Healing the Heart: When
Failure is Not an Option
September 12, 2013
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Our Panelists
Nazanin Moghbeli, MD, MPH,
Cardiologist
Salil Shah, MD, Cardiothoracic
Surgeon
Heart Failure
Nazanin Moghbeli, MD, MPH, FACC
September 10, 2013
Overview
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What is heart failure?
Why should I know about it?
What are the causes of heart failure?
What are the signs and symptoms?
How do you treat this disease?
What can I do to prevent worsening heart
failure?
Definition of Heart Failure
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Heart failure: is caused by damage to the heart and can be
caused by many different reasons.
 i.e. heart attack or uncontrolled high blood pressure.
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Heart failure in this case - does not mean the heart
has fully stopped.
The heart is pumping with less strength than usual
Understanding what is going on with the heart…
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Blood moves through the body at a slower rate. As a result, the
heart cannot pump enough oxygen and nutrients to meet the
body's needs.
As a result, the kidneys may respond by causing the body to retain
fluid (water) and salt.
Often fluid builds up in the arms, legs, ankles, feet, lungs, or other
organs, the body becomes congested (full of fluid); hence the term
congestive heart failure to describe the condition.
How common is Heart Failure?
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Heart failure affects nearly 5.7 million Americans.
Roughly 670,000 people are diagnosed with heart failure each
year.
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It is the leading cause of hospitalization in people older than 65.
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1 in every 5 people will develop heart failure in the US.
Mortality Data *
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80% of men and 70% of women with less than 65 years of age
and HF will die within 8 years
Up to 42% of patients die of HF within 5 years of hospitalization of
HF.
Sudden cardiac death is 6 to 9 times more likely in a HF patient as
compared to the general population.
What causes Heart Failure (HF)?
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HF is caused by conditions that damage the heart:
Coronary artery disease (CAD)= a disease of the
arteries of the heart. If arteries of the heart become
blocked or narrowed, the heart can be damaged by lack
of oxygen and nutrients.
Heart attack= occurs when the heart arteries become
suddenly blocked, stopping the flow of blood to the
heart muscle. This damages the heart muscle, resulting
in a scarred area that no longer functions well.
Other causes of HF:
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Alcohol
High blood pressure
Valve disease
Thyroid disease
Heart defects present at birth can all cause heart failure
Preeclampsia
Symptoms associated with CHF:
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Congested lungs:
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Shortness of breath: at rest, with exercise, or if lying flat
Lung congestion can cause a dry hacking cough/wheezing
Fluid and water retention.
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Less blood released by kidneys causes fluid and water retention,
resulting in swollen ankles, legs, abdomen (called edema), and weight
gain.
May cause an increased need to urinate during the night.
Stomach bloating may cause a loss of appetite or nausea.
Symptoms often found in HF:
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Dizziness, fatigue, and weakness.
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Less blood to major organs and muscles can cause fatigue/weakness
Less blood to the brain can cause dizziness or confusion.
Rapid or irregular heartbeats.
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The heart beats faster to pump enough blood to the body. This can
cause a rapid or irregular heartbeat.
How do we treat heart failure
• Medications that lower blood pressure and
heart rate, thereby decreasing the strain on
the heart
• Restriction of water and salt
• Treating diabetes, high blood pressure,
coronary artery disease
• Exercise
• Smoking cessation
Advanced treatment options for HF
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Mechanical Devices
Heart transplantation (completely replacing the current
nonfunctioning heart with a better functioning heart).
Left Ventricular Assist Device (LVAD)
Heart Transplantation *
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Heart transplant patients can live a near-normal quality of life and
functional capacity.
50% of all patients will live at least 9-10 years.
Gold standard for appropriately selected patients with advancedstage HF
Heart Transplantation
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Only 2000 people a year receive transplants in the U.S
Over 10% of people on the waiting list die each year waiting on a
heart to become available.
Hence additional options must be sought to improve outcomes
and avoid deaths for these patients.
What can I do?
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Exercise
Cholesterol control
Weight management
Medications as needed
Avoid over the counter medications such as
Motrin, decongestants
• Avoid alcohol excess
Einstein Heart Failure Services
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Diagnosis and workup of heart failure:
Treatment, including careful monitoring of heart failure
medications
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Education
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Team approach: PCP, patient, heart failure team
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Mechanical support, transplant evaluation and referral
Surgical Treatment of
Heart Failure
September 12, 2013
Objectives
•Differentiate between acute and chronic heart failure
•Surgical management of acute heart failure
•Device options and efficacy
•Surgical Management of Chronic Heart Failure
•Ventricular Remodeling
•Device placement and management
•The Future
Acute vs Chronic Heart
Failure
• Acute
– A sudden change in heart function related to
some new event that has caused damage to
the heart.
