Choosing the Optimal Candidate for Durable MCS
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- Ashley Chambers
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1 Choosing the Optimal Candidate for Durable MCS Paolo C. Colombo, M.D., F.A.C.C. Sudhir Choudhrie Professor of Cardiology Director, Center for Advanced Cardiac Care: Heart Failure, MCS & Transplant Division of Cardiology Columbia University Medical Center
2 Presenter Disclosure Information Paolo Colombo, MD The following relationships exist related to this presentation: Research Grant: Abbott Consultant: Abbott (no honoraria)
3 Choosing the Optimal Candidate for Durable MCS or I, the HF specialist, should choose the right candidate (i.e. right time) for LVAD implantation
4 The root of the problem John - July yo man h/o, HTN, AWMI, CABG, ICM, HFrEF for 7 years, LVEF 25%, LVEDd 7.0 cm, stable on neurohomonal blockade, until 2 admissions for ADHF 2/2 in the past year for diet indiscretion ( I ate a pizza the night before ) Increased lasix requirement from 20 to 60 mg daily ICD shock x1 Creat 1.5 (1.1) mg/dl Na: 136 I can walk at least 2 blocks without stopping He asks his cardiologist how sick he is: Do not to worry, we got the water out of your body, you have not had a shock in more than 3 weeks, and you will be fine
5 Defining Advanced Heart Failure ( 250,000 patients in the US) HF HOSPITALIZATIONS SEVERE FUNCIONAL LIMITATION: 6-MWD <300 m Peak VO 2 <14 ml kg 1 min 1 or <50% of predicted DE-ESCALATION of HF medications due to renal failure and hypotension DIURETIC RESISTANCE LOW NA Recurrent ARRHYTHMYAS: Afib/VT/ICD shocks RV FAILURE Need for IV INOTROPES for symptomatic relief or to maintain hemodynamics and end-organ function Yancy CW JACC 2017 & Fang JC J Cardiac Failure 2015
6 Lung Cancer Hospitalization and Prognosis Setoguchi et al AHJ 2007;154:260
7 Heart Failure and Research Funding Lung Cancer 390,000 patients AHA.org
8 Objective Assessment of Functional Capacity: CPET and 6-Minute Walk Test Ross RM et al BMC Pulmonary Medicine. 2010;10:31
9 RHC = Objective Assessment of Hemodynamics 35 yo man, DCM on ACEI, BB, Aldo-antagonist (recent dose reduction 2/2 hypotension); creat 1.6 mg/dl (1.3 mg/dl, 6 months ago). States: I feel good, I can walk at least 10 blocks non-stop. BP 90/60; 12 cm JVD; Lungs: clear VO 2 max: 12.7 ml/kg/min RHC RA 13 RV 55/24 PAP 51/28 (37) PCWP 26 PA sat 48.5% CO/CI 3.14/1.8
10 Inability to Tolerate Beta-blockers or ACE Inhibitors Predicts Mortality in Patients with Heart Failure Fonarow GC/ Stevenson LW JACC 2018 Kettleson M / Stevenson LW JACC 2003
11 Diuretic Resistance & Hyponatremia Predict Mortality in Patients with Heart Failure Neuberg GW / Packer M AHJ 2002 Rusinaru D / Doughty RN AHJ 2012
12 ICD shocks Predict Mortality in Patients with Heart Failure The most common cause of death among patients who received any ICD shock was progressive heart failure Poole J / Bardy GH NEJM 2008
13 Seattle Heart Failure Model Heart Transplant:84% LVAD:68% Levy W et al Circulation. 2006;113(11):1424
14 Importance of the RV Progressive RV dysfunction causes end-organ damage (irreversible?) We do NOT have great solution for long-term RV MCS (RVAD)
