liviu klein md, ms monitoring of director, mechanical ... klein hf pap.pdfliviu klein md, ms...
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Liviu Klein MD, MS Associate Professor Director, Mechanical
Circulatory Support and Heart Failure Device
Programs
Value of Continuous Monitoring of
Pulmonary Artery Pressures in Heart
Failure
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Financial Relationship Disclosure
I will NOT discuss off label/ investigational use of products.
The following financial relationships exist: Employer: University of California San Francisco. Current research support: CVRx, Department of Health and
Human Services, National Institutes of Health, Novartis, St. Jude Medical, Sunshine Heart.
Consultant: Boston Scientific, HeartWare, InfoBionic, Microsoft, Otsuka, St. Jude Medical, Thoratec.
Honoraria: None. Stockholder: InfoBionic.
Value of Continuous Monitoring of Pulmonary Artery Pressures in Heart Failure
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Heart Failure Hospitalizations
Go AS et al. Circulation. 2014; 129: e28-e292.
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High Post Discharge Mortality
Solomon SD et al. Circulation. 2007; 116: 1482-1487.
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Dharmarajan K et al. JAMA. 2013; 309: 355-363.
Heart Failure ReHospitalizations
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Heart Failure ReHospitalizations
Dharmarajan K et al. JAMA. 2013; 309: 355-363.
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Heart Failure Signs/ Symptoms in Hospitalized Patients
Admission Discharge Symptoms (%) Dyspnea on exertion 79 58 Dyspnea at rest 42 5 Orthopnea 50 12 PND 33 4 Fatigue 53 57
Signs (%)
JVP > 8 cm 33 6 Rales 57 13 S3 gallop 20 6 Edema > 2+ 50 13
Gattis WA et al. J Am Coll Cardiol. 2004; 43: 1534-1540.
• Among pts. with severe heart failure 1
– PCWP 33 ± 6 mmHg, CI 1.8 ± 0.5, LVEF 0.18 ± 0.06 – CXR: 27% no congestion, 41% minimal congestion
• Among pts. with moderate heart failure 2
– PCWP 30 ± 9 mmHg, CI 2.1 ± 0.8, LVEF 0.18 ± 0.06 – No rales 84%, no edema 80%, no JVP 50%, no orthopnea
22% • Hemodynamic congestion may not be
recognized clinically (doesn’t translate into symptoms/signs) until too late
Congestion Does not Translate in EARLY Signs/Symptoms
1 Mahdyoon H et al. Am J Card. 1989; 63: 625-630. 2 Stevenson LW et al. JAMA. 1989; 261: 884-889.
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Ability to Predict High PWP Sens. Spec. PPV NPV
Dyspnea on exertion 66 52 45 27 Orthopnea 66 47 61 37 Edema 46 73 79 46 JVD 70 79 85 62 S3 73 42 66 44 CXR Cardiomegaly 97 10 61 --- Redistribution 60 68 75 52 Interstitial edema 60 73 78 53 Pleural effusion 43 79 76 47
Adapted from Chakko S. et al. Am J Med. 1991; 90: 353-358. Adapted from Butman SM. Et al. J Am Coll Cardiol. 1993; 22: 968-975.
Abnormal LV function (Sys and/or Dia)
Neurohormonal activation => ↑ Blood volume ↑ LV diastolic pressure
Hemodynamic congestion (Increased PWP)
Alveolar edema
↑ PA Pressure
↑ RV + RA Pressure
Systemic congestion (Leg edema; JVD; Hepatomegaly)
S
Y
M
P
T
O
M
S
The Congestion Iceberg in Heart Failure
Redistribution in pulmonary vascular bed + interstitial edema
↑ Hydrostatic pressure ↑ Oncotic pressure ↑ Permeability Lymphatic drainage capacity Alveolar-capillary membrane integrity
Abnormal lung mechanics Respiratory muscle dysfunction Other factors
Dyspnea
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Main Reasons for Broken Care Symptoms worsen Patient
MD Office
ED
Hospitalization
Readmission
Doesn’t recognize early signs and symptoms
Limited time Limited staff Limited diagnostics Limited monitoring Limited intervention Limited patient education
Only alternative ED MD with no patient relationship Safest route medically and legally
Pressure on length of stay shortens time to test new medication regimen or educate
Symptoms worsen Reactive Care
Standard of Care for Heart Failure in 2015
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Weights and Heart Failure Hospitalizations
Chaudhry SI et al. Circulation. 2007; 116: 1549-1554.
