FIFTH ANNUAL SYMPOSIUM

Tri-City Cardiology Consultants

FIFTH ANNUAL SYMPOSIUM

Faculty Disclosure

Banner Baywood Medical Center- Chief of Staff

NYHA class III-IV symptomsClinical signs of fluid retention and/or peripheral hypoperfusionObjective evidence of severe LV dysfuntion◦ LVEF ≤ 0.30◦ Pseudonormal or restrictive mitral inflow pattern by Doppler◦ High left and/or right-sided filling pressures◦ Elevated b-type natriuretic peptideSevere reduction in exercise capacity◦ 6 minute walk distance < 300 meters◦ Peak VO2 < 12-14 ml/kg/min> 1 hospitalization in the past 6 monthsPresence of above despite optimal medical management

Eur J Heart Failure 2007; 9-68-94

CRT non-respondersSevere LV Dysfunction with tenuous fluid balanceSuboptimal neurohormonal inhibitor dosage limited by hypotension or cardiorenal syndromeRequire IV diuretics or thiazides with loop diuretics◦ Diuretic resistanceRequire IV inotropesA recent HF hospitalizationPersistent symptoms despite optimal medical and device therapyRecurrent ICD dischargesMultiple comorbidities

Optimize neurohormonal inhibition and device therapyHigh risk conventional cardiac surgeryImplantable hemodynamic monitoring to fluid optimizationHeart transplantationMechanical circulatory supportPalliative care/hospice

Severe disease despite adequate medical therapy◦ Unacceptable QOL from CHF Sxs◦ Unacceptable risk of death despite maximum

medical therapy◦ No other reasonable (surgical) options

Absence of other non-cardiac conditions that would limit life expectancy

Age > 70Coexisting systemic illness with poor prognosisInfiltrative diseaseIrreversible PH (MCS has changed this)Acute pulmonary parenchymal diseaseSevere PAD or cerebrovascular diseaseIrreversible hepatic dysfunctionActive infectionPsychosocial instability, substance abuse (includes smoking!), noncomplianceSevere obesity or osteoporosis (relative)Neoplasm within the last 5 years

Heart Transplants in Major Metropolitan Statistical Areas (2010)

MSA Population Transplants Per 100,000

New York 21,976,224 110 0.05

Los Angeles 17,775,984 143 0.8

Chicago 9,725,317 76 0.8

Philadelphia 6,382,714 98 1.5

Houston 5,641,077 107 1.9

Total 61,501,316 534 0.9

Bridge to Transplant - Inserted for short to intermediate term support in patients actively listed for transplantDestination Therapy - Inserted with the intention of long term support in patients who are not transplant candidatesBridge to Recovery - Inserted for short term support in a condition that is anticipated to reverseBridge to Decision – Inserted for support when ultimate therapy is not able to be determined at the time of implantation

To Do:◦ Discuss and consider VAD when NYHA III◦ Consider with poor functional capacity and frequent

decompensations◦ Consider if frequent arrhythmias◦ Have a low threshold for RHC

Not to Do:◦ Wait for progressive renal dysfunction◦ Wait for multiple pressors◦ Wait for cardiac cachexia◦ Necessarily assume PA pressures contraindicate

The recipient is the key!◦ Anticoagulation: aspirin, warfarin for INR target of

2-2.5 unless another indication◦ Prevention of infections: meticulous management of

percutaneous driveline / exit site◦ Management of hypertension: keep MAP 70-90◦ Maintain adequate pulsatility, avoidance of aortic

valve degeneration with valve opening◦ Management of comorbid conditions

Failure to:◦ Prescribe evidence based medications◦ Review medicines that exacerbate CHF◦ Titrate to target doses◦ Help patients adhere to prescribed medication

regimen◦ Address co-morbid conditions◦ Device therapy◦ Provide adequate diet counseling◦ Comply with dietary restrictions◦ Seek early care with escalating symptoms◦ Perform adequate discharge planning & instructions

AHF patients have neurocognitive defects and may not be able to remember details◦ Try to have a caregiver present◦ Repetition by multiple members of the team is good◦ It’s amazing how cardiac output, treated depression

and normal serum Na+ improves intellectThe patient is frightened and expects the worst (most have been given a death sentence – the failing heart)◦ Less likely to comprehend and remember

Repetitive admissionsIV inotropesProgressive renal dysfunctionCardiac cachexia/ anemia/ hyponatremiaBlood pressure issues resulting in the inability to use neurohormonal inhibition