Heart Failure:Heart Failure:

Case 1Case 1• 67 year old man• Presented with anterior wall MI in May.

Underwent stent placement in the LAD. The other arteries were patent.

• Echo demonstrated mildly-moderate decreased LV systolic function with anteroapical akinesis

• Unremarkable recovery. Started on aspirin, plavix, simvastatin, atenolol 25mg and discharged home

• 67 year old man• Presented with anterior wall MI in May.

Underwent stent placement in the LAD. The other arteries were patent.

• Echo demonstrated mildly-moderate decreased LV systolic function with anteroapical akinesis

• Unremarkable recovery. Started on aspirin, plavix, simvastatin, atenolol 25mg and discharged home

November 1November 1

• Acute onset of shortness of breath

• Wife called Mada,

• HR 94 BP 114/60 RR 28 sat 91%

• Bibasilar crackles

• Acute onset of shortness of breath

• Wife called Mada,

• HR 94 BP 114/60 RR 28 sat 91%

• Bibasilar crackles

ECGECG

Chest x-rayChest x-ray

EchoEcho

• Dilated LV with moderately-severely decreased function.

• Anteroseptal and apical dyskinesis

• Moderate-severe mitral regurgitation

• Normal RV size and function

• Mild pulmonary hypertension

• Dilated LV with moderately-severely decreased function.

• Anteroseptal and apical dyskinesis

• Moderate-severe mitral regurgitation

• Normal RV size and function

• Mild pulmonary hypertension

What happened?What happened?

Biomechanical Model of Heart FailureBiomechanical Model of Heart Failure

Myocardial Myocardial Dysfunction Dysfunction Myocardial Myocardial

Dysfunction Dysfunction

↑↑AfterloadAfterload↑↑AfterloadAfterload

↑↑ PreloadPreload↑↑ PreloadPreload

↑↑ ContractilityContractility↑↑ ContractilityContractility

Neurohormonal Neurohormonal ActivationActivation

Neurohormonal Neurohormonal ActivationActivation

Renin-Renin-Angiotensin Angiotensin AldosteroneAldosterone

Renin-Renin-Angiotensin Angiotensin AldosteroneAldosterone

Sympathetic Sympathetic StimulationStimulation

Sympathetic Sympathetic StimulationStimulation

VasoconstrictionVasoconstrictionVasoconstrictionVasoconstriction

Sodium & Water Sodium & Water RetentionRetention

Sodium & Water Sodium & Water RetentionRetention

Cardiac Cardiac Remodeling Remodeling

Cardiac Cardiac Remodeling Remodeling

Beta Beta BlockersBlockers

Beta Beta BlockersBlockers×××× ACE-I ACE-I

ARBARBACE-I ACE-I ARBARB××××SpironolactoneSpironolactoneSpironolactoneSpironolactone ××××

××××DiureticsDiureticsDiureticsDiuretics

What didn’t happen that should have happened?

What didn’t happen that should have happened?

AABB

CC

DDPreventionLife style

modification

PreventionLife style

modification

ACE-I/ARB Beta

Blockers

ACE-I/ARB Beta

BlockersRestrict Diet

Diuretics Aldospirone

Digoxin

Restrict DietDiuretics

Aldospirone Digoxin

CRT ± ICD Assist devices Transplantation

CRT ± ICD Assist devices Transplantation

Stages in Heart FailureStages in Heart Failure

Refractory Symptoms

Heart Failure

Symptoms

Structural Heart

Disease

Patients at Risk

AHA / ACC HF guidelinesAHA / ACC HF guidelinesAHA / ACC HF guidelinesAHA / ACC HF guidelines

Hospital CourseHospital Course

• Admitted with a diagnosis of acute decompensated heart failure.

• What is the first thing you do?

• Admitted with a diagnosis of acute decompensated heart failure.

• What is the first thing you do?

