aorta
Bypasses blood flow from the left ventricle
Only has exteriorized driveline connected to external monitor and power source
Must be placed surgically
Can be used as bridge to transplant or as destination therapy

39. Heartmate II Pros: Excellent flow device Very durable
Easily implantable
Has excellent long term efficacy and data
Cons:
Difficult to explant
Need chronic anticoagulation
Device does have defined lifespan
Patient must be of a certain size to accommodate device

40. The Future
Heartware
Impella RP
outflow
inflow

41. Heartware Continuous axial flow pump Connects LV apex to Aorta
Bypasses blood flow from the left ventricle
Only has exteriorized driveline connected to external monitor and power source
Must be placed surgically
Can be used as bridge to transplant or as destination therapy
Small device can be placed in any body habitus
Can be used for biventricular long-term support
Currently on trial

42. Impella RP
Catheter-based percutaneous VAD (22 Fr pump mounted on a 11 Fr catheter)
Treatment: Right ventricular dysfunction
Flow: > 4 L/min
Duration of support: up to 14 days
Pump Inflow: Inferior Vena Cava (IVC) Pump Outflow: Pulmonary Artery (PA)
outflow
inflow

43. Thank You!!
We’d like to thank you for joining us today for Healing the Heart: When Failure is Not an Option
I’d especially like to thank Doctor Mogli and Doctor Shah who have helped us here today and given us all very important information that can help us live healthier, more productive and happier lives.

44. Contact Information
Dr. Moghbeli
Einstein Advance Heart Failure Program Location
5501 Old York Road
Philadelphia, PA 19141
To talk to one of our team, call the Heart Failure Hotline at
Dr. Shah
Salil G. Shah
5501 Old York Road
Klein 409
Philadelphia, PA
As we sign off today, your screen shows you the contact information for both Dr. Mogli and Dr. Shaw. Einstein Health Talks is a series of webinars designed to inform and educate you about health topics affecting you, your loved ones, your household and your community.
Thank you again for joining ust today and we look forward to seeing you again soon on another Einstein Heath Talks. Thank you.