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Treatment Strategies for End Stage Heart Failure: Medications, Heart Transplantation and Pumps
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Cesar Guerrero-Miranda M.D. Transplant Cardiology, Heart Failure and Mechanical
Circulatory SupportBaylor University Medical Center
April 29nd, 2017
Disclosures: No industry relationship.
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Objectives
How to define end stage heart failure. Review treatment options and strategies. Review indications and contraindications for
heart transplantation and mechanical circulatory support.
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Allen L A et al. Circulation 2012;125:1928-52
Clinical Course of Heart Failure
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HF Stage D
Terminology:
Advanced HF
Refractory HF
End-stage HF
Patients with marked HF symptoms even at rest
equals definition of NYHA Class IV HF
Recurrent hospitalizations despite GDMT
Yancy CW et al. 2013 HF Guidelines. J Am Coll Cardiol 2013 Jun 5
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Clinical Course & Events: Useful for Identifying Patients With Advanced HF
Repeated (≥2) hospitalizations or ED visits for HF in the past year. Progressive deterioration in renal function (e.g., rise in BUN and creatinine). Weight loss without other cause (e.g., cardiac cachexia). Intolerance to ACE inhibitors due to hypotension and/or worsening renal
function. Intolerance to beta-blockers due to worsening HF or hypotension. Frequent systolic blood pressure <90 mm Hg. Persistent dyspnea with dressing or bathing requiring rest. Inability to walk 1 block on the level ground due to dyspnea or fatigue. Recent need to escalate diuretics to maintain volume status. Progressive decline in serum sodium, usually to <133 mEq/L. Frequent ICD shocks.
Yancy CW et al. 2013 HF Guidelines. J Am Coll Cardiol 2013 Jun 5
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Treatment Options in Advanced HF
Inotropes
Transplantation
LVADs
Palliative care
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Inotropic Therapy: Historical Data
Source: ACC.17 Presentations
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Inotropic Therapy: New data
Source: ACC.17 Presentations
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Inotropic Harm
Long-term use of either continuous or intermittent, intravenous parenteral positive inotropic agents, in the absence of specific indications or for reasons other than palliative care, is potentially harmful in the patient with HF.
Use of parenteral inotropic agents in hospitalized patients without documented severe systolic dysfunction, low blood pressure, or impaired perfusion, and evidence of significantly depressed cardiac output, with or without congestion, is potentially harmful.
I IIa IIb III
I IIa IIb III
Harm
Harm
Yancy CW et al. 2013 HF Guidelines. J Am Coll Cardiol 2013 Jun 5
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Cardiac Transplantation
Evaluation for cardiac transplantation is indicated for carefully selected patients with stage D HF despite GDMT, device, and surgical management.
I IIa IIb III
Cardiac transplantation considered gold standard for treatment of refractory end-stage HF
Yancy CW et al. 2013 HF Guidelines. J Am Coll Cardiol 2013 Jun 5
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In December 3, 1967Christiaan Barnardperformed the firsthuman-to-humanheart transplant atthe Groote SchuurHospital in CapeTown, South Africa.
1st Human Heart Transplant - 1967
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Indications for Heart Transplant1. Cardiogenic shock with reversible organ dysfunction.
2. Low cardiac output state or refractory HF requiring inotropes.
3. Class III-IV HF with poor exercise tolerance:
RHC: PSAP < 50 mmHg AND TPG < 15 OR PVR <3 WU AND SBP > 85 mmHG
4. Refractory ventricular arrhythmia.
5. Refractory angina.
The Journal of Heart and Lung Transplantation, Vol 35, No 1, January 2016
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Special Considerations
Congenital heart disease with or without associated ventricular dysfunction
Restrictive cardiomyopathies: Infiltrative (sarcoid, amyloid, Fabry’s ds,
hemochromatosis, endomyocardial fibrosis).
Idiopathic (must rule out constriction).
Hypertrophic, non obstructive cardiomyopathy.
Arrhythmogenic Right Ventricular Cardiomyopathy
The Journal of Heart and Lung Transplantation, Vol 35, No 1, January 2016
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Contraindications for Cardiac Transplant Severe systemic disease with poor survival. Severe peripheral vascular disease. Irreversible pulmonary hypertension (PVR >3) Severe COPD, emphysema or pulmonary dz. CVA with severe cognitive impairment. Uncontrolled diabetes with proteinuria, renal disease,
vasculopathy, neuropathy. Active infection, malignancy or bleeding. Ongoing substance abuse, smoking or other psychosocial
serious problems. Lack of family support or adequate financial resources. Severe obesity (BMI > 35, IBW >140%).
The Journal of Heart and Lung Transplantation, Vol 35, No 1, January 2016
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0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Surv
iva
l (%
)
Years
1982-1991 (N=21,391)
1992-2001 (N=39,913)
2002-2008 (N=24,485)
2009-6/2014 (N=20,577)
Adult Heart TransplantsKaplan-Meier Survival by Era
Median survival (years):1982-1991=8.5; 1992-2001=10.4; 2002-2008=11.9; 2009-6/2014=NA
All pair-wise comparisons were significant at p < 0.05.
(Transplants: January 1982 – June 2014)
2016JHLT. 2016 Oct; 35(10): 1149-1205
The most effective treatment for end-stage heart disease Median survival 11.9
years 1-year survival: 88% 5-year survival: 75% 10-year survival: now
approximately 56%
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12 5 6 50
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1-4 5-9 10-19 20-29 30-39 40-49 50-74 75+
% o
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spla
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Average number of heart transplants per year
Number of centers Percentage of transplants
Adult and Pediatric Heart TransplantsAverage Center Volume (Transplants: January 2009 – June 2015)
2016JHLT. 2016 Oct; 35(10): 1149-1205
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Adult and Pediatric Heart Transplants:The number of transplants has remained flat over the last 15 years
0
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Other
North America
Europe
2016JHLT. 2016 Oct; 35(10): 1149-1205
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Source: ACC.17 Presentations
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Types of Durable LVAD
Source: ACC.17 Presentations
2020
Indications for LVAD Placement• Bridge to Decision
• Bridge to Transplant
• Destination Therapy
• Bridge to Recovery
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0
10
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30
40
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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
% o
f P
ati
en
ts
Year of Transplant * LVAD, RVAD, TAH, ECMO
Adult Heart Transplants
% of Patients Bridged with Mechanical Circulatory Support*(Transplants: January 2000 – December 2014)
2016JHLT. 2016 Oct; 35(10): 1149-1205
2222
Destination LVAD Eligibility
Broadly similar to transplant Coexistent illness with limiting prognosis Psychosocial instability, substance abuse, etc.
Less inclusive (compared to Tx) Severe Right heart failure
More inclusive (compared to Tx) Older patients (over 70 yrs old)Obesity: BMI up to 40 Creatinine up to 2pulmonary hypertension with PVR >3 DM, PVD, some infections not as problematic.
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Source: ACC.17 Presentations
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Longterm Complications
GI Bleeding
Driveline Infections
Device Thrombosis
Hemolysis
AI
Stroke
Late RV failure
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Conclusions
Landscape of advanced HF has changed due to emergingspecialized therapies.
Heart transplantation remains the most successful therapyfor end stage cardiomyopathy, although severe donorshortage limits its beneficial only for a small fraction of thesepatients.
LVAD utilization is gaining increased acceptance as devicetechnology improves and transplantation rates remains flat.
Efforts to improve DT LVAD outcomes, perhaps nottransplantation, represents the greatest hope for addressingend stage heart failure.
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Baylor Heart Center App
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Thank you