Comprehensive inhibition of neurohormonal activation

Comprehensive inhibition of neurohormonal activation

– achieve euvolemia with diuretics and salt restriction

– ACE-inhibitors– Beta-blockers (so far only carvedilol,

bisoprolol and extended release metoprolol)

– Careful spironolactone

– achieve euvolemia with diuretics and salt restriction

– ACE-inhibitors– Beta-blockers (so far only carvedilol,

bisoprolol and extended release metoprolol)

– Careful spironolactone

COPERNICUSCOPERNICUSNEJM 2001NEJM 2001COPERNICUSCOPERNICUSNEJM 2001NEJM 2001

Beta BlockerBeta BlockerBeta BlockerBeta Blocker

242424240000 20202020161616161212121288884444 28282828

PlaceboPlacebo

CarvedilolCarvedilol

MonthsMonthsMonthsMonths

Su

rviv

al %

Su

rviv

al %

35%35%35%35%

100100100100

90909090

80808080

60606060

70707070

50505050

ACE-InhibitorACE-InhibitorACE-InhibitorACE-Inhibitor

CONSENSUSNEJM 1987CONSENSUSNEJM 1987

1001001001009090909080808080

6060606070707070

50505050

MonthsMonths

PlaceboPlacebo

EnalaprilEnalapril

121211111010998877665500

4433221100

4040404030303030

Su

rviv

al %

Su

rviv

al %

PlaceboPlacebo

EnalaprilEnalapril

31%31%31%31%

Spironolactone

RALESRALESNEJM 1999NEJM 1999

If...If...

• If the patient cannot tolerate ACE-inhibitor, ARB may be substituted (valsartan)

• If the patient cannot tolerate beta blocker, ACE-I and ARB may be combined

• Isosorbide and hydralazine can be considered in patients who cannot tolerate ACE-I

• If the patient cannot tolerate ACE-inhibitor, ARB may be substituted (valsartan)

• If the patient cannot tolerate beta blocker, ACE-I and ARB may be combined

• Isosorbide and hydralazine can be considered in patients who cannot tolerate ACE-I

Now what should we do?Now what should we do?• A. Cardiac catheterization to see if the stent

is patent• B. Stress thallium to see if there is residual

ischemia• C. Exercise echo to see if the mitral

regurgitation and pulmonary hypertension worsen with exercise

• D. Transesophageal echo to determine severity of mitral regurgitation

• A. Cardiac catheterization to see if the stent is patent

• B. Stress thallium to see if there is residual ischemia

• C. Exercise echo to see if the mitral regurgitation and pulmonary hypertension worsen with exercise

• D. Transesophageal echo to determine severity of mitral regurgitation

Other considerationsOther considerations

• A. Put in a defibrillator

• B. Put in a pacemaker to allow for target doses of beta blocker

• C. Put in a biventricular pacemaker

• D. Add amiodarone for the prevention of sudden cardiac death

• A. Put in a defibrillator

• B. Put in a pacemaker to allow for target doses of beta blocker

• C. Put in a biventricular pacemaker

• D. Add amiodarone for the prevention of sudden cardiac death

Implantable Cardiac Defibrillator (ICD)

Implantable Cardiac Defibrillator (ICD)

SCD-HeFTSCD-HeFTN Engl J Med 2005N Engl J Med 2005SCD-HeFTSCD-HeFTN Engl J Med 2005N Engl J Med 2005

ICD

ICD implantation:• Patients with LVEF<30% • NYHA II-IV

ICD implantation:• Patients with LVEF<30% • NYHA II-IV

23%

N=2,521 IHD/NIHDNYHA class II-III LVEF < 35%

Biventricular PacingBiventricular Pacing

Cardiac-Resynchronization Therapy (CRT)

Cardiac-Resynchronization Therapy (CRT)

• Ventricular conduction delays cause dysynchronous contraction

• Biventricular pacing synchronizes ventricle contraction

• Ventricular conduction delays cause dysynchronous contraction

• Biventricular pacing synchronizes ventricle contraction

Cardiac Function:

EF↑ LV size↓ MR ↓

Exercise Capacity

Quality of life

Hospitalizations

Mortality

Cardiac Function:

EF↑ LV size↓ MR ↓

Exercise Capacity

Quality of life

Hospitalizations

Mortality

CARE-HFCARE-HFN Engl J Med. 2005N Engl J Med. 2005CARE-HFCARE-HFN Engl J Med. 2005N Engl J Med. 2005

36% Survival

Cardiac-Resynchronization Therapy (CRT)

Cardiac-Resynchronization Therapy (CRT)

CRT Implantation:• Patients with LVEF<35% • NYHA III-IV• Optimal Medical Therapy• QRS >120 ms

CRT Implantation:• Patients with LVEF<35% • NYHA III-IV• Optimal Medical Therapy• QRS >120 ms

