Treatment Options for Advanced Heart Failure

Transcription

1 Advanced Heart Failure Definition Treatment Options for Advanced Heart Failure Liviu Klein MD, MS Associate Professor of Medicine Director, Mechanical Circulatory Support and Heart Failure Device Programs Patients with symptoms (shortness of breath, fatigue, leg swelling) on minimal exertion (NYHA class IV) for more than 2 months More than 2 hospitalizations for heart failure in the last year Intolerant of heart failure medications, due to low blood pressure or worsening kidney function Requiring IV medications to keep the fluid off Advanced Heart Failure 1-yr hospitalization: 60% (2/3 > than once) 1-yr mortality 50% (40% HF, 10% sudden) Cardiovascular Mortality Stage IV small cell lung cancer Constanzo MR et al. Am Heart J. 2008; 155: Go AS et al. Circulation. 2014; 129: e28-e292. 1

2 End Stage Heart Failure in the US 320 million US population ~ 1.5% with HF => ~ 5.1 million 55% with Diastolic ~ 3.5 million 45% with Systolic ~ 2.3 million? NYHA class IV younger than 80 yrs.: ~ 80,000 pts. Miller LW et al. Circulation. 2011; 123: % NYHA class I 35% NYHA class II 20% NYHA class IIIA 5% NYHA class IIIB 5% NYHA class IV Adult Heart Transplant Survival Heart Transplant Survival at UCSF Lund LH et al. J Heart Lung Transplant. 2013; 32:

3 Functional Status After Heart Transplant Re-hospitalizations After Heart Transplant Lund LH et al. J Heart Lung Transplant ; 32: Lund LH et al. J Heart Lung Transplant. 2013; 32: Immunosupression Therapy After Heart Transplant Post Transplant Morbidity Outcome Within 1 Year Within 5 Years Within 10 Years Hypertension 72.8% 92.6% Kidney Dysfunction 26.7% 53.0% 68.2% Abnormal Creatinine < 2.5 mg/dl 18.3% 33.2% 37.5% Creatinine > 2.5 mg/dl 6.6% 15.8% 21.1% Chronic Dialysis 1.5% 2.9% 6.1% Renal Transplant 0.3% 1.2% 3.6% High cholesterol 60.2% 88.0% Diabetes 26.5% 38.0% Cardiac Allograft Vasculopathy 7.9% 30.4% 49.7% Lund LH et al. J Heart Lung Transplant ; 32: Lund LH et al. J Heart Lung Transplant ; 32:

4 Living with a Heart Transplant Blood tests for checking levels, CBC, CHEM As often as weekly Infectious disease follow-up Pre-existing exposure to TB, CMB, HBV Active infections Immunizations/ travel Endocrine follow-up Insulin treatment Bone density/ treatment of osteoporosis Nephrology follow-up Immunosupreesive medication induced renal dysfunction Living with a Heart Transplant Dermatology follow-up Cancer screening and treatment Judicious sun protection Nutrition for weight management Weight increases early post transplant (steroids) and late (laziness) Screening and health maintenance Breast/ Pap exam Colonoscopy Psychology follow-up Depression Heart Transplants: Not Enough 2127 adult transplants in US in 2013 < 25% in adults over age 65 Lund LH et al. J Heart Lung Transplant. 2013; 32: Durable Ventricular Assist Devices Pulsatile (1 st generation) HeartMate XVE, Novacor Continuous axial flow (2 nd generation) HeartMate II Jarvik, HeartAssist 5 (MicroMed) Continuous centrifugal flow (3 nd generation) VentrAssist HVAD HeartMate III, EvaHeart, Mag-Lev Total artificial heart Syncardia Carmat 4

5 Durable Ventricular Assist Devices First Generation VAD: HM XVE Pusher plate VAD fills and empties Vents air to outside Intraperitoneal or abdominal wall pocket Device infection: 40% 18 month durability Second Generation VAD: HM II Axial flow rotary pump Mechanical bearing Small Durable (> 5 years) Third Generation VAD: HVAD Pericardial placement Centrifugal continuous flow Hybrid magnetic/ hydrodynamic suspension impeller Integrated inflow cannula Thin (4.2 mm), flexible driveline with fatigue resistant cables 5

6 Potential Complications Infections (15%) Driveline, pocket, sepsis Bleeding (20%) Mostly gastrointestinal from AV malformations Stroke (10%) Ischemic/ hemorrhagic Device failure/ thrombosis (5-10%) Can be predicted by blood tests Right Ventricular Failure (1-5%) Inotropes 7-14 days Requiring RVAD VADs Improve Quality of Life Rogers JG et al. J Am Coll Cardiol. 2010; 55: VADs Improve Functional Capacity BTT VAD Survival at UCSF Died Explant Transplant On going support Rogers JG et al. J Am Coll Cardiol. 2010; 55:

7 The Rise of the Machines: 2013 The Future is Here: Smaller VADs XVE HM II 2420 VADs (1052 as DT) 2127 transplants MVAD HeartMate X Kirklin JK et al. J Heart Lung Transplant. 2014; 33: will see a fully implantable, miniaturized VAD, inserted via a minimal invasive surgery, providing 10 years of life, with a QALY < 50,000$ 27 7