intervention in end-stage heart failure. is it ever too late ?

Intervention in end-stage heart failure.Is it ever too late ?

Can you solve my problem ?

Emergency room

• 61 old man• No medical history• well until 3 weeks before intake• Progressive deterioration• fatique, cough, shortness of breath• No chest pain• At intake respiratory distress

Clinical history• Had regular check-up by GP• physically active up to 3 weeks

before intake (holiday spain) • Had a good physical condition • No familial CV-history

Clinical exam• Respiratory distress• Bilateral inspiratory rales• Gallop rhythm• Congested CVP• 168 cm, 78 kg, BSA 1.87

ECG

RX thorax

Lab results (intake)

• CRP 41 mg/l• Troponine 1.86 µg/l• CK 285 U/l (CK-MB < 0.7 %)• Lactate 2.8 mmol/l• Creatinine 1.78 mg/dl

Hemodynamics• Heart rate : 118/min• CO: 3.2 l/min (thermodilution), CI 1.71• 95/65 mmHg• Mixed venous saturation 42 %

• (mmHg) : systolic diastolic mean----------------------------------------------------------------------------• R.A. 12• R.V. 65 18• A.P. 63 45 50• PCW 39• AO 116 89 99• LV 116 36

What to do ?• Day 6 ICU• Not being able to wean from

inotropic support (Dobutamine/dopamine)

• Repetitive VT’s• Impending multiorgan failure

Use of a Continuous-Flow Device in Patients Awaiting Heart Transplantation

Leslie W. Miller, M.D., Francis D. Pagani, M.D., Ph.D., Stuart D. Russell, M.D., Ranjit John, M.D., Andrew J. Boyle, M.D., Keith D. Aaronson, M.D., John V. Conte, M.D., Yoshifumi Naka, M.D., Donna Mancini, M.D., Reynolds M. Delgado, M.D., Thomas E. MacGillivray, M.D., David J. Farrar, Ph.D., O.H. Frazier, M.D., for the HeartMate II Clinical Investigators

NEJM 2007 357:885-96.

results• The principal outcomes occurred in 100 patients (75%).

• The median duration of support was 126 days (range, 1 to 600).

• The survival rate during support was 75% at 6 months and 68% at 12 months.

• At 3 months, therapy was associated with significant

improvement in functional status (according to the New York Heart Association class and results of a 6-minute walk test) and in quality of life (according to the Minnesota Living with Heart Failure and Kansas City Cardiomyopathy questionnaires).

• Major adverse events included postoperative bleeding, stroke, right heart failure, and percutaneous lead infection.

• Pump thrombosis occurred in two patients.

Surviva l F unction (includ ing HT X)Comple te Censored

0 100 200 300 400 500

Surviva l T ime (days)

0 ,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

Cu

mu

lativ

e P

rop

ort

ion

Su

rviv

ing

Kaplan Meier curve voor totale overleving na plaatsing assist device tot en met transplantatie: ca. 60% na 500 dagen. UZ Leuven (2000-2007).

1: Critical cardiogenic shock

2: Progressive decline

3: Stable but inotrope dependent

4: “recurrent” decompensation

5: comfortable at rest but are exercise intolerant for most activity

6: able to do some mild activity, but fatigue results within minutes with meaningful physical exertion.

7: NYHA Class IIIB

INTERMACS PATIENT PROFILE/STATUS

LVAD

Partial support ?

Partial support – The concept

• Pace-maker pocket• Outflow to subclavian

artery• Inflow from left

atrium (thoracotomy)• Cable tunneled to

abdomen

Implantation LVAD

• Lisinopril • Carvedilol• Spironolactone

• B²-adrenergic-receptor agonist ?

N Engl J Med 2006;355:1873

N Engl J Med 2001;345:1435-1443.Rematch-trial

CHF and CAD and no symptoms of angina• Revascularisation has not been

shown to improve cardiac function or symptoms or to prevent reinfarction or death

• Appealing theoretical possibilities: imaging – myocardium that is viable but not contracting normally

PCI - Revascularisation = reasonable class IIa (B)• Significant lesions• Suitable for PCI and high likelihood

of success and low procedural risk• Vessels substending significant

area of viable myocardium or be associated with ischemia on noninvasive testing

Asymptomatic ischemia or CCS I or II

Poor LV-function CADCABG

Duke University Cardiovascular Database

• EF less than 0.35

• 10-year survival CABG 46 %

• 10-year survival medical therapy 27 %

Class I, level evidence: B

• Significant left main coronary artery stenosis or left main equivalent

• Proximal LAD with 2- or 3-vessel disease

Class III

• CABG should not be performed without evidence of intermittent ischemia and without evidence of significant revascularizable myocardium