Tri-City Cardiology Consultants FIFTH ANNUAL SYMPOSIUM

Transcription

1 Tri-City Cardiology Consultants FIFTH ANNUAL SYMPOSIUM

2 Faculty Disclosure Banner Baywood Medical Center -Chief of Staff FIFTH ANNUAL SYMPOSIUM

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4 NYHA class III-IV symptoms Clinical signs of fluid retention and/or peripheral hypoperfusion Objective 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 peptide Severe reduction in exercise capacity 6 minute walk distance < 300 meters Peak VO2 < ml/kg/min > 1 hospitalization in the past 6 months Presence of above despite optimal medical management Eur J Heart Failure 2007;

5 CRT non-responders Severe LV Dysfunction with tenuous fluid balance Suboptimal neurohormonal inhibitor dosage limited by hypotension or cardiorenal syndrome Require IV diuretics or thiazides with loop diuretics Diuretic resistance Require IV inotropes A recent HF hospitalization Persistent symptoms despite optimal medical and device therapy Recurrent ICD discharges Multiple comorbidities

6 Optimize neurohormonal inhibition and device therapy High risk conventional cardiac surgery Implantable hemodynamic monitoring to fluid optimization Heart transplantation Mechanical circulatory support Palliative care/hospice

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8 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

9 Age > 70 Coexisting systemic illness with poor prognosis Infiltrative disease Irreversible PH (MCS has changed this) Acute pulmonary parenchymal disease Severe PAD or cerebrovascular disease Irreversible hepatic dysfunction Active infection Psychosocial instability, substance abuse (includes smoking!), noncompliance Severe obesity or osteoporosis (relative) Neoplasm within the last 5 years

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15 Heart Transplants in Major Metropolitan Statistical Areas (2010) MSA Population Transplants Per 100,000 New York 21,976, Los Angeles 17,775, Chicago 9,725, Philadelphia 6,382, Houston 5,641, Total 61,501,

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

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23 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

24 The recipient is the key! Anticoagulation: aspirin, warfarin for INR target of unless another indication Prevention of infections: meticulous management of percutaneous driveline / exit site Management of hypertension: keep MAP Maintain adequate pulsatility, avoidance of aortic valve degeneration with valve opening Management of comorbid conditions

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26 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

27 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 intellect The patient is frightened and expects the worst (most have been given a death sentence the failing heart) Less likely to comprehend and remember

28 Repetitive admissions IV inotropes Progressive renal dysfunction Cardiac cachexia/ anemia/ hyponatremia Blood pressure issues resulting in the inability to use neurohormonal inhibition