treatment of heart failure: beyond medical therapy veronica franco, md assistant professor –...
TRANSCRIPT
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Treatment of Heart Failure:Beyond Medical Therapy
Veronica Franco, MDAssistant Professor – ClinicalDivision of Cardiovascular [email protected]
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Stage A Heart Failure
J Am Coll Cardiol 2005;46:1116-1143
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Sudden Death in Heart Failure
MERIT-HF Lancet 1999
NYHA Class 2 NYHA Class 3 NYHA Class 4
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BiV Pacemaker/CRT
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Diuretic Digoxin
Diuretic Digoxin ACE-1
Diuretic Digoxin ACE-1 Beta Blocker
ICD Medical Therapy
0
4
8
12
16
Death at Year 1
Effects of Medical Education on Mortality
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Device Placement
V1
Right BBB
Left BBB
V1
RV pacing
LV pacing
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AHA/ACC/HRS 2008 guidelines for device therapy
Cardiac Resynchronization Therapy
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
I IIa IIb III
A
I IIa IIb III
B
I IIa IIb III
C
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AHA/ACC/HRS 2008 guidelines for device therapy
Cardiac Resynchronization Therapy
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
I IIa IIb III
A
I IIa IIb III
B
I IIa IIb III
C
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Device Placement – RAFTPts w/ QRS > 120 ms + LBBB + LVEF<30%
Tang et al. Engl J Med 2010; 363:2385-2395
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Mitral Valve Repair
Westaby S: Heart 2000; 83: 603
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DOR Procedure
Left ventricular restoration by endoventricular patch repair (the Dor procedure) as opposed to simple linear aneurysmectomy
Westaby S: Heart 2000; 83: 603
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LVAD
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Total Artificial Heart (TAH-t)
<>
CardioWest
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
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Cardiac Transplantation
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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
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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.
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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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