1. Natural History of Heart Failure
Allen Circulation 2012
Lanken Am J Respir Crit Care Med 2008

2. Current Estimate of the Number of
Advanced HF Patients
Miller and Guglin JACC 2013

3. Stage D Heart Failure
Chronic HF patients whose symptoms persist or decline despite maximal GDMT. They will generally need:
Inotropic support
Mechanical circulatory device support
Transplant
Hospice/Palliative care

4. Neprilysin Inhibition Potentiates Actions of
Endogenous Vasoactive Peptides That Counter
Maladaptive Mechanisms in Heart Failure
Neurohormonal activation
Vascular tone
Cardiac fibrosis, hypertrophy
Sodium retention
Endogenous
vasoactive peptides
(natriuretic peptides, adrenomedullin,
bradykinin, substance P,
calcitonin gene-related peptide)
Neprilysin
inhibition
Neprilysin
Inactive metabolites

5. PARADIGM-HF: Cardiovascular Death or Heart Failure Hospitalization (Primary Endpoint)40
Enalapril
(n=4212)
1117 32
914 24
LCZ696
(n=4187)
Kaplan-Meier Estimate of
Cumulative Rates (%) 16
HR = 0.80 ( )
P =
Number needed to treat = 21 8
180
360
540
720
900
1080
1260
Days After Randomization
Patients at Risk
LCZ696
Enalapril
4187
4212
3922
3883
3663
3579
3018
2922
2257
2123
1544
1488
896
853
249
236

6. HFrEF. Class I Hospital Universitario A Coruña ACEi (or ARB) BB MRA
2012 ESC Guidelines
HFrEF. Class I

7. Guideline directed medical therapy
Hospital Universitario
A Coruña
Yancy, JACC 2013
Guideline directed medical therapy

8. Non-pharmacologic Optimization of the Heart Failure Patient with Low LVEF
Cardiac Resynchronization Therapy (CRT)
LVEF <35%
NYHA class III – IV
QRS > 120 ms
Optimal medical therapy

9. Non-pharmacologic Optimization of the Heart Failure Patient with Low LVEF
Implantable Cardiac Defibrillators
Ischemic Etiology
(Strength of Evidence = A)
Non-ischemic Etiology
(Strength of Evidence = B)
Primary prevention of ventricular arrhythmias
LVEF <35%
Lindenfeld, J, et al.
J Card Failure
2010; 6,

10. Acute Heart Failure – What do the New
Guidelines Say
JJ McMurray EHJ 2012

11. INTERMACS PROFILES
Miller and Guglin JACC 2013

12. Decision tree for elective mechanical
circulatory support in advanced heart failure
Peura Circ 2012

13. Mechanical Circulatory Support Devices
Peira Circulation 2012

14. Advanced Heart Failure Treated with
Continuous-Flow Left Ventricular Assist Device
NEJM 2009

15. Comparison of Pulsatile and Continuous Flow
Ventricular Assist Devices
Slaughter JHLT 2010

16. Medical Management vs. LVAD
Rose, EA; et al
NEJM 2001; 345:

17. Survival Rates
Kirkland, JK, et. al
JHLT 2013; 32:

18. Survival of Patients with Advanced Heart Failure
Treated with Continuous-Flow and Pulsatile Left
Ventricular Assist Devices
NEJM 2009

19. Algorithm for Selection of LVAD
Candidates
Miller and Guglin JACC 2013

20. Decision tree for elective mechanical
circulatory support in advanced heart failure
Stewart Circ 2012

21. VADs– What do the New Guidelines Say
JJ McMurray EHJ 2012

22. VADs– What do the New Guidelines Say

24. VADs– What do the New Guidelines Say

25. VADs– Timing is Everything
Peura Circulation 2012

26. VADs– Timing is Everything
Peura Circulation 2012

27. VADs– not for all
Peura Circulation 2012

28. Outcomes of Destination Therapy Clinical
Trials
NEJM 2009

29. VADs and Complications
• Mechanical wear
• Valve dysfunction
• Thrombembolic complications

30. Unexpected Abrupt Increase in
Left Ventricular Assist Device Thrombosis
Starling NEJM 2013