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Intervention in end-stage heart failure. Is it ever too late ?

Intervention in end-stage heart failure. Is it ever too late ?. Can you solve my problem ?. Emergency room. 61 old man No medical history well until 3 weeks before intake Progressive deterioration fatique, cough, shortness of breath No chest pain At intake respiratory distress.

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Intervention in end-stage heart failure. Is it ever too late ?

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  1. Intervention in end-stage heart failure.Is it ever too late ? Can you solve my problem ?

  2. Emergency room • 61 old man • No medical history • well until 3 weeks before intake • Progressive deterioration • fatique, cough, shortness of breath • No chest pain • At intake respiratory distress

  3. Clinical history • Had regular check-up by GP • physically active up to 3 weeks before intake (holiday spain) • Had a good physical condition • No familial CV-history

  4. Clinical exam • Respiratory distress • Bilateral inspiratory rales • Gallop rhythm • Congested CVP • 168 cm, 78 kg, BSA 1.87

  5. ECG

  6. RX thorax

  7. Lab results (intake) • CRP 41 mg/l • Troponine 1.86 µg/l • CK 285 U/l (CK-MB < 0.7 %) • Lactate 2.8 mmol/l • Creatinine 1.78 mg/dl

  8. Hemodynamics • Heartrate : 118/min • CO: 3.2 l/min (thermodilution), CI 1.71 • 95/65 mmHg • Mixed venoussaturation 42 % • (mmHg) : systolicdiastolicmean ---------------------------------------------------------------------------- • R.A. 12 • R.V. 65 18 • A.P. 63 45 50 • PCW 39 • AO 116 89 99 • LV 116 36

  9. What to do ? • Day 6 ICU • Not being able to wean from inotropic support (Dobutamine/dopamine) • Repetitive VT’s • Impending multiorgan failure

  10. Use of a Continuous-Flow Device in Patients Awaiting Heart Transplantation Leslie W. Miller, M.D., Francis D. Pagani, M.D., Ph.D., Stuart D. Russell, M.D., Ranjit John, M.D., Andrew J. Boyle, M.D., Keith D. Aaronson, M.D., John V. Conte, M.D., Yoshifumi Naka, M.D., Donna Mancini, M.D., Reynolds M. Delgado, M.D., Thomas E. MacGillivray, M.D., David J. Farrar, Ph.D., O.H. Frazier, M.D., for the HeartMate II Clinical Investigators NEJM 2007 357:885-96.

  11. results • The principal outcomes occurred in 100 patients (75%). • The median duration of support was 126 days (range, 1 to 600). • The survival rate during support was 75% at 6 months and 68%at 12 months. • At 3 months, therapy was associated with significantimprovement in functional status (according to the New YorkHeart Association class and results of a 6-minute walk test) and in quality of life (according to the Minnesota Living withHeart Failure and Kansas City Cardiomyopathy questionnaires). • Major adverse events included postoperative bleeding, stroke,right heart failure, and percutaneous lead infection. • Pump thrombosisoccurred in two patients.

  12. Kaplan Meier curve voor totale overleving na plaatsing assist device tot en met transplantatie: ca. 60% na 500 dagen. UZ Leuven (2000-2007).

  13. INTERMACS PATIENT PROFILE/STATUS LVAD 1: Critical cardiogenic shock 2: Progressive decline 3: Stable but inotrope dependent 4: “recurrent” decompensation 5: comfortable at rest but are exercise intolerant for most activity 6: able to do some mild activity, but fatigue results within minutes with meaningful physical exertion. 7: NYHA Class IIIB Partial support ?

  14. Partial support – The concept • Pace-maker pocket • Outflow to subclavian artery • Inflow from left atrium (thoracotomy) • Cable tunneled to abdomen

  15. Implantation LVAD • Lisinopril • Carvedilol • Spironolactone • B²-adrenergic-receptor agonist ?

  16. N Engl J Med 2006;355:1873

  17. N Engl J Med 2001;345:1435-1443. Rematch-trial

  18. CHF and CAD and no symptoms of angina • Revascularisation has not been shown to improve cardiac function or symptoms or to prevent reinfarction or death • Appealing theoretical possibilities: imaging – myocardium that is viable but not contracting normally

  19. Asymptomatic ischemia or CCS I or II PCI - Revascularisation = reasonable class IIa (B) • Significant lesions • Suitable for PCI and high likelihood of success and low procedural risk • Vessels substending significant area of viable myocardium or be associated with ischemia on noninvasive testing

  20. Poor LV-function CADCABG

  21. Duke University Cardiovascular Database • EF less than 0.35 • 10-year survival CABG 46 % • 10-year survival medical therapy 27 %

  22. Class I, level evidence: B • Significant left main coronary artery stenosis or left main equivalent • Proximal LAD with 2- or 3-vessel disease

  23. Class III • CABG should not be performed without evidence of intermittent ischemia and without evidence of significant revascularizable myocardium

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