Device Therapy for Heart Failure

Transcription

1 Device Therapy for Heart Failure Dr. Shelley Zieroth FRCPC Assistant Professor, Cardiology, University of Manitoba Director of Cardiac Transplant and Heart Failure Clinics St Boniface General Hospital, Winnipeg, MB Head, Medical Heart Failure Program WRHA Cardiac Sciences Program

2 Objectives ICD CRT (BIV pacers) VADs (ventricular assist devices) and MCS (mechanical circulatory support)

3 General Rx Strategies in HF Asymptomatic Mild/Mod Severe Refractory Correct Cause: Arrhythmias Ischemia Pressure Load ICD as indicated Dig + Spironolactone Diuretics VAD, Tx Tailored Rx β-blockers carvedilol, metoprolol, bisoprolol Angiotensin Converting Enzyme Inhibitors/ARB No Added Salt gm Na Activity as Tolerated Customized Ex Training Modified from Warner-Stevenson, ACC HF Summit CRT

4 Cardio-Renal Syndrome Courtesy CHFsolutions website

5 Ultrafiltration Superior wt loss Improved and sustained symptom control No increase adverse biochemical events

6 Diamonds.. Devices are A Heart Failure Doc s s Best Friend Part 1: ICD s and CRT

7 Probability of Survival (%) ICDs Reduce Mortality MADIT II Medical Therapy (n=490) SCD-HeFT 23% RRR MADIT-II 31% RRR MADIT-1 54% RRR MADIT II ICD Therapy (n=742) Secondary Prevention Medical Therapy (n=932) Time (Y) Secondary Prevention ICD Therapy (n=934)

8 Anticipating Future Device Needs and Costs in Manitoba A recent technology assessment document for a Canadian insurance company estimated a cost effectiveness of ICD s: $ / life-year gained $ / quality adjusted life-year gained Current (May 2007) cost estimates per device: ICD $ CRT/ICD $ (a mere $5590 more than ICD alone)

9 ICD Statistics: Primary Prevention For every 100 patients with an ICD for Primary Prevention over 5 years: 6-77 deaths prevented 30 die regardless have an inappropriate shock complications of device (implant or future) 30 nothing will happen

10 CRT Cardiac Resynchronization Therapy

11 Hemodynamic Effects of Bi-ventricular Pacing Increased LV ejection fraction and fractional shortening Increased cardiac output Prolonged diastole and LV filling time Reduced LV end diastolic and end systolic volumes Increased LV synchrony and pulse pressure Increased peak oxygen uptake Decreased PCWP Decreased MR Decreased apoptosis and interstitial remodeling Decreased TNF-α D Ascia, European Heart Journal (2006) 27,

12 CRT 70% of patients improve NYHA Patients with symptomatic (NYHA III-IV) HF despite OMM, and who are in normal sinus rhythm with a QRS duration 120 msec and an LVEF 35%, (Class I, Level A) COMPANION Time to Primary Endpoint CRT 19% RRR CRT-D 20% RRR CARE-HF Percentage Free of Primary Endpoint 36%RRR COMPANION Death from/or Hospitalization for HF CARE-HF Unplanned Hospitalization Due to Worsening HF % of patients % M edical Therapy Alone p < % M edical Therapy + Cardiac Resync. Cleland JGF et al. N Engl J Med 2005;352: Bristow MR et al. N Engl J Med 2004;350: Hunt et al, AHA/ACC Guidelines on HF Circ 2005

13 Device Referral Algorithm 1 prevention ICD CRT/BIV LVEF 35% LVEF 35% Non-ischemic CMO For min 9 mos NYHA II-III (I??) Ischemic** CMO with QRS 120ms and NSR (or rate controlled afib) NYHA III-IV Refer for ICD consideration. Unless contraindicated ** LVEF 30 d post MI or 90 days post revascularization Refer for CRT +/-ICD consideration, Unless contraindicated

14 Echo Dyssynchrony Pre-CRT Post-CRT

15 Diamonds.. Devices are A Heart Failure Doc s s Best Friend Part 2: VADS

16 Mechanical Circulatory Support Left Ventricular Assist Device/System Short Term Support LV Recovery Device Removal Long-Term Support and Destination Therapy Intermediate Support Bridge to Transplant and Transplant Candidacy

17 ECMO: Extracorporeal Membranous Oxygenation V-V V (primary lung) V-A A (primary heart) Peripheral or central cannulation

18 ECMO:Post-Cardiotomy Cardiotomy Shock 74% alive at 5 years 24% survive to discharge Doll et al, Ann Thorac Surg 2004;77:151 7

19 Recovery Devices (Short Term) Levitronix Centrimag Pump Impella LP Impella LD +RD BVS 5000 Pump AB5000 Ventricle

20 Longterm Devices Novacor LVAD Pulsatile Levacor Rotary HeartMate II

21 REMATCH RESULTS LVAD OMM 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% MONTHS 1 yr p= yr p=0.09

22 VAD Survival and Complications

23 REMATCH RESULTS LVAD OMM OHTx RM Late Post RM Lung Tx 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%? MONTHS

24 CCTN: Mechanical Circulatory Support (VAD/Impella+ECMO) Algorithm Potential MCS Candidate -Bridge to recovery, candidacy, transplant - marginal hemodynamics CI <2.0 L/min/m 2 PCWP >20mmHg MvO 2 < 60% U/O < 30cc/hr x 2hrs - maximal medical therapy, eg Dobutamine > 5 ug/kg/min Milrinone > 0.5 ug/kg/min

25 Conclusion Device therapy has revolutionized advanced heart failure treatment Mechanical circulatory support or ventricular assist devices can be useful as: Bridge to Transplant Bridge to Recovery Potential for Destination Therapy