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10.5% 9.7% 8.2% 6.4% 11.9% 53.3% Hospitalization $20.9 Lost Productivity/ Mortality* $4.1 Home Healthcare $3.8 Drugs/Other Medical Durables $3.2 Physicians/Other.

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Presentation on theme: "10.5% 9.7% 8.2% 6.4% 11.9% 53.3% Hospitalization $20.9 Lost Productivity/ Mortality* $4.1 Home Healthcare $3.8 Drugs/Other Medical Durables $3.2 Physicians/Other."— Presentation transcript:




4 10.5% 9.7% 8.2% 6.4% 11.9% 53.3% Hospitalization $20.9 Lost Productivity/ Mortality* $4.1 Home Healthcare $3.8 Drugs/Other Medical Durables $3.2 Physicians/Other Professionals $2.5 Nursing Home $4.7 Total Cost $39.2 billion Heart Disease and Stroke Statistics 2010 Update: A Report From the AHA Circulation, Feb 2010; 121: e46 - e215

5 Non-ischemic cardiomyopathy Valvular disease Viral/bacterial cardiomyopathy Peripartum cardiomyopathy Idiopathic/familial cardiomyopathy Myocarditis Connective tissue disorders Drugs/Toxins Alcohol Ischemic cardiomyopathy Hypertension Coronary artery disease Myocardial infarction

6 Increasing Severity Class I Cardiac disease No symptoms No limitation in ordinary physical activity Class II Mild symptoms (mild shortness of breath and/or angina) Slight limitation during ordinary activity Class IIIa and IIIb Marked limitation in activity due to symptoms Comfortable only at rest Class IV Severe limitations Symptoms even while at rest Mostly bedbound patients New York Heart Association Functional Classification of Heart Failure


8 Katz AM Heart Failure

9 Beta Blockers Aldosterone Antagonists Hydralazine and Isosorbide Dinitrate In African American population with stage III and IV heart failure, strength of evidence = A Loop Diuretics Lindenfeld, J, et al. J Card Failure 2010; 6,

10 Strength of Evidence = B Antiplatelet agents (Aspirin) Ischemic etiology of HF Digoxin In stage II and III HF Thiazide diuretics Warfarin MI patients with LV thrombus Strength of Evidence = C Digoxin In stage IV HF Metalazone Lindenfeld, J, et al. J Card Failure 2010; 6,

11 Inotropes Commonly used on an outpatient basis for stage IIIb – IV heart failure Milrinone and Dobutamine are the only FDA approved drugs for outpatient use Not recommended for acute heart failure exacerbations in ischemic patients Probable benefit in non-ischemic exacerbations OPTIME-CHF JAMA 2002; 287:1541-7

12 Cardiac Resynchronization Therapy (CRT) LVEF <35% NYHA class III – IV QRS > 120 ms Optimal medical therapy

13 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,

14 Decreased end organ perfusion Renal function Liver function Pulmonary function We need more support!

15 A mechanical circulatory device used to partially or completely replace the function of either the left ventricle (LVAD); the right ventricle (RVAD); or both ventricles (BiVAD)

16 Are there any contraindications to VAD support? End-stage lung, liver, or renal disease Metastatic disease Medical non-adherence or active drug addiction Active infectious disease Inability to tolerate systemic anticoagulation (recent CVA, GI bleed, etc.,) Moderate to severe RV dysfunction for some LVADs What are our other issues in this particular patient? What are the patients goals? What are our goals? What happens if we dont meet our goals?

17 Lietz and Miller Curr Opin Cardiol 2009, 24:246–251 INTERMACS SCORE Interagency Registry for Mechanically Assisted Circulatory Support Long-Term LVAD Ideal candidates are INTERMACS classes 3-4 Short-Term LVAD Candidates are INTERMACS classes 1-2 Not a LVAD Candidate INTERMACS 1 or those with multisystem organ failure

18 Long-term placement Destination Therapy (DT) Not a heart transplant candidate NYHA IV LVEF <25% Maximized medical therapy >45 of 60 days; IABP for 7 days; OR 14 days Functional limitation with a peak oxygen consumption of less than or equal to 14 ml/kg/min Life expectancy < 2 years Bridge to Transplantation (BTT) Patient is approved and currently listed for transplant NYHA IV Failed maximized medical therapy coverage-database

19 Destination Therapy (DT) HeartMate II (Thoratec)


21 Pump Speed (RPM) – How quickly the pump rotates Pump Power (Watts) – Measure of motor voltage and current Pump Flow (L/min) - Estimated value of the volume running through the pump Pulsitility Index – The measure of the left ventricular pressure during systole

22 VS


24 Inflow cannula (poor position, obstruction) Pump/rotor dysfunction (thrombus) Battery dysfunction Outflow graft (kink, leak) Drive line infection / fracture Controller malfunction


26 Winston Churchill

27 Rose, EA; et al NEJM 2001; 345:

28 Kirkland, JK, et. al JHLT 2013; 32:

29 Kirkland, JK, et. al JHLT 2013; 32:

30 Shock Team Evaluation for mechanical circulatory support (MCS) Try to avoid the bridge to decision or the bridge to nowhere


32 Utilized for LV support only; not appropriate to use with RV failure Impella 2.5 can be inserted through the femoral artery during a standard catheterization procedure; provides up to 2.5 L of flow Impella 5.0 inserted via femoral or axillary artery cut down; provides up to 5L of flow The catheter is advanced through the ascending aorta into the left ventricle Pulls blood from an inlet near the tip of the catheter and expels blood into the ascending aorta FDA approved for support of up to 6 hours

33 Used for LV support; not appropriate in RV failure Cannulas are inserted percutaneously through the femoral vein and advanced across the intraatrial septum into the left atrium The pump withdraws oxygenated blood from the left atrium and returns it to the femoral arteries via arterial cannulas Provides up to 5L/min of flow Can be used for up to 14 days

34 Can be used for LV and/or RV support Cannula are typically inserted via a midline sternotomy Capable of delivering flows up to 9.9 L/min Can be used for up to 30 days

35 Used for patients with a combination of acute cardiac and respiratory failure A cannula takes deoxygenated blood from a central vein or the right atrium, pumps it past the oxygenator, and then returns the oxygenated blood, under pressure, to the arterial side of the circulation Can be used for days to weeks


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