N = 813 NYHA III-IV

What other therapies are available

What other therapies are available

• Prevention - Control risk factorsPrevention - Control risk factors

• Life style modificationsLife style modifications

• Treat etiologic cause / aggravating Treat etiologic cause / aggravating factorsfactors

• Optimized Drug therapyOptimized Drug therapy

• Specialized care – eg Shikum Lev or Specialized care – eg Shikum Lev or Heart Failure clinicsHeart Failure clinics

• Prevention - Control risk factorsPrevention - Control risk factors

• Life style modificationsLife style modifications

• Treat etiologic cause / aggravating Treat etiologic cause / aggravating factorsfactors

• Optimized Drug therapyOptimized Drug therapy

• Specialized care – eg Shikum Lev or Specialized care – eg Shikum Lev or Heart Failure clinicsHeart Failure clinics

What is the prognosis?What is the prognosis?

One Year Clinical Event Rate in Heart Failure

One Year Clinical Event Rate in Heart Failure

(%)

(%)

0

30

60

90

Death Rehospitalization0

30

60

90

Death Rehospitalization0

30

60

90

Free from events0

30

60

90

Free from events

26%26%

66%66%

27%27%

Acute Exacerbations Contribute to the Progression of Heart Failure

Acute Exacerbations Contribute to the Progression of Heart Failure

Am J Cardiology 2005Am J Cardiology 2005

TimeTime

Ven

tric

ula

r fu

nct

ion

Ven

tric

ula

r fu

nct

ion

Acute eventAcute event

Treatment – All PatientsTreatment – All PatientsTreatment – All PatientsTreatment – All Patients

• Prevention - Control risk factorsPrevention - Control risk factors

• Life style modificationsLife style modifications

• Treat etiologic cause / aggravating Treat etiologic cause / aggravating factorsfactors

• Optimized Drug therapyOptimized Drug therapy

• Specialized care – Increase complianceSpecialized care – Increase compliance

• Advanced TreatmentAdvanced Treatment

• Prevention - Control risk factorsPrevention - Control risk factors

• Life style modificationsLife style modifications

• Treat etiologic cause / aggravating Treat etiologic cause / aggravating factorsfactors

• Optimized Drug therapyOptimized Drug therapy

• Specialized care – Increase complianceSpecialized care – Increase compliance

• Advanced TreatmentAdvanced Treatment

Next patientNext patient

• 76 year old man

• CABG and AVR 10 years ago

• Normal LV systolic function on most recent echo

• Presents to the ER with acute decompensated heart failure.

• 76 year old man

• CABG and AVR 10 years ago

• Normal LV systolic function on most recent echo

• Presents to the ER with acute decompensated heart failure.

In the ERIn the ER

• HR 118 and irregular

• Blood pressure 132/64

• RR 22

• O2 Sat 94%

• HR 118 and irregular

• Blood pressure 132/64

• RR 22

• O2 Sat 94%

The ECGThe ECG

What happened?What happened?

Heart Failure with preserved EF

Heart Failure with preserved EF

Inability to fill normally

LA pressure

diastolicdysfunction

AtrialfibrillationCHF

HFPEF- EtiologyHFPEF- Etiology

• Left ventricular hypertrophy– Hypertension– Aortic stenosis

• Coronary artery disease• Diabetes• Elderly• Infiltrative/restrictive• Unexplained

• Left ventricular hypertrophy– Hypertension– Aortic stenosis

• Coronary artery disease• Diabetes• Elderly• Infiltrative/restrictive• Unexplained

Distribution of LV Functionin Patients Age>65 yrs with CHF

Distribution of LV Functionin Patients Age>65 yrs with CHF

0%10%20%30%40%50%60%70%80%90%

100%

Patients with CHF

Normal LVEF

Borderline LVEF

Impaired LVEF

0%10%20%30%40%50%60%70%80%90%

100%

Patients with CHF

Normal LVEF

Borderline LVEF

Impaired LVEF

Gottdiener et al 2002. AIM 137(8):631-639

Pressure/Volume RelationshipPressure/Volume Relationship

Burkhoff et al 2003. Circ 107(5):656-658.

Diastolic Heart Failure - Diagnosis

Diastolic Heart Failure - Diagnosis

Is there a test thatwill diagnose

diastolic heart failure?

