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Congestive Heart Failure: Update 2002. Bruce D. Hettleman, MD DHMC December 2, 2002. CASE PRESENTATION. 71 yo retired submarine captain is admitted with pulmonary edema and an elevated troponin. His PMH is notable for advanced CAD and previous MI. He had CABGX3 in 1990.

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congestive heart failure update 2002
Congestive Heart Failure: Update 2002

Bruce D. Hettleman, MD

DHMC

December 2, 2002

case presentation
CASE PRESENTATION
  • 71 yo retired submarine captain is admitted with pulmonary edema and an elevated troponin. His PMH is notable for advanced CAD and previous MI. He had CABGX3 in 1990.
  • Echo demonstrated a severely dilated LV with an EF of 20% and 3+/4 mitral regurgitation.
  • EKG showed sinus rhythm at 52 with first degree AV block and LBBB.
  • Cardiac Cath revealed a patent IMA to the LAD, patent SVG to the RCA and a severely diseased SVG to the circumflex.
what should be done once the patient is initially stabilized
What should be done once the patient is initially stabilized?
  • 1. Perform urgent repeat bypass surgery and mitral valve replacement.
  • 2.Perform percutaneous intervention (stent) on the SVG to the circumflex.
  • 3. Put in a dual chamber pacemaker
  • 4.Maximize medical therapy because he is too high a risk for revascularization.
case presentation continued
Case Presentation--Continued
  • After stenting the SVG to the circumflex his pulmonary edema subsequently responded to medical therapy and he was able to ambulate but remained Class III CHF.
  • Discharge medications consisted of a diuretic,digoxin, beta blocker, ace inhibitor, aspirin, plavix and spironolactone.
  • He was given dietary and weight-based diuretic adjustment guidelines.
  • Follow-up in CHF Clinic was scheduled for 1 month.
what is the most likely adverse event after adding aldactone in the treatment of chf
What is the most likely adverse event after adding aldactone in the treatment of CHF?
  • 1. Hypotension
  • 2. Breast enlargement
  • 3. Yellow vision
  • 4. Hyperkalemia
  • 5. Worsening CHF
after starting aldactone in class iv chf when should electrolytes be rechecked
After starting aldactone in Class IV CHF, when should electrolytes be rechecked?
  • 1. No worries, mate
  • 2. One week ( big worries, mate)
  • 3. Four weeks
  • 4. Three months
drugs that have shown to prolong life in chf are
Drugs that have shown to prolong life in CHF are:
  • 1. ACE inhibitors
  • 2. Beta Blockers
  • 3. Digoxin
  • 4. Aldactone
  • 5. 1,2 and 4
dig trial effect of digoxin on survival in chf
DIG Trial: Effect of Digoxin on Survival in CHF
  • NHLBI sponsored study of 7,788 patients with class II and III CHF and LVEFs < 45% or > 45%
  • Randomized, controlled, double-blinded
  • 93% of patients on ACEIs
  • Superimposable survival curves
  • 25% reduction with Dig on first CHF hospitalization
slide10

Weight of Evidence: ACE Inhibitors

Approximately 7000 patients evaluated in long-term

placebo-controlled clinical trials

Improvement in cardiac function, symptoms, and

clinical status; equivocal effects on exercise tolerance

Decrease in all-cause mortality by 20%-25% (P<.001) and

decrease in combined risk of death and hospitalization

by 30%-35% (P<.001)

- Effect shown in SOLVD Treatment, CONSENSUS, and V-HeFT II trials

Garg and Yusuf, 1995.

slide11

Weight of Evidence: -Blockade

Traditionally contraindicated in heart failure, due to impaired inotropy, early lack of tolerability, and worsening heart failure

Over 10,000 patients have now been evaluated in long-term placebo-controlled clinical trials;

Improvement in cardiac function and NYHA class; and decrease in mortality and morbidity shown in multiple clinical trials

Effects shown in patients already receiving ACE inhibitors

will a permanent pacemaker help this man
Will a permanent pacemaker help this man?
  • 1. No, he has no indication for a pacemaker and if you put one in medicare will send you the bill.
  • 2. Yes, he should have a VVI back up pacemaker prior to discharge because he has LBBB and may unpredictably develop complete heart block and die.
  • 3. Yes, the placement of a routine DDD pacemaker will reliably improve his hemodynamics
  • 4.Yes, he ought to have a brand-spankin new biventricular resynchronization device because he has LBBB.
slide14

Cardiac Resynchronization Therapy for Heart FailureMechanisms, Clinical Outcomes,Patient Selection, and Implant

ventricular dysynchrony and cardiac resynchronization
Ventricular Dysynchrony and Cardiac Resynchronization
  • Ventricular Dysynchrony1
    • Electrical: Inter- or Intraventricular conduction delays typically manifested as left bundle branch block
    • Structural: disruption of myocardial collagen matrix impairing electrical conduction and mechanical efficiency
    • Mechanical: Regional wall motion abnormalities with increased workload and stress—compromising ventricular mechanics
  • Cardiac Resynchronization
    • Therapeutic intent of atrial synchronized biventricular pacing
      • Modification of interventricular, intraventricular, and atrial-ventricular activation sequences in patients with ventricular dysynchrony
      • Complement to optimal medical therapy

