Intervention in end-stage heart failure. Is it ever too late ? Can you solve my problem ?
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Transcript of Intervention in end-stage heart failure. Is it ever too late ? Can you solve my problem ?
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Intervention in end-stage heart failure.Is it ever too late ?
Can you solve my problem ?
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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
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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
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Clinical exam• Respiratory distress• Bilateral inspiratory rales• Gallop rhythm• Congested CVP• 168 cm, 78 kg, BSA 1.87
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ECG
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RX thorax
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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
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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
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What to do ?• Day 6 ICU• Not being able to wean from
inotropic support (Dobutamine/dopamine)
• Repetitive VT’s• Impending multiorgan failure
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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.
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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.
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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).
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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 ?
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Partial support – The concept
• Pace-maker pocket• Outflow to subclavian
artery• Inflow from left
atrium (thoracotomy)• Cable tunneled to
abdomen
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Implantation LVAD
• Lisinopril • Carvedilol• Spironolactone
• B²-adrenergic-receptor agonist ?
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N Engl J Med 2006;355:1873
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N Engl J Med 2001;345:1435-1443.Rematch-trial
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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
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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
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Poor LV-function CADCABG
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Duke University Cardiovascular Database
• EF less than 0.35
• 10-year survival CABG 46 %
• 10-year survival medical therapy 27 %
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Class I, level evidence: B
• Significant left main coronary artery stenosis or left main equivalent
• Proximal LAD with 2- or 3-vessel disease
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Class III
• CABG should not be performed without evidence of intermittent ischemia and without evidence of significant revascularizable myocardium