15 Palliation i.v. Inotropes 26% 6% 25% 8% Hershberger RE J Card Fail 2003;9:180 Rose EA NEJM 2001;345:1435 Death sentence: patients sit on the death row
16 Advanced Heart Failure Promptly! HF specialist Yancy CW JACC 2017 & Fang JC J Cardiac Failure 2015
17 2010 CMS Criteria for Destination Therapy CMS criteria for LVAD- Destination Therapy (DT) Not Transplant candidate Peak VO2 14 or unable to exercise LVEF 25% LVAD-DT Failed to respond to medications (class IV) for >45 out of last 60d or or i.v. Inotropes >14days or or Intra-Aortic Balloon Pump >7 days
18 THANK YOU INTERMACS! Too sick? Would this patient feel better if on inotropes? Too well
19 Survival Free from LVAD Rescue is 2 Times Higher in INTERMACS 6/7 than INTERMACS 4: 78% vs. 39% MedaMACS: 166 patients class III IV HF ejection fraction 30% 1 HF hospitalization in the previous year excluding patients listed for transplant or receiving chronic intravenous inotropic therapy Stewart GC / Stevenson LW Circ Heart Fail 2016
20 Can we safely and effectively treat less sick patients? Prospective, nonrandomized, observational, multicenter clinical trial N=
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23 Starling RC / Rogers JACC HF 2017
24 Improved 6MWT, NYHA, QOL and Depression in LVAD Patients
25 Adverse Events were More Frequent in LVAD patients
26 Suggested Management Pathway in non-inotrope Dependent HF Patients Every 1-3 months Patient HF specialist Technology
27 INTERMACS 1 Too sick?
28 Case continued. John - July 2017 (2 years later) had 8 hospitalizations over the past 2 years. his diuretics increased to Lasix 100 mg BID + Metolazone 5mg TIW is now on lisinopril 2.5 at night has been off BBs for the past 4 weeks has been admitted to the local hospital after her third ICD shock Transferred to Columbia VS: BP 70/palp HR 105 SR PE: cool to touch 1+ peripheral edema Admitted to the CCU Dobutamine 5 mcg/kg/min / Lasix IV Labs: SCr 2.10 / GFR 40 / BUN 76 / Na 127 TB 2.2 / Alb 3.1 / Alk Phos 250/ INR 2.5 NT-proBNP 7000 Urine protein 2+/ 24hr RHC 5 RA 19 mmhg PAP 51/28/38 mmhg PCWP 22 mmhg FCO 1.96 L/min FCI 1.2L/min/m2 PVR 8.1 WU
29 Milrinone.25mcg/kg/min Dobutamine 5 mcg/kg/min IABP 1:1 VS: BP 100/70 HR 84 SR Labs: Scr 1.6 GFR 48 BUN 40 Na 136 TB 1.3 DB 1 Alb 3.4 INR 1.2 RHC: RA 8 mmhg PAP 47/19/26 mmhg PCWP 14 mmhg FCO 3.5 L/min FCI 2.1 L/min/m2 Risk Profile: MELD Score 15 (Low Risk) CVP/PCWP 0.57 (Low Risk) PAPi 3.5 (Low risk) PVR 3.4 WU (Moderate risk) RVSWi 650 mm Hg ml/m 2 (Low Risk) HeartMate II risk score1.0 (Low risk) LOW RISK, really????? US: Liver: nodularities suggestive of cirrhosis Liver Biopsy: Moderate centrilobular fibrosis, w/ some bridging central to central sinusoidal fibrosis and nodularity (stage 2)
30 Triad of Evil RV failure Renal Failure INOPERABLE? Vasodilation (eg, liver failure, bleeding)
31 To VAD or NOT to VAD That is the Question NO Too high risk (i.e. patient will not benefit) Resource utilization $$$ Morbidity/re-hospitalization YES 58% Need to treat 2 patients to save 1 life!! 8%OMM REMATCH
32
33 VASODILATION / VASOPLEGIA SVR Treatment: Standard vasopressors: PHE, EPI, NE, Vasopressin Methylene Blue
34 Post op MAP goal >70 mmhg MAP = SVR X CO RV LV CO VULNERABLE RV LIMITED RV RESERVE RELATIVE RV FAILURE