1 Tavazzi L. Eur Heart J 2000;21:1211-1214

cardiac resynchronization
Cardiac Resynchronization

Click to Start/Stop

clinical consequences of ventricular dysynchrony
Clinical Consequences of Ventricular Dysynchrony
  • Abnormal interventricular septal wall motion1
  • Reduced dP/dt3,4
  • Reduced pulse pressure4
  • Reduced EF and CO4
  • Reduced diastolic filling time1,2,4
  • Prolonged MR duration1,2,4

1 Grines CL, Bashore TM, Boudoulas H, et al. Circulation 1989;79:845-853.

2 Xiao, HB, Lee CH, Gibson DG. Br Heart J 1991;66:443-447.

3 Xiao HB, Brecker SJD, Gibson DG. Br Heart J 1992;68:403-407.

4 Yu C-M, Chau E, Sanderson JE, et al. Circulation. 2002;105:438-445.

proposed mechanisms improved intraventricular synchrony
Proposed Mechanisms: Improved Intraventricular Synchrony

Improved Intraventricular

Synchrony1,2

 dP/dt 1,3,4 EF1,5

 Pulse Pressure 3,4  SV&CO1, 2

 MR1

 LVESV1

 LA Pressure1

1Yu C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445

2 Søgaard P, Kim W, Jensen H, et al. Cardiology 2001;95:173-182

3 Kass D Chen-Huan C, Curry C, et al. Circulation 1999;99:1567-73

4 Auricchio A, Ding J, Spinelli J, et al. J Am Coll Cardiol 2002;39:1163-1169

5 Stellbrink C, Breithardt O, Franke A, et al. J Am Coll Cardiol 2001;38:1957- 65

prevalence of inter or intraventricular conduction delay
Prevalence of Inter- or Intraventricular Conduction Delay

Moderate to Severe HF Population3,4,5

General HF Population1,2

IVCD >30%

IVCD 15%

1 Havranek E, Masoudi F, Westfall K, et al. Am Heart J 2002;143:412-417

2 Shenkman H, McKinnon J, Khandelwal A, et al. Circulation 2000;102(18 Suppl II): abstract 2293

3 Schoeller R, Andresen D, Buttner P, et al. Am J Cardiol. 1993;71:720-726

4 Aaronson K, Schwartz J, Chen T, et al. Circulation 1997;95:2660-2667

5 Farwell D, Patel N, Hall A, et al. Eur Heart J 2000;21:1246-1250

increased mortality rate with lbbb
Increased Mortality Rate with LBBB
  • Increased 1-year mortality with presence of complete LBBB (QRS > 140 ms)
  • Risk remains significant even after adjusting for age, underlying cardiac disease, indicators of HF severity, and HF medications

All patients N=5517

20

LBBB N=1391

HR* 1.70

(1.41-2.05)

16.1

15

11.9

HR * 1.58

(1.21-2.06)

1-Year Mortality (%)

10

7.3

5

5.5

* HR = Hazard Ratio

0

All Cause

Sudden Cardiac

Cause of Death

Baldasseroni S, Opasich C, Gorini M, et al. Am Heart J 2002;143:398-405

proposed mechanisms of cardiac resynchronization
Proposed Mechanisms of Cardiac Resynchronization

Cardiac Resynchronization

Improved Intraventricular Synchrony

Improved Atrioventricular Synchrony

Improved Interventricular Synchrony

Yu C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445

summary of proposed mechanisms
Summary of Proposed Mechanisms

Cardiac Resynchronization

Intraventricular

Synchrony

Atrioventricular

Synchrony

Interventricular

Synchrony

 RV Stroke

Volume

 dP/dt,  EF,  CO

( Pulse Pressure)

 LA

Pressure

 LV Diastolic

Filling

 MR

 LVESV

 LVEDV

Reverse Remodeling

Yu C-M, Chau E, Sanderson J, et al. Circulation 2002;105:438-445

achieving cardiac resynchronization mechanical goal atrial synchronized bi ventricular pacing
Achieving Cardiac ResynchronizationMechanical Goal: Atrial-synchronized bi-ventricular pacing
  • Transvenous Approach
    • Standard pacing lead in RA
    • Standard pacing or defibrillation lead in RV
    • Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus

Right AtrialLead

Left VentricularLead

Right VentricularLead

crt improves quality of life score and nyha functional class
CRT Improves Quality of Life Score and NYHA Functional Class

1Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026- 2033

2 Gras D, Leclercq C, Tang A, et al. Eur J Heart Failure 2002;4:311-320

3 Kuhlkamp V. JACC 2002;39:790-797

4 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118

5Abraham W, Fisher W, Smith A, et al.N Engl J Med. 2002;346:1845-1853

6 Leon A. NASPE Scientific Sessions – Late Breaking Clinical Trials. May 2002; Medtronic Inc. data on file

QoL NYHA

PATH-CHF1 (n=41) ++

InSync (Europe)2 (n=103) ++

InSync ICD (Europe)3 (n=84) ++

MUSTIC4 (n=67) +

MIRACLE5 (n=453) ++

MIRACLE ICD6 (n=364) ++

+Statistically significant improvement with CRT (p  0.05)

 Not statistically significant or No statistical analysis performed on dataBlank Indicates test neither performed nor reported

crt improves exercise capacity
CRT Improves Exercise Capacity

6 Min Walk Peak VO2 Exercise Time

PATH-CHF1 (n=41) ++

InSync (Europe)2 (n=103) +

InSync ICD (Europe)3 (n=84) +

MUSTIC4 (n=67) +

MIRACLE5 (n=453) +++

MIRACLE ICD6 (n=364) ++

+Statistically significant improvement with CRT (p  0.05)

 Not statistically significant or No statistical analysis performed on dataBlank Indicates test neither performed nor reported

1Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026- 2033

2 Gras D, Leclercq C, Tang A, et al. Eur J Heart Failure 2002;4:311-320

3 Kuhlkamp V. JACC 2002;39:790-797

4 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118

5Abraham W, Fisher W, Smith A, et al.N Engl J Med. 2002;346:1845-1853

6 Leon A. NASPE Scientific Sessions – Late Breaking Clinical Trials. May 2002; Medtronic Inc., data on file

crt improves cardiac function structure
CRT Improves Cardiac Function/Structure

LVEF

MR

Other

PATH-CHF1 (n=41)

+LVEDP + LV dP/dtmax

InSync (Europe)2 (n=103)

+

+ Filling Time

InSync ICD (Europe)3 (n=84)

+

+ Filling Time

MUSTIC4 (n=67)

 LVEDD,LVESD Filling Time

MIRACLE5 (n=453)

+

+

+ LVEDD, + LVEDV, LVESV

MIRACLE ICD6 (n=362)

+

+ LVESV, + LVEDV

+Statistically significant improvement with CRT (p  0.05)

 Not statistically significant or No statistical analysis performed on dataBlank Indicates test neither performed nor reported

1Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026- 2033

2 Gras D, Leclercq C, Tang A, et al. Eur J Heart Failure 2002;4:311-320

3 Kuhlkamp V. JACC 2002;39:790-797

4 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118

5Abraham W, Fisher W, Smith A, et al.N Engl J Med. 2002;346:1845-1853

6 Young J. ACC Scientific Sessions – Late Breaking Clinical Trials III. March 2002; Medtronic Inc., data on file

cardiac resynchronization outcomes sustained for at least 12 months
Cardiac Resynchronization OutcomesSustained for at least 12 months

+Statistically significant improvement with CRT (p  0.05) No statistically significant improvement with CRTBlank Indicates test neither performed nor reported

1 Gras D, Leclercq C, Tang A, et al. Eur J Heart Fail 2002;4:311-320

2Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol 2002;39:2026-2033

3 Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol 2002;40:111-118

step 1 cannulate cs attain lds model 6216a
Step 1: Cannulate CSAttain LDS Model 6216A
  • Use extreme care when passing the guide catheter through vessels
  • Due to the relative stiffness of the catheter, damage to the walls of the vessels may include dissections or perforations
step 2 perform venograms
Step 2: Perform Venograms

Varying Patient Anatomy 1,2,3

1. Potkin et al. Am J Cardiol 1987;60:1418-1421

2. Neri et al. Europace 2000;I :D95 Abstract 88/2

3. Hill et al.Europace2000;I:D238 Abstract 167/2

Photos Courtesy of Dr. Daniel Gras

cardiac venous anatomy
Cardiac Venous Anatomy

Step 2: Perform Venograms

Great

Postero-lateral

CS Os

Antero-

lateral

Lateral

Middle

Anterior

Posterior

lead in lateral cardiac vein
Lead in Lateral Cardiac Vein

Step 2: Perform Venograms

step 4 place lead attain otw model 419334
Step 4: Place LeadAttain OTW Model 4193

Courtesy ofDr. Daniel Gras

Click to Start/Stop

lao view tracking over the wire
LAO View: Tracking Over the Wire

Courtesy ofDr. Daniel Gras

Click to Start/Stop

step 4 place leads attain lv model 2187
Step 4: Place Leads Attain LV Model 2187

Video compliments of Dr. Vince Paul

Click to Start/Stop

biventricular pacing is indicated for the reduction of chf symptoms in patients with
Biventricular Pacing is indicated for the reduction of CHF symptoms in patients with:
  • 1. Stable Class III-IV CHF
  • 2. QRS> 130 ms
  • 3.EF <35%
  • 4. Optimal medical therapy