Heart Failure:

Case 1 67 year old man Presented with anterior wall MI in May. Underwent stent placement in the LAD. The other arteries were patent. Echo demonstrated mildly-moderate decreased LV systolic function with anteroapical akinesis Unremarkable recovery. Started on aspirin, plavix, simvastatin, atenolol 25mg and discharged home 67 year old man Presented with anterior wall MI in May. Underwent stent placement in the LAD. The other arteries were patent. Echo demonstrated mildly-moderate decreased LV systolic function with anteroapical akinesis Unremarkable recovery. Started on aspirin, plavix, simvastatin, atenolol 25mg and discharged home

November 1 Acute onset of shortness of breath Wife called Mada, HR 94 BP 114/60 RR 28 sat 91% Bibasilar crackles Acute onset of shortness of breath Wife called Mada, HR 94 BP 114/60 RR 28 sat 91% Bibasilar crackles

ECG

Chest x-ray

Echo Dilated LV with moderately-severely decreased function. Anteroseptal and apical dyskinesis Moderate-severe mitral regurgitation Normal RV size and function Mild pulmonary hypertension Dilated LV with moderately-severely decreased function. Anteroseptal and apical dyskinesis Moderate-severe mitral regurgitation Normal RV size and function Mild pulmonary hypertension

What happened?

Biomechanical Model of Heart Failure Myocardial Dysfunction ↑ Afterload ↑ Preload ↑ Contractility Neurohormonal Activation Renin- Angiotensin Aldosterone Sympathetic Stimulation VasoconstrictionVasoconstriction Sodium & Water Retention Cardiac Remodeling Beta Blockers ×× ACE-IARBACE-IARB ×× SpironolactoneSpironolactone ××××DiureticsDiuretics

What didn’t happen that should have happened?

A A B B C C D D Prevention Life style modification Prevention Life style modification ACE-I/ARB Beta Blockers ACE-I/ARB Beta Blockers Restrict Diet Diuretics Aldospirone Digoxin Restrict Diet Diuretics Aldospirone Digoxin CRT ± ICD Assist devices Transplantation CRT ± ICD Assist devices Transplantation Stages in Heart Failure Refractory Symptoms Heart Failure Symptoms Structural Heart Disease Patients at Risk AHA / ACC HF guidelines

Hospital Course Admitted with a diagnosis of acute decompensated heart failure. What is the first thing you do? Admitted with a diagnosis of acute decompensated heart failure. What is the first thing you do?

Comprehensive inhibition of neurohormonal activation –achieve euvolemia with diuretics and salt restriction –ACE-inhibitors –Beta-blockers (so far only carvedilol, bisoprolol and extended release metoprolol) –Careful spironolactone –achieve euvolemia with diuretics and salt restriction –ACE-inhibitors –Beta-blockers (so far only carvedilol, bisoprolol and extended release metoprolol) –Careful spironolactone

COPERNICUS NEJM 2001 COPERNICUS Beta Blocker Placebo Carvedilol MonthsMonths Survival % 35%35% ACE-InhibitorACE-Inhibitor CONSENSUS NEJM 1987 CONSENSUS NEJM Months Placebo Enalapril Survival % Placebo Enalapril 31%31%

Spironolactone RALES NEJM 1999

If... If the patient cannot tolerate ACE- inhibitor, ARB may be substituted (valsartan) If the patient cannot tolerate beta blocker, ACE-I and ARB may be combined Isosorbide and hydralazine can be considered in patients who cannot tolerate ACE-I If the patient cannot tolerate ACE- inhibitor, ARB may be substituted (valsartan) If the patient cannot tolerate beta blocker, ACE-I and ARB may be combined Isosorbide and hydralazine can be considered in patients who cannot tolerate ACE-I

Now what should we do? A. Cardiac catheterization to see if the stent is patent B. Stress thallium to see if there is residual ischemia C. Exercise echo to see if the mitral regurgitation and pulmonary hypertension worsen with exercise D. Transesophageal echo to determine severity of mitral regurgitation A. Cardiac catheterization to see if the stent is patent B. Stress thallium to see if there is residual ischemia C. Exercise echo to see if the mitral regurgitation and pulmonary hypertension worsen with exercise D. Transesophageal echo to determine severity of mitral regurgitation

Other considerations A. Put in a defibrillator B. Put in a pacemaker to allow for target doses of beta blocker C. Put in a biventricular pacemaker D. Add amiodarone for the prevention of sudden cardiac death A. Put in a defibrillator B. Put in a pacemaker to allow for target doses of beta blocker C. Put in a biventricular pacemaker D. Add amiodarone for the prevention of sudden cardiac death

Implantable Cardiac Defibrillator (ICD) SCD-HeFT N Engl J Med 2005 SCD-HeFT ICD ICD implantation: Patients with LVEF<30% NYHA II-IV ICD implantation: Patients with LVEF<30% NYHA II-IV 23% N=2,521 IHD/NIHD NYHA class II-III LVEF < 35%