35 POD0 Case continued. Milrinone 0.25 DBA 5 Levo 6 Pitressin 3 MAP 73 CVP 14 / PAP 32 / W13 CI 2.2 Creat 1.6 LA 3.5 Lasix drip 5 mg/h UO 75 cc/h Heart Mate II 8800 / PI 3.4 RVAD For Vasoplegia w/ relative RV failure Milrinone 0.20 Epi 3 Levo 12 Pitressin 6 MAP 72 CVP 16 / PAP 30 / W13 CI 2.2 Creat 2.2 LA 3.4 Lasix drip 10 mg/h UO 50 cc/h (going down) Heart Mate II 8800 / PI 3.0
36 RV Support Devices V-A ECMO Protek Duo Impella RP Pros Bedside insertion Gas exchange More mobility Compatible w/ any centrifugal flow pump Less anticoagulation? Easy insertion/removal Prospective data Cons Risk of systemic emboli Need to allow enough pulm flow to feed the LV Less mobility Catheter stability? NOT feasible if TV intervention More anticoagulation? Less mobility NOT feasible if TV intervention
37 Similar Changes in Hemodynamics with prvad and srvad srvad prvad Coromelis / Garan ISHLT 2017
38 Case continued. prvad removed POD10 ICU LOS 15 days Total LOS 42 days John was discharged to acute rehab Success???? Sustainable????
39 Columbia - MULTIDISCIPLINARY APPROACH NEUROLOGY Dr. Willey RENAL Dr. Radhakhrishnan GI Dr. Gonda Cardiology CTICU Patient Intensivists HEMATOLOGY Dr. Eisenberger CT Surgery PHARMACIST D. Jennings 9:10 AM EP / VT Ablation Dr. Iyer VAD PROGRAM MANAGER B. Cagliostro SOCIAL WORKER M. Staker PALLIATIVE CARE Dr. Nakagawa ID Dr. Scully
40 2 years COLUMBIA DESTINATION THERAPY INTERMACS 1-3: Columbia University: 96% National average: 82,6% Percent Survival [% (70% CI)] Months after Device Implant Intermacs NYCP % (93.2%-93.8%) 98.0% (96.5%-98.9%) % (87.7%-88.4%) 91.4% (88.8%-93.4%) % (83.1%-83.9%) 89.3% (86.5%-91.6%) % (76.4%-77.4%) 86.2% (83.0%-88.8%) % (64.1%-65.3%) 76.5% (72.2%-80.2%) % (53.0%-54.4%) 69.0% (63.8%-73.5%) % (43.5%-45.2%) 62.3% (56.3%-67.7%) % (36.1%-38.0%) 46.7% (39.5%-53.5%)
41 Yes: a great LVAD and transplant candidate: 2 years ago EARLY REFERRAL is KEY! To avoid Renal, Liver and RV failure
42 2017 ACC Expert Consensus for Optimization of Heart Failure Treatment Annual review by a heart failure specialist for patients with established advanced HF discuss current and potential therapies for both anticipated and unanticipated events, possible HF disease trajectory and prognosis, patient preferences, and advanced care planning. HF specialist Heart Failure Specialist An initial followed by routine annual (or biennal) assessment by a heart failure specialist should be the standard for all symptomatic heart failure patients to review response to treatment, and risk stratification based on cardiopulmonary exercise test and right heart catheterization when indicated. This specialized HF assessment will help to recognize early signs of clinical deterioration (ie, advanced HF) and should be embedded in providers (i.e. general cardiologists and practitioners) mindset similar to how mammogram and colonoscopy screenings are reflexively considered standard of care.
43 Thank you!
เอกราช อร ยะช ยพาณ ชย
30 July 2016 เอกราช อร ยะช ยพาณ ชย Heart Failure and Transplant Cardiology aekarach.a@chula.ac.th Disclosure Speaker, CME service: Merck, Otsuka, Servier Consultant, non-cme service: Novartis, Menarini
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