Stable Heart Failure Patients
End Stage Heart Failure
Advanced Therapy Patients
Decompensated HF 2011 Readmission Rate 30 D
UCSD
US Average
22
24
26
28
The Three Elements of Decompensated Heart Failure Pathophysiology Increased preload Volume overload
Increased Afterload Vasoconstriction
Myocardial dysfunction Decreased cardiac output
Treatment Diuretics Lasix,
Bumex
Vasodilators Nitroglycerin, Nipride, Natricor
Inotropes
Dobutamine, Dopamine, Milrinone
Outcomes with Standard Care Change in Weight During Hospitalization January 2001 to April 2006 (n=96,094)
Evidence of Incomplete Relief From Congestion 27%
Enrolled Discharges (%)
30 26%
25
Nearly 50% of ADHF patients discharged with weight gain or losing less than 5 lbs
20 13%
15 10
7%
16%
6% 3%
5 0
(10)
Change in Weight (lbs) Adhere National Benchmark Report Data, January 2001 to April 2006. Note: n represents the number of patients who have both baseline and discharge weight, and the percentage is calculated based on the total
Diuretic Optimization Strategies Evaluation in Acute Heart Failure (DOSE) G. Michael Felker, MD, MHS, FACC Christopher M. O’Connor, MD, FACC on behalf of the NHLBI Heart Failure Clinical Research Network
Aims To evaluate the safety and efficacy of various initial strategies of loop diuretic administration in patients with ADHF Route of administration: Continuous infusion vs. Q12 hours bolus
Dosing Low intensification (1 x oral dose) vs. high intensification (2.5 x oral dose)
Death, Rehospitalization, or ED Visit HR for Continuous vs. Q12 = 1.19 95% CI 0.86, 1.66, p = 0.30
0.5
Continuous
Proportion with Death, Rehosp, or ED visit
Proportion with Death, Rehosp, or ED Visit
0.6
Q12
0.4
0.3
0.2
0.1
0 0
10
20
30
Days
HR for High vs. Low = 0.83 95% CI 0.60, 1.16, p = 0.28
40
50
60
0.6
High
0.5
Low
0.4
0.3
0.2
0.1
0 0
10
20
30
Days
40
50
60
Conclusions There was no statistically significant difference in global symptom relief or change in renal function at 72 hours for either: Intermittent bolus vs. continuous infusion Low intensification vs. high intensification
Aquaphoresis for Diuretic Resistance
My Own Aquapheresis Statistics Treatment summary Oct 27, 2010 through May 11, 2011 Number of treatments (circuits):
19
Average treatment time:
27.73 hours
Average fluid removed/treatment:
4.12 Liters or 9.07 Lbs
Most common fluid removal rate(s):
46% (10 - 100 ml/hr) 38% (110 - 200 ml/hr)
Most common blood flow rate(s):
63% (25-30 ml/min) 28% (35-40 ml/min)
Source: Data downloaded from your Aquadex device(s)
Do Not Sit on the Stage D Patient
Prognostication in Heart Failure: The Heart Failure Trajectory
Supply and Demand Transplant Limited supply High Demand
LVAD Unlimited supply Demand limited strict selection criteria Costs
Patient Preference
Stage D CHF
TX
LVAD
HeartMate II LVAS Key Design Features Relatively Simple Design Valveless Only one moving part, the rotor Blood immersed bearings designed for minimization of blood damage All motor drive and control electronics are outside of the implanted blood pump
Speed range: 6,000 to 15,000 rpm Flow range: 3 – 10 L/min
TAH Attributes No right heart failure No arrythmias, no antiarrythmic drugs No inotropes Low CVP, High Output, Control of the Circulation No afterload dependence Rescues patients in acutely decompensating cardiogenic shock (crash and burn patients)
VAD Development: 2nd Generation Updated Heartmate II outcomes Heart Transplant
Medical Therapy
Outcomes with Heartmate II already competing with gold standard treatment
Mechanical heart pump a temporary fix for the broken heart of a Portland teenager
Hentz fought the idea for days, snapping at family and nurses and shouting, "I hate you!" at one of her cardiologists, Dr. Eric Adler.
Is a VAD a treatment for Cardiorenal Syndrome? Unanswered question Challenges Need uniform diagnostic criteria Most patients have concomitant medicalrenal disease If patient gets better, than it was cardiorenal, if they don’t , they either have bad right heart failure or some other diagnosis.