Heart Failure One Year Survival

Heart Failure One Year Survival

Preserved Preserved LVFLVF

Preserved Preserved LVFLVF

Adjusted SurvivalP=0.26=0.26

Adjusted SurvivalP=0.26=0.26

Reduced Reduced LVFLVF

Reduced Reduced LVFLVF

Su

rviv

al (

%)

Su

rviv

al (

%)

Su

rviv

al (

%)

Su

rviv

al (

%)

100100100100

90909090

80808080

60606060

70707070

50505050121212120000 101010108888666644442222

MonthsMonthsMonthsMonths

• CONSENSUS I• VeHFT I• SOLVD• SAVE• VeHFT II• CONSENSUS II• ATLAS• PROVED• RADIANCE• DIG

• CONSENSUS I• VeHFT I• SOLVD• SAVE• VeHFT II• CONSENSUS II• ATLAS• PROVED• RADIANCE• DIG

MDC CIBIS I CIBIS II ANZ PRECISE MOCHA MERIT-HF COPERNICUS CAPRICORN CHF-STAT

ELITE ValHFT ELITE II CHARM RESOLVD PRAISE WATCH RALES GESICA COMET

World’s Literature of Large or Randomized Trials of the Treatment of

Systolic Heart Failure

World’s Literature of Large or Randomized Trials of the Treatment of

Systolic Heart Failure

Randomized Trials of Treatment of D-CHF

Randomized Trials of Treatment of D-CHF

Zile et al 2002. Circ 105(12):1503-1508.

CHARM – PreservedPrimary Endpoints

CHARM – PreservedPrimary Endpoints

0%

5%

10%

15%

20%

25%

CV Death Hosp adm CHF

Candasartan

Placebo

0%

5%

10%

15%

20%

25%

CV Death Hosp adm CHF

Candasartan

Placebo

P=0.072

Diastolic CHF – Goals of Therapy

Diastolic CHF – Goals of Therapy

• Reduce preload• Decrease heart rate• Normalize blood pressure• Maintain atrial contraction• Improve relaxation• Cause regression of LVH• Decrease interstitial fibrosis• Treat ischemia• Decrease neurohumoral activation

• Reduce preload• Decrease heart rate• Normalize blood pressure• Maintain atrial contraction• Improve relaxation• Cause regression of LVH• Decrease interstitial fibrosis• Treat ischemia• Decrease neurohumoral activation

In the ERIn the ER• The patient was given IV beta blocker and

digoxin, with slowing of his heart rate to the 80s.

• Echo demonstrated :– Dilated atria– Normal LV chamber size with mild hypertrophy.

Normal RV size and function– Normally functioning aortic prosthesis– Mild-moderate mitral regurgitation– Mild pulmonary hypertension

• The patient was given IV beta blocker and digoxin, with slowing of his heart rate to the 80s.

• Echo demonstrated :– Dilated atria– Normal LV chamber size with mild hypertrophy.

Normal RV size and function– Normally functioning aortic prosthesis– Mild-moderate mitral regurgitation– Mild pulmonary hypertension

What do you do now?What do you do now?

• A. Begin anticoagulation, and plan to cardiovert the patient in 3 weeks

• B. Begin anticoagulation and plan for TEE cardioversion in the next few days

• C. Begin anticoagulation, and initiate amiodarone therapy in preparation for cardioversion

• D. Give digoxin in order to lead to spontaneous cardioversion

• A. Begin anticoagulation, and plan to cardiovert the patient in 3 weeks

• B. Begin anticoagulation and plan for TEE cardioversion in the next few days

• C. Begin anticoagulation, and initiate amiodarone therapy in preparation for cardioversion

• D. Give digoxin in order to lead to spontaneous cardioversion

Case PresentationCase Presentation

• 66 year old male

• Shortness of breath – few months

• FC NYHA I III• Chest CT: enlarged lymph nodes

• Biopsy: Sarcoidosis

• Treated with Steroids

• 66 year old male

• Shortness of breath – few months

• FC NYHA I III• Chest CT: enlarged lymph nodes

• Biopsy: Sarcoidosis

• Treated with Steroids

Case PresentationCase Presentation

• Systolic murmur on the apex

• Echo 1 year previously:

• Mod-severe Mitral Regurgitation

• LV size and Function normal

• Moderate PHT (50 mmHg)

• Started on Enalapril, metoprolol & Fusid

• Systolic murmur on the apex

• Echo 1 year previously:

• Mod-severe Mitral Regurgitation

• LV size and Function normal

• Moderate PHT (50 mmHg)