Biventricular Pacing

Cardiac-Resynchronization Therapy (CRT) Ventricular conduction delays cause dysynchronous contraction Biventricular pacing synchronizes ventricle contraction Ventricular conduction delays cause dysynchronous contraction Biventricular pacing synchronizes ventricle contraction Cardiac Function: EF↑ LV size↓ MR ↓ Exercise Capacity Quality of life Hospitalizations Mortality Cardiac Function: EF↑ LV size↓ MR ↓ Exercise Capacity Quality of life Hospitalizations Mortality

CARE-HF N Engl J Med CARE-HF 36% Survival Cardiac-Resynchronization Therapy (CRT) CRT Implantation: Patients with LVEF<35% NYHA III-IV Optimal Medical Therapy QRS >120 ms CRT Implantation: Patients with LVEF<35% NYHA III-IV Optimal Medical Therapy QRS >120 ms N = 813 NYHA III-IV

What other therapies are available Prevention - Control risk factorsPrevention - Control risk factors Life style modificationsLife style modifications Treat etiologic cause / aggravating factorsTreat etiologic cause / aggravating factors Optimized Drug therapyOptimized Drug therapy Specialized care – eg Shikum Lev or Heart Failure clinicsSpecialized care – eg Shikum Lev or Heart Failure clinics Prevention - Control risk factorsPrevention - Control risk factors Life style modificationsLife style modifications Treat etiologic cause / aggravating factorsTreat etiologic cause / aggravating factors Optimized Drug therapyOptimized Drug therapy Specialized care – eg Shikum Lev or Heart Failure clinicsSpecialized care – eg Shikum Lev or Heart Failure clinics

What is the prognosis?

One Year Clinical Event Rate in Heart Failure (%) 26% 66% 27%

Acute Exacerbations Contribute to the Progression of Heart Failure Am J Cardiology 2005 Time Ventricular function Acute event

Treatment – All Patients Prevention - Control risk factorsPrevention - Control risk factors Life style modificationsLife style modifications Treat etiologic cause / aggravating factorsTreat etiologic cause / aggravating factors Optimized Drug therapyOptimized Drug therapy Specialized care – Increase complianceSpecialized care – Increase compliance Advanced TreatmentAdvanced Treatment Prevention - Control risk factorsPrevention - Control risk factors Life style modificationsLife style modifications Treat etiologic cause / aggravating factorsTreat etiologic cause / aggravating factors Optimized Drug therapyOptimized Drug therapy Specialized care – Increase complianceSpecialized care – Increase compliance Advanced TreatmentAdvanced Treatment

Next patient 76 year old man CABG and AVR 10 years ago Normal LV systolic function on most recent echo Presents to the ER with acute decompensated heart failure. 76 year old man CABG and AVR 10 years ago Normal LV systolic function on most recent echo Presents to the ER with acute decompensated heart failure.

In the ER HR 118 and irregular Blood pressure 132/64 RR 22 O2 Sat 94% HR 118 and irregular Blood pressure 132/64 RR 22 O2 Sat 94%

The ECG

What happened?

Heart Failure with preserved EF Inability to fill normally  LA pressure diastolic dysfunction Atrial fibrillation CHF

HFPEF- Etiology Left ventricular hypertrophy –Hypertension –Aortic stenosis Coronary artery disease Diabetes Elderly Infiltrative/restrictive Unexplained Left ventricular hypertrophy –Hypertension –Aortic stenosis Coronary artery disease Diabetes Elderly Infiltrative/restrictive Unexplained

Distribution of LV Function in Patients Age>65 yrs with CHF Gottdiener et al AIM 137(8):

Pressure/Volume Relationship Burkhoff et al Circ 107(5):

Diastolic Heart Failure - Diagnosis Is there a test that will diagnose diastolic heart failure?

Heart Failure One Year Survival Preserved LVF Adjusted Survival =0.26 P=0.26 Adjusted Survival =0.26 P=0.26 Reduced LVF Survival (%) MonthsMonths

CONSENSUS I VeHFT I SOLVD SAVE VeHFT II CONSENSUS II ATLAS PROVED RADIANCE DIG CONSENSUS I VeHFT I SOLVD SAVE VeHFT II CONSENSUS II ATLAS PROVED RADIANCE DIG  MDC  CIBIS I  CIBIS II  ANZ  PRECISE  MOCHA  MERIT-HF  COPERNICUS  CAPRICORN  CHF-STAT  ELITE  ValHFT  ELITE II  CHARM  RESOLVD  PRAISE  WATCH  RALES  GESICA  COMET World’s Literature of Large or Randomized Trials of the Treatment of Systolic Heart Failure

Randomized Trials of Treatment of D-CHF Zile et al Circ 105(12):

CHARM – Preserved Primary Endpoints P=0.072

Diastolic CHF – Goals of Therapy Reduce preload Decrease heart rate Normalize blood pressure Maintain atrial contraction Improve relaxation Cause regression of LVH Decrease interstitial fibrosis Treat ischemia Decrease neurohumoral activation Reduce preload Decrease heart rate Normalize blood pressure Maintain atrial contraction Improve relaxation Cause regression of LVH Decrease interstitial fibrosis Treat ischemia Decrease neurohumoral activation

