Surgery and device intervention for the elderly with heart failure: assessing the need Devices and Technology for heart failure in 2011 Assessing cardiovascular function / prognosis (in the elderly): composite scores - Better than VO 2 alone Selection for heart transplant or LVAD Lars H Lund Karolinska University Hospital Stockholm, Sweden Disclosures: Research grants: OrionPharma, AstraZeneca Consultant: AstraZeneca, StJude, Thoratec Lecture fees: AstraZeneca, OrionPharma, Vingmed/Thoratec, HeartWare, Astellas, Novartis
Peak VO 2 limitations: Derived before most evidence based therapies Less useful in women Influenced by age and body weight Requires reaching the ventilatory threshold, RER 1.05-1.10-1.15? Attempts to improve: other data from the CPET: % predicted VO 2 VO 2 at ventilatory threshold Ventilatory efficiency VE/VCO 2 But still single variables: composite scores better
Heart Failure Survival Score: HFSS History Physical examination (continued) Age Heart rate Race (white vs nonwhite) 1 Body mass index Sex Jugular venous distension 1 Duration of CHF Rales 1 Cardiac arrest 1 Mitral regurgitation 1 Syncope 1 Tricuspid regurgitation 1 Embolic episode 1 S 1 3 Stroke 1 Hepatomegaly 1 Cause of CHF Laboratory data Ischemic cardiomyopathy 1 Electrocardiography Valvular cardiomyopathy 1 Rhythm Idiopathic cardiomyopathy 1 Normal sinus rhythm 1 Alcoholic cardiomyopathy 1 Atrial fibrillation or flutter 1 Hypertensive cardiomyopathy 1 Paced 1 Myocarditis 1 IVCD 1 NYHA class of CHF Q-wave infarction Angina 1 3 Chest roentgenogram Canadian Cardiovascular Society class of Cardiomegaly angina Myocardial 3 infarction in prior 6 months 1 3 Blood chemistries Coronary artery bypass grafting 3 Bicarbonate Internal cardioverter-defibrillator Blood urea nitrogen Permanent pacemaker 1 Creatinine Drug or alcohol abuse 1 Sodium Comorbid illnesses (modified Charlson's Aspartate aminotransferase index) AIDS 12 Radionuclide ventriculography Cerebrovascular disease 1 LVEF Chronic obstructive pulmonary disease 1 Cardiopulmonary exercise test Dementia 1 Peak oxygen consumption (peak VO 2 ) Diabetes with end-organ damage 1 Percent of maximal predicted peak VO 2 Diabetes without end-organ damage 1 Oxygen pulse Hemiplegia 1 Peak systolic blood pressure Leukemia 1 Peak heart rate Liver disease (mild) 1 Right heart catheterization Liver disease (moderate or severe) 1 Cardiac output Lymphoma 1 Cardiac index Peptic ulcer disease 1 Right atrial pressure Peripheral vascular disease 1 Pulmonary artery systolic pressure Renal disease (moderate or severe) 1 Pulmonary artery diastolic pressure Rheumatologic disease 1 Pulmonary artery mean pressure Solid tumor (metastatic) 1 PCWP Solid tumor (without metastases) 1 Pulmonary vascular resistance Physical examination Pulmonary vascular resistance index Systolic blood pressure Transpulmonary gradient Diastolic blood pressure Coronary angiography Mean blood pressure Three-vessel disease ( 70% diameter stenosis) or left main coronary artery disease ( 50% diameter stenosis) 3 Collected 80 variables and tested for univariate correlation to survival. Italics denotes independent prediction of survival with p<0.15 (40 variables). Underlined italics denotes inclusion in HFSS. Aaronson, Circ. 1997
7 variables selected for HFSS: - Best independent predictors - Weakly correlated with each other Represent different aspects of pathophysiology Ischemic cardiomyopathy - Resting heart rate - LVEF - Mean arterial BP - QRS > 0.12 - Peak VO 2 Serum sodium - Ischemia Sympathetic activation Systolic function Integrated measure Fibrosis and dyssynchrony Integrated measure Renin Angiotensin Aldosterone and ADH Aaronson, Circ. 1997
Derivation: Penn 73% 93% Validation: Columbia 88% 60% 43% 35% Good discrimination and calibration Low risk: no transplant Med and Hi risk: listed for transplant Aaronson, Circ. 1997
HFSS calculation for transplant and LVAD selection
Peak VO2 validated but HFSS better discrimination and calibration and better AUC of the ROC: Beta-blocker era Lund, AJC 2003 Serial evaluations Lund, AJC 2005 Women Green, AJC 2007 Elderly Parikh, AJC 2008 Different ethnic origins Goda, AJC 2009 With CRT / ICD therapy Goda, JHLT 2010
Modern era: CRT / ICD patients Peak VO2: Poor discrimination and calibration: HFSS: Good discrimination and calibration: Goda, JHLT 2010
DT-LVAD: age > 65 Peak VO2: Fair discrimination and calibration: HFSS: Good discrimination and calibration:
The HFSS better than the peak VO 2 alone for transplant and LVAD selection Also in the elderly But the HFSS still requires the peak VO2 DT-LVAD underutilized Tool for DT-LVAD referral Seattle Heart Failure Model: SHFM
Mostly HeartMate II Heartware HVAD Ketchum, JHLT 2010 Strueber, JACC 2011 But, not actuarial survival and SHFM derived in clinical trials, not in transplant or LVAD referred
ESC-HF 2011, Göteborg, Poster 301
Summary Assess prognosis to select for transplant and DT-LVAD Also in elderly Composite scores better than peak VO 2 alone HFSS extensively validated in Tx and LVAD referred SHFM does not require the peak VO 2 And has now been validated in Tx and LVAD referred Limitation: many Tx and LVAD are inotrope dependent - But should expand DT-LVAD to also ambulatory patients - To increase awareness in community: Still need easier referral criteria: Walk a block, walk one flight of stairs?