Treatment of Heart Failure:Beyond Medical Therapy

Veronica Franco, MDAssistant Professor – ClinicalDivision of Cardiovascular MedicineVeronica.Franco@osumc.edu

Stage A Heart Failure

J Am Coll Cardiol 2005;46:1116-1143

Sudden Death in Heart Failure

MERIT-HF Lancet 1999

NYHA Class 2 NYHA Class 3 NYHA Class 4

BiV Pacemaker/CRT

Diuretic Digoxin

Diuretic Digoxin ACE-1

Diuretic Digoxin ACE-1 Beta Blocker

ICD Medical Therapy

0

4

8

12

16

Death at Year 1

Effects of Medical Education on Mortality

Device Placement

V1

Right BBB

Left BBB

V1

RV pacing

LV pacing

AHA/ACC/HRS 2008 guidelines for device therapy

Cardiac Resynchronization Therapy

For patients that have a LVEF ≤ 35%, QRS ≥ 120 ms and sinus rhythm, CRT with or without ICD is recommended for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy

For patients that have a LVEF ≤ 35%, QRS ≥ 120 ms and atrial fibrillation, CRT with or without ICD is reasonable for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy

For patients that have a LVEF ≤ 35%, CRT with or without ICD is reasonable for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy and expected frequent pacing post CRT implantation

I IIa IIb III

A

I IIa IIb III

B

I IIa IIb III

C

AHA/ACC/HRS 2008 guidelines for device therapy

Cardiac Resynchronization Therapy

For patients that have a LVEF ≤ 35%, QRS ≥ 120 ms and sinus rhythm, CRT with or without ICD is recommended for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy

For patients that have a LVEF ≤ 35%, QRS ≥ 120 ms and atrial fibrillation, CRT with or without ICD is reasonable for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy

For patients that have a LVEF ≤ 35%, CRT with or without ICD is reasonable for those with NYHA class III or ambulatory class IV HF symptoms on optimal medical therapy and expected frequent pacing post CRT implantation

I IIa IIb III

A

I IIa IIb III

B

I IIa IIb III

C

Device Placement – RAFTPts w/ QRS > 120 ms + LBBB + LVEF<30%

Tang et al. Engl J Med 2010; 363:2385-2395

Mitral Valve Repair

Westaby S: Heart 2000; 83: 603

DOR Procedure

Left ventricular restoration by endoventricular patch repair (the Dor procedure) as opposed to simple linear aneurysmectomy

Westaby S: Heart 2000; 83: 603

LVAD

Total Artificial Heart (TAH-t)

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CardioWest

One-year survival rate following human heart transplant for patients receiving the CardioWest temporary Total Artificial Heart was 70%, compared to 31% for control patients who did not receive the device: NEJM 2004

Cardiac Transplantation

Indications for Cardiac Transplantation or LVAD therapy

Recurrent admissions Peak VO2 < 14 mL/kg/min NYHA class IIIb or IV symptoms despite optimal

therapy Cardiorenal syndrome Low cardiac output symptoms

Contraindications for Transplantation

Age > 70 yo BMI > 35 Active infection or cancer Severe renal failure or pulmonary hypertension Severe complications of DM – retinopathy or neuropathy Social concerns: active smoking or drug/alcohol abuse,

lack of social support.

Contraindications for LVAD

Severe RV failure Bleeding diathesis Severe renal failure Active infection Social concerns, active drug abuse, lack of social

support. Life expectancy < one year for other reasons than HF

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