Stage D Heart Failure. Eric Adler MD Associate Clinical Professor of Medicine Medical Director Cardiac Transplantation

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1 Stage D Heart Failure Eric Adler MD Associate Clinical Professor of Medicine Medical Director Cardiac Transplantation

2 What are the Stages of HF Stage Description Treatment A At risk for HF B Structural Heart Disease; no symptoms C Symptoms D Refractory HT,diabetes,CAD, cardiotoxins, Family hx Prior MI, LVSD, valvular disease Structural disease with SOB, fatigue, decreased exercise capacity Symptoms at rest despite maxium medical therapy Rx HT, lipid disorders Smoking cessation, exercise Limit ETOH ACE in appropriate pts All measures in stage A ACE and β blockers in Appropriate pts Restrict Na Diuretics,digoxin, ACE and β blockers All measures in stages A,B,C Mechanical devices, transplant, continuous inotropic infusions, hospice care

3 Why Should I care about Stage D HF Refractory to Medical Management 10% of HF 20-30% of Hospitalized HF Patients $7-10 Billion Yr on management Mortality is > 50%/year

4 Internists Care for the Majority of Heart Failure Patients in the US Proportion of Patients with HF Receiving Care From Given Type of Physician (N = 44,926) a 11% Family Pract 3% 23% Cardiologists Internal Medicine 63% 4

5 No Improvement in End Stage Heart Failure Treatment in Last 25 Years John C. Loh et al. Circ Heart Fail. 2013;6: Copyright American Heart Association, Inc. All rights reserved.

6 Stage D HF has a Terrible Quality of Life CHF III Dialysis Hepatitis Major Depression Normal Physical Function Bodily Pain General Health Vitality Social Funciton Mental Health

7 The Heart Failure Readmission Cycle Evidence of Incomplete Relief From Congestion symptomatic 50% Improved (but still symptomatic) 38% No improvem ent 12%

8 Jessup,NEJM 2003; 348:20

9 TREATMENT OF HF LASIX DOES NOT CURE HF

10 Do Not Sit on the Stage D Patient

11 The Heart Failure Roller Coaster Allen L A et al. Circulation 2012;125:

12 Stage D Patients Pearls Admitted 2 times/ Year No longer tolerating HF meds BP too low for BB Creatinine too high for ACE Diuretic Resistant/Sodium too low for Diuretics Starting to develop Pulmonary HTN More isolated, depressed Often called non compliant low cerebral perfusion Develop nausea, abdominal pain as much as fatigue and shortness of breath

13 Stage D HF Pearls Ask the following Did you get short of breath walking from the car to this appointment Have you been admitted to the hospital more than twice in a year.

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16 Donor After Cardiac Death (DCD Donors)

17 UCSD HEART TRANSPLANT Number of Transplants 1 Year Survival (Percentage) % 40 90% % 25 70% 20 60% % 40% %

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19 One Heart Goes to Three People

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21 I thank everyone from the bottom of my new heart and liver, said Taitano, father of six children and grandfather of thirteen. I owe the team here everything. After these transplants, it is like nothing was ever wrong with me. I went in one door very sick and came back out a new person. I can breathe again. I can speak again. 2 1

22 Supply and Demand Transplant Limited supply High Demand LVAD Unlimited supply Demand limited strict selection criteria Costs Patient Preference Stage D CHF TX LVAD

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24 Axial Pump Propeller in a pipe Centrifugal Pump Bladed disk spinning in a cavity Pusher: viewed as an auger trying to screw itself into the inlet fluid Thrower: fluid is captured and thrown tangentially out off the blade tips The Journal of Heart and Lung Transplantation, Moazami et al., Vol 32, No 1, January 2013 Comparison of Axial vs Centrifugal Pumps

25 WHY? LVADs Improve Survival in Intermacs 1-4 Patients Number Needed to Treat = 3 Source: Park SJ, AHA 2010

26 Months after Device Implant Intermacs CASD % (93.8%-94.4%) 97.9% (94.4%-99.2%) % (89.1%-90.0%) 97.9% (94.4%-99.2%) % (85.3%-86.3%) 95.3% (90.6%-97.7%) % (80.8%-82.0%) 91.3% (84.7%-95.1%) 26

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30 Patient Update S/P HM2 or HM3 LVAD No recent hospitalizations Part of Local LVAD support Group Not spending there Saturdays with doctors anymore, well sort of..

31 1 week Post 6 weeks Post 4 months post LVAD 4 Weeks Post Transplant

32 32 BiVAD at UCSD

33 Figure 1. Photograph of the Patient s Tattoo Entered into the Medical Record to Document His Perceived End-of-Life Wishes. This patient s presumed signature has been masked.

34 Why is Palliative Care important for End Stage Heart Failure Palliative Care improves symptoms, and well being of both patients and family members Palliative Care dramatically reduces costs Recent studies suggest paradoxical improvement in survival. Adler et al. Circulation 2009

35 Table 3. Guidelines for Communication With Patients About Heart Failure Prognosis and Plan of Care Assessment: Ask the patient what he or she understands about his or her condition. Prognosis: Be conscious that prognostic uncertainty is no excuse for a failure to communicate about the implications of advanced heart disease. Preparation: Prepare the patient emotionally for what to expect. Provide approximate time estimates (eg, months or years?). Talk about some likely scenarios. Preferences: Discuss healthcare proxy, goals if patient is permanently brain injured, cardiopulmonary resuscitation, ventilators, and location of care. Discuss deactivation of ICD/cardiac resynchronization therapy/vad, if applicable. Planning for the worst: Suggest getting financial and emotional affairs in order. Help to mobilize community and family supports (eg, palliative care, home care, hospice referrals).

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37 Conclusion Stage D HF: 2 Blocks, 2 Admissions = Cardiopulmonary Exercise Test Stage D HF is associated with a 1 year survival of 50% VAD and Transplant both offer a 1 year survival of roughly 90% and a dramatic improvement in quality of life. VAD technology continues to evolve. Adaptation for VAD in ambulatory hf will depend on ability to mitigate adverse events