1. 1 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

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 2

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 3

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 4

5. OUTCOMES OF CONTINUOUS HOME MILRINONE THERAPY Group1 yr survBaseline NYHA6 m NYHA (if alive) Bridge to TX/VAD83.3%3.892 Weaning strategy73.43.922 Palliative care11.13.763 5 Muthsusamy, JHLT 2012, 31:S14

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

7. ~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 THE PROBLEM 2000 heart transplants per year Courtesy John O’Connell, MD

8. DURABLE MECHANICAL CIRCULATORY SUPPORT 8

9. ASSESSING THE BENEFIT HEARTMATE II RISK SCORE 9 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 10 Cowger, JACC, 2013

11. PATIENT 1 11

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 12

13. WHAT DO YOU RECOMMEND 13 1.Hospice 2.Bridge to hospice with milrinone 3. Long term home milrinone 4. Heart transplant 5. Mechanical circulatory support

14. SURVIVAL IN HEART FAILURE 14 3 2.5 2 1.5 1 0.5 0 No CKD CKD Age 75-85 Age > 85 12341234 Hospitalizations Median Survival (years) Setoguchi, Am Heart J 2007

15. PATIENT 2 HEARTMATE II RISK SCORE 15 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 16 Cowger, JACC 2013

17. 17 ProfileDescriptionTime to MCS 1“Crashing and burning” - critical cardiogenic shock.Within hours 2 “Progressive decline” – inotrope dependence with continuing deterioration. Within a few days 3 “Stable but inotrope dependent” - describes clinical stability on mild- moderate doses of intravenous inotropes. (Patients stable on temporary circulatory support without inotropes are within this profile). Within a few weeks 4 “Recurrent advanced heart failure” - “recurrent” rather than “refractory” decompensation. Within weeks to months 5 “Exertion intolerant” - describes patients who are comfortable at rest but are exercise intolerant. Variable 6 “Exertion limited” – a patient who is able to do some mild activity but fatigue results within a few minutes or any meaningful physical exertion. Variable 7 “Advanced ” - describes patients who are clinically stable with a reasonable level of comfortable activity, despite history of previous decompensation that is not recent. Not a candidate for MCS

18. SURVIVAL TO DISCHARGE 18 Boyle JHLT 2011

19. LENGTH OF STAY 19 Boyle JHLT 2011

20. RISK FACTORS FOR EARLY DEATH Risk FactorHazard RatioP-value Prior stroke1.740.005 Prior CABG1.84<0.0001 INTERMACS 12.870.0001 INTERMACS 21.840.01 BiVAD3.27<0.0001 Prior valve surgery1.810.0007 20 Kirklin, JHLT 2012, 31:117

21. 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

22. 22 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

23. 23 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

24. HOSPITALIST ASSESSMENT 24 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.

25. 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

26. 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

27. SHOCK II 27

28. 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

29. Saturday, May 22, 2010 19 days post transplant

30. 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

31. 31

32. 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 32

33. MANAGEMENT OPTIONS 1. Continue medical management 2. Intraaortic balloon pump 3. Temporary mechanical circulatory support 4. Durable mechanical circulatory support 5. Palliative care 33

34. 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 34

35. WHAT’S THE DIFFERENCE Same heart Same age Case 4 –Late presentation –Later referral –Irreversible end-organ damage Where do you draw the line? 35

36. 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 36

37. WHO HAS THE VAD? 37