In the ER The patient was given IV beta blocker and digoxin, with slowing of his heart rate to the 80s. Echo demonstrated : –Dilated atria –Normal LV chamber size with mild hypertrophy. Normal RV size and function –Normally functioning aortic prosthesis –Mild-moderate mitral regurgitation –Mild pulmonary hypertension The patient was given IV beta blocker and digoxin, with slowing of his heart rate to the 80s. Echo demonstrated : –Dilated atria –Normal LV chamber size with mild hypertrophy. Normal RV size and function –Normally functioning aortic prosthesis –Mild-moderate mitral regurgitation –Mild pulmonary hypertension

What do you do now? A. Begin anticoagulation, and plan to cardiovert the patient in 3 weeks B. Begin anticoagulation and plan for TEE cardioversion in the next few days C. Begin anticoagulation, and initiate amiodarone therapy in preparation for cardioversion D. Give digoxin in order to lead to spontaneous cardioversion A. Begin anticoagulation, and plan to cardiovert the patient in 3 weeks B. Begin anticoagulation and plan for TEE cardioversion in the next few days C. Begin anticoagulation, and initiate amiodarone therapy in preparation for cardioversion D. Give digoxin in order to lead to spontaneous cardioversion

Case Presentation 66 year old male Shortness of breath – few months FC NYHA I  III Chest CT: enlarged lymph nodes Biopsy: Sarcoidosis Treated with Steroids 66 year old male Shortness of breath – few months FC NYHA I  III Chest CT: enlarged lymph nodes Biopsy: Sarcoidosis Treated with Steroids

Case Presentation Systolic murmur on the apex Echo 1 year previously: Mod-severe Mitral Regurgitation LV size and Function normal Moderate PHT (50 mmHg) Started on Enalapril, metoprolol & Fusid Systolic murmur on the apex Echo 1 year previously: Mod-severe Mitral Regurgitation LV size and Function normal Moderate PHT (50 mmHg) Started on Enalapril, metoprolol & Fusid

Trans-Esophageal Echo Prolapse of posterior mitral leaflet Rupture Chordea: Severe Mitral Regurgitation Prolapse of posterior mitral leaflet Rupture Chordea: Severe Mitral Regurgitation LV MV LA

Course Surgery - Flail P2 Repair of mitral valve by resection of P2 and suture and implantation of ring Two weeks after surgery: NYHA I-II Echo 1 months later: no MR, no PHT Surgery - Flail P2 Repair of mitral valve by resection of P2 and suture and implantation of ring Two weeks after surgery: NYHA I-II Echo 1 months later: no MR, no PHT

Next case 41 year old woman Previously healthy Presents with acute decompensated heart failure 41 year old woman Previously healthy Presents with acute decompensated heart failure

Echo

Patient begins to deteriorate, and is in low grade cardiogenic shock What are possible causes? What do you do? What are possible causes? What do you do?

A Stepwise Approach

Mechanical pump designed to take over the work of the left heart

Indications Transplant candidate or Destination candidate Hemodynamics: –Cardiac index < 2l/min/m 2 –PCWP > 20mmHg –SBP < 80mmHg or MAP < 65mmHg –On maximal medical therapy Transplant candidate or Destination candidate Hemodynamics: –Cardiac index < 2l/min/m 2 –PCWP > 20mmHg –SBP < 80mmHg or MAP < 65mmHg –On maximal medical therapy

Cardiac considerations Right ventricular function Valve disease (aortic regurgitation, mitral stenosis) Intracardiac shunt Ventricular arrhythmias Ischemia (consider RCA graft) Right ventricular function Valve disease (aortic regurgitation, mitral stenosis) Intracardiac shunt Ventricular arrhythmias Ischemia (consider RCA graft)

Non-cardiac considerations Neurologic status Infection Risk of bleeding Urine output/urea Bilirubin Pulmonary disease Patient preference Neurologic status Infection Risk of bleeding Urine output/urea Bilirubin Pulmonary disease Patient preference

Technical considerations BSA < 1.5m 2 Prosthetic valves Reoperation LV thrombus BSA < 1.5m 2 Prosthetic valves Reoperation LV thrombus

Patient populations Post-cardiotomy failure Myocarditis Acute MI Acute decompensation of chronic heart failure Ventricular arrhythmias Post-cardiotomy failure Myocarditis Acute MI Acute decompensation of chronic heart failure Ventricular arrhythmias

Probability of Survival to Transplant Frazier et al., J Thorac CV Surg 2001

Rematch

Follow up The patient underwent LVAD placement, and underwent cardiac transplant one year later.

Advanced Treatment in HF Revascularization for Ischemia Revascularization Valve Repair or Replacement Valve Ventricular Resynchronization (CRT) Implantable Cardiac Defibrillator (AICD) Ventricular Assist Devices (LVAD) Artificial Heart / Heart Transplant

Thank you