1. Αντιμετώπιση καρδιακής ανεπάρκειας προχωρημένου και τελικού σταδίου
Β. Μπιστόλα
Καρδιολόγος
Μονάδα Καρδιακής Ανεπάρκειας
Β’ Παν/κη Καρδιολογική Κλινική
ΠΓΝ ΑΤΤΙΚΟΝ

2. Conflict of interest
Honoraria/travel grants: Novartis, Servier, Pfizer

3. Which treatment(s) improve survival and QoL in advanced HF?
Heart transplantation
Left ventricular assist devices
Chronic inotropic infusions
1+ 2
All of the above

4. Which treatment(s) improve survival and QoL in advanced HF?
Heart transplantation
Left ventricular assist devices
Chronic inotropic infusions
1+ 2
All of the above

5. Natural history of heart failure
Allen LA, et al. Circulation. 2012

6. Dismal prognosis of advanced HF
1-year survival of inotrope dependent patients: 11%
Rogers J, JACC 2007

7. ESC HF treatment algorithm

8. Stepwise therapy for heart failure
Stepwise therapy for heart failure. Medication and device therapy for heart failure due to systolic dysfunction is based on the patient's New York Heart Association class. Clinical trials with various therapies show mortality benefit when added to existing therapy; hence, the stepwise approach. ACE indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CRT, cardiac resynchronization therapy; VAD, ventricular assist device; and NYHA, New York Heart Association.
Owens, Brozena, Jessup. Circ Res. 2016

9. Who should be evaluated for advanced HF therapies?
ESC
ACC/AHA
Metra M, et al. Eur J Heart Fail. 2007
Yancy CW, et al. Circulation 2013

10. Therapeutic decision making algorithm in advanced HF
Ammirati et al. Eur J Int Med 2014

11. LVAD indications
ESC HF GD 2016

12. LVADs improve survival awaiting transplantation
Frazier OH, et al. JTCS 2001;122:

13. LVAD as destination therapy-REMATCH trial
122 pts
NYHA IV
LVEF≤25%
70% on inotropes
Rose EA, et al. N Engl J Med 2001; 345:

14. Continuous vs pulsatile VADs
Slaughter MS et al. NEJM 2009;361:

15. DT CAP Trial Quality Of Life Improvements74
225 m 30
Park SJ. AHA Scientific Sessions, November 2010.

16. LVADs: unresolved issues
Complications
Bleeding (perioperative-3mo/gastrointestinal>3mo)
Infections (most common >3mo)
Stroke
Right heart failure
Hemolysis/thrombosis
Very high cost
Incremental cost-effectiveness ratio of destination therapy CF VAD vs OMT $ per QALY
Kirklin et al. 8th annual INTERMACS report JHLT 2017
Rogers JG, et al. Circ Heart Fail 2012

17. VAD technology

18. Axial vs centrifugal pump
HEARTWARE noninferior to HMII
Lower rates of device removal with HEARTWARE (8.8% vs 16.2%)
Higher rates of stroke with HEARTWARE (29.7% vs. 12.1%)

19. Mehra MR et al. N Engl J Med 2017;376:440-450
Reduced pump thrombosis with fully magnetically levitated centrifugal HMIII pump
HMIII vs HMII
294 patients with advanced HF
97.4% INTERMACS 2-4
Primary EP: Survival free of disabling stroke or free of reoperation for replacement or removal of pump within 6 months
Mehra MR et al. N Engl J Med 2017;376:

20. Is the time ready to expand use of LVADs in ambulatory advanced HF?
200 pts, ambulatory advanced HF Nonrandomized, HMII vs OMT

21. LVAD is superior to OMM in ambulatory advanced HF with poorer baseline QoL
Stehlik, J et al. Circ Heart Fail. 2017

22. OMT vs LVAD in INTERMACS 4-7
ISHLT featured abstract
MEDAMACS Registry:
Ambulatory patients (NYHA III–IV, EF ≤ 35%, INTERMACS 4-7)
1 HF hosp +1 high-risk feature: Additional HF Hosp/Low Peak VO2 or 6MWT<300m/NT-BNP >4000/SHFM 1-y survival ≤ 83%

23. Heart transplantation: the gold standard therapy for advanced HF
Drakos S. JACC 2014

24. Heart transplantation: indications and contraindications
CPET
Off β-blocker: pVO2 ≤14 ml/kg/min
On β-blocker: pVO2 ≤12 ml/kg/min
Age <50y or women: additional criteria, ≤50% pVO2
Prognostic scores (additionally to CPET):
Seattle HFM: 1-y <80%
HFSS: medium/high risk
ESC HF Guidelines 2016

25. The heart transplant evaluation
The heart transplant evaluation. The advanced heart failure specialist must determine whether the patient's functional status is limited enough, with optimal medical therapy to require transplantation and ensure that there are no medical, social, or psychological contraindications to transplantation. See text for details.
Kittleson M M , Circulation. 2011;123:

26. Heart transplants in Europe (n=2235 in 2015)
Source: European Council newsletter

27. Medical therapy of advanced HF
Heart 2007;93;626

28. Recommendations for inotropes in end-stage HF

29. Inotropes in end-stage HF
Ginwalla M, Heart Fail Clin 2016

30. Pulsed levosimendan infusions in outpatients with advanced HF-LEVOREP study
Four 2-weekly infusions
120 advanced heart failure (EF≤35%, NYHA class III/IV)
Primary EP: % of patients showing a ≥20% improvement in the 6MWT and a ≥15% score increase in KCCQ at 24 weeks
Pre-specified secondary EP: short-term (8weeks) and long-term (24weeks) event-free survival

31. Levosimendan plus dobutamine vs single dobutamine in refractory HF
Nanas et al. Am J Cardiol 2004;95:94; Nanas et al. Am J Cardiol 2005;95:768

32. Chronic home inotropes in end-stage HF
Survival in non-HTx/LVAD candidates: 1-y 48%, 2-y 38%
197 advanced HF
Hashim T, et al. Circ Heart Fail 2015

33. Take home messages Advanced HF is associated with high mortality rate.
Treatment should be individualized and includes heart transplantation, LVAD implantation and medical therapies.
Timely referral to an advanced HF center for LVAD/HTx evaluation should be done before irreversible end-organ damage.
Heart transplantation remains the gold standard therapy. However, donor organ shortage limits its availability.
LVAD use is expanding, due to technological advances that have improved device durability, patient outcomes and device-related complications. There is a continuing need to reduce device-related complications and cost.