Stable Heart Failure Patients

End Stage Heart Failure

Advanced Therapy Patients

22 24 26 28

US Average

UCSD

Readmission Rate 30 D

Decompensated HF 2011

The Three Elements of

Decompensated Heart Failure

Increased preload

Volume overload

Increased Afterload

Vasoconstriction

Myocardial dysfunction Decreased cardiac output

Vasodilators

Nitroglycerin, Nipride, Natricor

Pathophysiology Treatment

Diuretics

Lasix, Bumex

Inotropes Dobutamine,

Dopamine, Milrinone

7% 6%

13%

26%

27%

16%

3% 2%

0

5

10

15

20

25

30

Enro

lled D

ischarg

es

(%)

(<-20) (–20 to –15) (-15 to –10) (–10 to –5) (–5 to 0) (0 to 5) (5 to 10) (>10)

Change in Weight (lbs)

Nearly 50% of ADHF patients

discharged with weight gain or

losing less than 5 lbs

Evidence of Incomplete Relief From Congestion

Change in Weight During Hospitalization January 2001 to April 2006 (n=96,094)

Adhere National Benchmark Report Data, January 2001 to April 2006.

Note: n represents the number of patients who have both baseline and discharge weight, and the percentage is calculated based on the total

patients in the corresponding population. Patients without baseline or discharge weight are omitted from the histogram calculations.

Outcomes with Standard Care

Diuretic Optimization Strategies

Evaluation in Acute Heart Failure

(DOSE) G. Michael Felker, MD, MHS, FACC

Christopher M. O’Connor, MD, FACC

on behalf of the

NHLBI Heart Failure Clinical Research Network

Aims

To evaluate the safety and efficacy of various initial

strategies of loop diuretic administration in patients with

ADHF

Route of administration:

Continuous infusion vs. Q12 hours bolus

Dosing

Low intensification (1 x oral dose) vs. high intensification (2.5 x

oral dose)

Death, Rehospitalization, or ED

Visit

HR for Continuous vs. Q12 = 1.19

95% CI 0.86, 1.66, p = 0.30 HR for High vs. Low = 0.83

95% CI 0.60, 1.16, p = 0.28

0

0.1

0.2

0.3

0.4

0.5

0.6

0 10 20 30 40 50 60

Days

Pro

po

rtio

n w

ith

De

ath

, R

eh

os

p,

or

ED

vis

it

High Low

0

0.1

0.2

0.3

0.4

0.5

0.6

0 10 20 30 40 50 60

Days

Pro

po

rtio

n w

ith

Death

, R

eh

osp

, o

r E

D V

isit

Continuous Q12

Conclusions

There was no statistically significant difference in global

symptom relief or change in renal function at 72 hours for

either:

Intermittent bolus vs. continuous infusion

Low intensification vs. high intensification

Aquaphoresis

for Diuretic

Resistance

My Own Aquapheresis

Statistics Treatment summary Oct 27, 2010 through May 11, 2011

Number of treatments (circuits): 19

Average treatment time: 27.73 hours

Average fluid removed/treatment: 4.12 Liters or

9.07 Lbs

Most common fluid removal rate(s): 46% (10 - 100 ml/hr)

38% (110 - 200 ml/hr)

Most common blood flow rate(s): 63% (25-30 ml/min)

28% (35-40 ml/min)

Source: Data downloaded from your Aquadex device(s)

Do Not Sit on the Stage D

Patient

Prognostication in Heart Failure: The

Heart Failure Trajectory

Supply and Demand

Transplant

Limited supply

High Demand

LVAD

Unlimited supply

Demand limited

strict selection criteria

Costs

Patient Preference

TX LVAD

Stage D CHF

HeartMate II LVAS Key Design Features

Relatively Simple Design

Valveless

Only one moving part, the rotor

Blood immersed bearings designed

for minimization of blood damage

All motor drive and control

electronics are outside of the

implanted blood pump

Speed range: 6,000 to 15,000

rpm

Flow range: 3 – 10 L/min

TAH Attributes

No right heart failure

No arrythmias, no antiarrythmic drugs

No inotropes

Low CVP, High Output, Control of the Circulation

No afterload dependence

Rescues patients in acutely decompensating cardiogenic

shock (crash and burn patients)

VAD Development: 2nd Generation

Updated Heartmate II outcomes

Medical Therapy

Heart Transplant

Outcomes with Heartmate II already competing with

gold standard treatment

Mechanical heart pump a temporary fix for the broken heart of a Portland teenager

Hentz fought the idea for days, snapping at family and nurses and shouting, "I hate you!" at one of her cardiologists, Dr. Eric Adler.

Is a VAD a treatment for

Cardiorenal Syndrome?

Unanswered question

Challenges

Need uniform diagnostic criteria

Most patients have concomitant medical-

renal disease

If patient gets better, than it was cardiorenal, if they

don’t , they either have bad right heart failure or some

other diagnosis.