Advanced Heart Failure Therapies
Including LVAD
_________________George Lui, MD
Medical Director,
Adult Congenital Heart Program at Stanford
Prevalence of Heart Failure
1.2-2.2% of adults in the United States between ages 40-59 have heart failure
> 10% of adults over 80 years of age have heart failure
Affects about 5.7 million Americans
Over 500,000 new cases per yearMozzafarian D et al. Circulation 2016; 133: e38
What does the Normal heart do?
Pumps blood to the lungs and the body
Deoxygenated blood returns from the body and then goes to the lung to receive oxygen
Oxygenated blood returns to the heart and then is pumped to the rest of the body
What causes Heart Failure?
Congenital heart disease Coronary artery disease
– “heart attack” Valve disease Hypertension Diabetes Heart muscle disease Alcohol or drug use Abnormal rhythm
ACHD = Heart FailureUnderlying Pathophysiology Examples
Cyanosis Eisenmenger Syndrome
Shunting ASD with left to right shunt
Abnormal anatomic/physiologic connection
Baffle stenosis in TGA Mustard/Senning
Multi-organ venous congestion Fontan circulation
Atrial arrhythmias TGA Mustard/Senning, Tetralogy of Fallot
Iatrogenic myocardial infarction Transecting coronary artery crossing RVOT
Pulmonary Hypertension Shunt related pulmonary hypertension
Dyssynchrony Chronic RV pacing
Increased LV mass and stiffness Coarctation of the aorta
Decreased systemic ventricular function
Systemic RV dysfunction in ccTGA
Decreased lung reserve Restrictive lung disease
Alshawabkeh Curr Heart Fail rep 2016; 13: 247
Symptoms of Heart Failure
Shortness of breath◦ Shortness of breath with exertion◦ Shortness of breath when lying flat
(orthopnea)◦ Shortness of breath at night (paroxysmal
noctural dyspnea) Swelling of the legs, abdomen Weight gain Fatigue
Stage A
At high risk, no structural disease
65 million pts/yr
Stage B
Structural heart disease,
asymptomatic10 mllion pts/yr
Stage D
Refractory HF
200,000 pts/yr
Therapy
• Treat Hypertension
• Treat lipid disorders
• Encourage regular exercise
• Discourage alcohol intake
• ACE inhibition
Therapy
• All measures under stage A
• ACE inhibitors in appropriate patients
• Beta-blockers in appropriate patients
Therapy
• All measures under stage A
Drugs:
• Diuretics
• ACE inhibitors
• Beta-blockers
• Digitalis
• Dietary salt restriction
Therapy
• All measures under stages A,B, and C
• Mechanical assist devices
• Heart transplantation
• Continuous (not intermittent) IV inotropic infusions for palliation
• Hospice care
Stage C
Structural heart dx prior/current
symptoms of HF5 milion pts/yr
Hunt, SA et al. ACC/AHA Guidelines CHF, 2001.
Treatment of Heart Failure
What is Stage D Heart Failure
Persistent shortness of breath at home
Recurrent volume overload despite maximal medical therapy
Recurrent hospitalizations
Hypotension or renal failure
Need for inotrope
Advanced Heart Failure Treatment Options
Chronic inotropes
Devices:
◦ Ventricular Assist Device (VAD)
◦ ECMO: Extracorporeal Membrane Oxygenation
Heart Transplant
Compassionate end-of-life care/hospice
Devices
Implanted Cardiac Defibrillator (ICD)
Biventricular pacemaker (CRT)
Ventricular Assist Device (VAD)
ECMO(Extracorporeal Membrane
Oxygenation)
What is a VAD?
Mechanical pump that assists the heart in pumping blood
VAD = Ventricular Assist Device LVAD = left sided VAD RVAD = right sided VAD
1st generation: Pump 2nd generation: Continuous (axial) 3rd generation: Continuous
(axial/centrifugal)
0
10
20
30
40
50
60
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
% o
f P
atie
nts
Year of Transplant
* LVAD, RVAD, TAH, ECMO
Adult Heart Transplants
% of Patients Bridged with Mechanical Circulatory Support*
2016
JHLT. 2016 Oct; 35(10): 1149-1205
(Transplants: January 2000 – December 2014)
VAD in Congenital Heart Disease
Gelow JM et al JHLT 2013; 32: 1059
• Anatomic placement issues
• Scar tissue (multiple prior surgeries)
• Single ventricle s/p Fontan
Adult and Pediatric Heart TransplantsNumber of Transplants by Year
18
7 32
2
67
1 1,2
61
2,3
57 2,9
98
3,5
25
3,8
22 4,5
28
4,7
54
4,7
35
4,9
39
4,8
38
4,8
02
4,6
83
4,6
02
4,5
15
4,2
00
4,1
10
4,0
44
3,9
13
3,8
38
3,8
07
3,9
36
4,0
01
4,0
13
4,0
42
4,0
71
4,1
63
4,2
33
4,2
54
4,4
77
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Nu
mb
er
of
tran
spla
nts
NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, the presented data may not mirror the changes in the number of heart transplants performed worldwide.
JHLT. 2014 Oct; 33(10): 996-1008
2015
JHLT. 2015 Oct; 34(10): 1244-1254
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Surv
ival
(%)
Years
CHD (N=2,217) ICM (N=42,892) NICM (N=46,174)
Retransplant (N=2,907) VCM (N=3,691)
Adult Heart TransplantsKaplan-Meier Survival by Diagnosis
2016
JHLT. 2016 Oct; 35(10): 1149-1205
Median survival (years):CHD=14.8; ICM=9.5; NICM=11.7; Retransplant=6.2; VCM=10.8
All pair-wise comparisons were significant at p < 0.05 except CHD vs. NICM.
(Transplants: January 1982 – June 2014)
Transplant Indications in CHD
Patients with Stage D HF refractory to medical therapy who will not benefit significantly from surgical, interventional or EP intervention
CHD patients with associated near-sudden death or life-threatening arrhythmias refractory to all therapeutic modalities
Patients with Stage C HF associated with reactive pulmonary HTN and a potential risk of developing fixed, irreversible pulm HTN
Ross HJ et al. Circulation 2016; 133: 802-820.
Challenges for ACHD patients
Complex anatomy
Pulmonary hypertension
Kidney, Lung, Liver disease
Obesity
Substance abuse
Allosensitization
Ross HJ et al. Circulation 2016; 133: 802-820.
Future Direction
Next generation VAD
Percutaneous VAD
Stem cell therapy
Gene therapies
Lacour-Gayet et al. Ann Thorac Surg 2009; 88: 17Rodefeld MD JTCVS 2010; 140: 529
Thank YouAdult Congenital Heart Program
Sue Fernandes, LPD, PA (Program Director)
Stafford Grady, MD
Christiane Haeffele, MD, MPH
Daniel Murphy, MD
Ian Rogers, MD, MPH
Anitra Romfh, MD
Joseph Wu, MD, PhD
Tara Drake, PA
Emily Dong, PA
Carrie Scribner, NP
Christy Sillman, RN, MSN
Jana Rubin
Maria Tirador
Chantel Cazarez-Davila
ACHD Sonographers
Beth Casilli
Anne Depucci
Xiu Tang
Lexi Vincent
Adult Congenital Cardiac Surgery
Frank Hanley, MD (Surgical Director)
Katsuhide Maeda, MD
Olaf Reinhartz, MD
Joseph Woo, MD
Top Related