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Weights and Non Heart Failure Hospitalizations
Chaudhry SI et al. Circulation. 2007; 116: 1549-1554.
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Lynga P et al. Eur J Heart Fail. 2012; 14: 438-444.
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Lynga P et al. Eur J Heart Fail. 2012; 14: 438-444.
Weights and Heart Failure Hospitalizations
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Main Reasons for Broken Care Symptoms worsen Patient
MD Office
ED
Hospitalization
Readmission
Doesn’t recognize early signs and symptoms
Limited time Limited staff Limited diagnostics Limited monitoring Limited intervention Limited patient education
Only alternative ED MD with no patient relationship Safest route medically and legally
Pressure on length of stay shortens time to test new medication regimen or educate
Symptoms worsen Proactive Care
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Chaudhry SI et al. New Engl J Med. 2010; 363: 2301-2309.
Telemonitoring and HF Hospitalizations: TELE-HF
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Ong M. AHA 2015.
Telemonitoring and Heart Failure : BEAT HF
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Ong M. AHA 2015.
Telemonitoring and Heart Failure : BEAT HF
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Ong M. AHA 2015.
Telemonitoring and Heart Failure : BEAT HF
Telemonitoring and Readmissions
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Main Reasons for Broken Care Symptoms worsen Patient
MD Office
ED
Hospitalization
Readmission
Doesn’t recognize early signs and symptoms
Limited time Limited staff Limited diagnostics Limited monitoring Limited intervention Limited patient education
Only alternative ED MD with no patient relationship Safest route medically and legally
Pressure on length of stay shortens time to test new medication regimen or educate
Symptoms worsen Directed Care
Hemodynamic
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Hemodynamics and Outcomes
Fonarow GC et al. Circulation 1994; 90: I-488
PCWP > 16 mm Hg
PCWP < 16 mm Hg
CI > 2.6 L/min/m2
CI < 2.6 L/min/m2
Mortality Risk (%) Mortality Risk (%)
0 6 12 18 24 0
10
20
30
40
50
60
0 6 12 18 24 0
10
20
30
40
50
60
Time (months)
P = NS
P = 0.001
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Congestion Precedes Most Heart Failure Hospitalizations
Zile MR et al. Circulation. 2008; 118: 1433-1441.
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Congestion Precedes Most Heart Failure Hospitalizations
Zile MR et al. Circulation. 2008; 118: 1433-1441.
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Nitinol Loops • 10 mm diameter • Maintain sensor position in vessel
Fused silica housing with
silicone coating Inductor coil
Pressure sensitive capacitor
Heart Failure Pressure Sensor Sensor • No battery • No leads • Small size (3.5 x 2 x 15mm)
CardioMEMS™ HF System
PA Sensor and Delivery System
120 cm 4.5 cm
Patient Electronics System
PA Pressure Database
Physician Access Via Secure Website
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Flow around sensor
No Impact on Blood Flow
Sensor in Distal PA
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Abraham WT et al. Am Heart J. 2011; 161: 558-566.
Accuracy of PA Measurements
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Abraham WT et al. Lancet. 2011; 377: 658-666.
CHAMPION Trial
Abraham WT et al. Lancet. 2011; 377: 658-666.
CHAMPION Trial
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Abraham WT et al. Lancet. 2011; 377: 658-666.
CHAMPION Trial
Abraham WT et al. Lancet. 2015; in press.
CHAMPION Trial – Long Term
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Abraham WT et al. Lancet. 2015; in press.
CHAMPION Trial – Long Term
Abraham WT et al. Lancet. 2015; in press.
CHAMPION Trial – Long Term
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Goldberg LR et al. HRS 2015
CHAMPION Trial: Symptoms vs. PAP Management
A Year Later @ UCSF
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• Congestion is the lead cause of HF hospitalizations • Congestion contributes to progression of HF • Patients leave hospital with congestion, resulting in
high rehospitalization rate • Congestion is often subclinical and difficult to assess
when present • Significant dissociation between hemodynamic and
clinical congestion, even when hemodynamics are very abnormal • Need for better monitoring of degree and changes in
congestion (more accurate and sensitive)
Congestion in Heart Failure
Conclusions • Monitoring PAP/ PWP can provide early
warning of condition worsening/ decompensation much better than body weight and before symptoms
• Most changes occur over a few days - weeks • Having a treatment algorithm based on PAP/
PWP values is key to successful treatment and preventing heart failure readmissions
• Always treat to max: drive pressures down to patient’s normal