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End stage Systolic Heart Failure

End stage Systolic Heart Failure. Treatment Options. Mr GJ, 48/M. Dilated Cardiomyopathy (2008) L4-5 canal stenosis /sciatica ( on disability pension since 2005) Smoker 30 pack yrs ,quit 2 weeks ago Marijuana use Heavy alcohol intake , quit 3 yrs ago

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End stage Systolic Heart Failure

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  1. End stage Systolic Heart Failure Treatment Options

  2. Mr GJ, 48/M • Dilated Cardiomyopathy (2008) • L4-5 canal stenosis/sciatica ( on disability pension since 2005) • Smoker 30 pack yrs ,quit 2 weeks ago • Marijuana use • Heavy alcohol intake, quit 3 yrs ago • Lives alone( wife died with cancer a year ago) • Worked many jobs, last one in horticulture and many other physical jobs

  3. Currently inpatient at JHH • Decompensated CHF( with Hypotension but not needing Ionotropes) • Acute Renal Failure (Cr 366) • Atrial Arrhythmia • Pulmonary Embolism Clinically recovered well and close to his baseline health

  4. Known to cardiology team since 09/2008, first reviewed in the clinic for pre op cardiac evaluation • Noted to have LBBB, No evidence of CHF clinically • Reviewed again in op clinic with Echocardiogram results(03/2009): Dilated Cardiomyopathy EF of 25-30% • Initiated heart failure therapy

  5. Current medications • Warfarin (new) • Thiamine100mg tds • Sotolol 40mg BD(New) • Epleronone 25mg OD • Frusemide 120mg TDS • Hydrochlorothiazide 25mg Alt days • Bisoprolol and Irbesartan(stopped during the current inpatient admission)

  6. ECG

  7. Echo pictures

  8. Echo picutures

  9. 12 months after initiation of heart failure meds, given his Age/ EF 11% / Abn ECG( LBBB,QRS 168) referred to AICD/Biven pacemaker placement • 03/2010: Procedure was long and difficult LV lead could not be placed (RA and RV lead in place)

  10. 3 Admissions with decompensated CHF in last 3 years including the current admission( Prev acute admission to this was in 2009) ? Compliance may be an issue

  11. Treatment Correction of systemic factors Inappropriate medications Superimposed infection Anemia Uncontrolled diabetes Thyroid dysfunction Electrolyte disorders

  12. Patient-related factors Medication noncompliance Dietary indiscretion Alcohol consumption Substance abuse

  13. Cardiovascular factors Superimposed ischemia /infarction Uncontrolled hypertension Unrecognized primary valvular disease Worsening secondary mitral regurgitation New onset or uncontrolled atrial fibrillation Excessive tachycardia Pulmonary embolism

  14. Treatment

  15. Digoxin only safe and effective oral positive inotropic agentSafety is related to Serum concentration levels

  16. Ionotropes Inotropic use in ADHF • Phosphodiesterase inhibitors: Milrinone • Calcium sensitising agents: Levosimendan • B receptor agonists: Dobutamine

  17. Levosimendan Several studies showed improved Short-term hemodynamic effects(Eur Heart J. 2006, J Am Coll Cardiol. 2000, and others) Long term effects less well established Lower mortality in the Levosimendan when compared to Dobutamine (Lancet. 2002 LIDO study)

  18. Vasodilator Therapy in ADHF with Nesiritide RCT in 7000 pts (N Engl J Med. 2011;365(1):32) No change in mortality or re hospitalisation rates, so NOT recommended routine use in broad population of patients

  19. Device Therapy Given unsuccessful Coronary sinus lead placement Role for attempting Epicardial lead placement Safe and reliable technique and should be considered as an equal alternative ,(European Journal of Cardio-thoracic Surgery2005)

  20. Heart Transplantation • Is he a candidate of HT? General Criteria • A history of repeated hospitalizations for HF • Escalation in the intensity of medical therapy • A reproducible VO2max of less than 14 mL/kg per min

  21. Heart failure and Pulmonary Embolism Thromboembolic events in CHF 1.5 to 2.7 per 100 patient-years Risk factors • Severity of myocardial dysfunction • Thrombus that protrudes into the left ventricular cavity • Atrial fibrillation

  22. Treatment Anticoagulation with Warfarin ?Need to Thrombolysis in the setting of acute hemodynamic compromise Role of prophylactic anticoagulation in severe CHF

  23. Growth Hormone Treatment in Chronic HF • IGF-I directly causes cardiomyocyte hypertrophy, augment myocardial contractility myofilament sensitization to Calcium, and retardation of cardiomyocyte apoptosis • Meta-Analysis (J Clin Endocrinol Metab 2007) Improves several relevant cardiovascular parameters • To be confirmed by a large RCT on hemodynamic, morphological, and functional parameters

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