• Started on Enalapril, metoprolol & Fusid

Trans-EsophagealEcho

Trans-EsophagealEcho

• Prolapse of posterior mitral leaflet

• Rupture Chordea:Severe Mitral Regurgitation

• Prolapse of posterior mitral leaflet

• Rupture Chordea:Severe Mitral Regurgitation

LVLV

MVMV

LALA

CourseCourse

• Surgery - Flail P2 • Repair of mitral valve by

resection of P2 and suture and implantation of ring

• Two weeks after surgery:

NYHA I-II• Echo 1 months later:

no MR, no PHT

• Surgery - Flail P2 • Repair of mitral valve by

resection of P2 and suture and implantation of ring

• Two weeks after surgery:

NYHA I-II• Echo 1 months later:

no MR, no PHT

Next caseNext case

• 41 year old woman

• Previously healthy

• Presents with acute decompensated heart failure

• 41 year old woman

• Previously healthy

• Presents with acute decompensated heart failure

EchoEcho

Patient begins to deteriorate, and is in low grade cardiogenic

shock

Patient begins to deteriorate, and is in low grade cardiogenic

shock

• What are possible causes?

• What do you do?

• What are possible causes?

• What do you do?

A Stepwise ApproachA Stepwise Approach

Mechanical pump designed to take over the work of the left heart

Mechanical pump designed to take over the work of the left heart

IndicationsIndications

• Transplant candidate or Destination candidate

• Hemodynamics:– Cardiac index < 2l/min/m2

– PCWP > 20mmHg– SBP < 80mmHg or MAP < 65mmHg– On maximal medical therapy

• Transplant candidate or Destination candidate

• Hemodynamics:– Cardiac index < 2l/min/m2

– PCWP > 20mmHg– SBP < 80mmHg or MAP < 65mmHg– On maximal medical therapy

Cardiac considerationsCardiac considerations

• Right ventricular function

• Valve disease (aortic regurgitation, mitral stenosis)

• Intracardiac shunt

• Ventricular arrhythmias

• Ischemia (consider RCA graft)

• Right ventricular function

• Valve disease (aortic regurgitation, mitral stenosis)

• Intracardiac shunt

• Ventricular arrhythmias

• Ischemia (consider RCA graft)

Non-cardiac considerationsNon-cardiac considerations

• Neurologic status

• Infection

• Risk of bleeding

• Urine output/urea

• Bilirubin

• Pulmonary disease

• Patient preference

• Neurologic status

• Infection

• Risk of bleeding

• Urine output/urea

• Bilirubin

• Pulmonary disease

• Patient preference

Technical considerationsTechnical considerations

• BSA < 1.5m2

• Prosthetic valves

• Reoperation

• LV thrombus

• BSA < 1.5m2

• Prosthetic valves

• Reoperation

• LV thrombus

Patient populationsPatient populations

• Post-cardiotomy failure

• Myocarditis

• Acute MI

• Acute decompensation of chronic heart failure

• Ventricular arrhythmias

• Post-cardiotomy failure

• Myocarditis

• Acute MI

• Acute decompensation of chronic heart failure

• Ventricular arrhythmias

Probability of Survival to TransplantProbability of Survival to Transplant

Frazier et al., J Thorac CV Surg 2001

Rematch Rematch

Follow upFollow up

• The patient underwent LVAD placement, and underwent cardiac transplant one year later.

• The patient underwent LVAD placement, and underwent cardiac transplant one year later.

Advanced Treatment in HF

Advanced Treatment in HF

RevascularizationRevascularizationfor Ischemiafor Ischemia

RevascularizationRevascularizationfor Ischemiafor Ischemia

Valve Valve Repair or Repair or

ReplacementReplacement

Valve Valve Repair or Repair or

ReplacementReplacement

Ventricular Ventricular Resynchronization (CRT)Resynchronization (CRT)

Ventricular Ventricular Resynchronization (CRT)Resynchronization (CRT)

Implantable Cardiac Implantable Cardiac Defibrillator (AICD)Defibrillator (AICD)

Implantable Cardiac Implantable Cardiac Defibrillator (AICD)Defibrillator (AICD)

Ventricular Assist Ventricular Assist Devices (LVAD)Devices (LVAD)

Ventricular Assist Ventricular Assist Devices (LVAD)Devices (LVAD)

Artificial Heart / Artificial Heart / Heart TransplantHeart TransplantArtificial Heart / Artificial Heart /

Heart TransplantHeart Transplant

Thank youThank you