• Chronic
– A gradual decline of heart function over a
period of time. (Often the body compensates
slowly for the loss of heart function).
Causes of Acute Heart Failure:
• Myocardial Infarction (aka Heart attack)
• Pulmonary Embolism (Blood clot in the lungs)
• Myocarditis (Inflammation)
• Post-partum Cardiomyopathy (Enlarged heart after pregnancy)
• Chronic heart failure with acute (new) flare
• Trauma (i.e. direct injury to the heart)
• Acute Heart Transplant Rejection
Management
• Most importantly, treatment is to prevent or
stop the failure of other organs that are
dependent on blood flow from the heart.
• This can be done medically or with
mechanical devices.
Intra-Aortic Balloon pump
• Device placed via the femoral artery (in
the leg) to increase heart blood flow.
• Pros:
– Can be placed and removed by a catheter.
– Will allow increased heart and brain blood
flow
• Cons:
– Does not increase the amount of blood
pumped by the heart
– Has never been shown to improve
survival.
Tandem Heart
• Centrifugal flow pump placed
percutaneously
• Designed to augment left ventricular
output and rest left ventricle
• Can augment cardiac output up to 5
LPM
Pros: Can fully augment left ventricular
cardiac output
Placed and removed percutaneously
Cons: Must have skilled person to place
the cannula trans-septal
Cannula position is difficult to control
and cannula can migrate
Tandem Heart
• Many case studies and retrospective reviews
to show efficacy, but no PRCT to show
efficacy versus convertional therapy.
• Theoretical advantage to allowing the left
ventricle to rest and provide the body with
support.
• No mechanism to deal with right ventricular
failure.
• Trial starting now to determine efficacy
versus other devices
Impella
• Axial flow device
• 2.5- 5.0 L/min Active forward flow
• Single Vascular access
• 5 Minute setup\
• Percutaneous or surgical cut-down for
placement
• Multiple configurations possible
• Operation independent of cardiac
function or rhythm
Console
Impella
New Technology
Impella LD/LP 5.0
Impella
CP
Impella
CP
Pumps
Impella LP2.5
Implantation
Impella RP
Investigational
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Physiology of Impella
Myocardial Protection
Hemodynamic Support
Inflow
(ventricle)
Outflow
(aortic root)
EDV, EDP
O2 Demand
Myocardial Protection
AOP
O2 Supply
Flow
Cardiac Power Output
Systemic Hemodynamic Support
Impella Unloading Effect
ECMO
• Extracorporeal Membraneous
Oxygenation
• Blood is removed from the venous
system either peripherally via
cannulation of a femoral vein or centrally
via cannulation of the right atrium,
– Oxygenate
– Extract carbon dioxide
• Blood is then returned back to the body
either peripherally via a femoral artery or
centrally via the ascending aorta.
ECMO
• Cadillac of mechanical support
• Full cardiopulmonary bypass
• Provides body with oxygenated blood
• Provides body with full cardiac output
• Allows heart and lungs to rest as body
recovers from injury and insult
ECMO
Pros: Can be placed percutaneously
anywhere
Provides full heart and lung
support
Allows for bridge to decision
Cons: Must be removed surgically
Need trained staff to monitor
and adjust 24 hrs/day while on
support
Have increased bleeding and
vascular complications
Bottomline
• All therapies have their place
• If chosen and used correctly will take an
almost uniformly deadly situation and
provide a chance for recovery
• There are indications for each device and
all devices are approved to be used in
acute cardiogenic shock situations.
Chronic Heart Failure
• Decline of heart function over a period of time where
the body compensates slowly for the decrement in
heart function.
• Treatment:
– Medication-Ionotropes, afterload reduction
– Ventricular Remodeling
– Mechanical Support-LVAD/RVAD
– Heart Transplantation
Heartmate II
• Continuous axial flow pump
• Connects LV apex to Aorta
• Bypasses blood flow from
the left ventricle
• Only has exteriorized
driveline connected to
external monitor and power
source
• Must be placed surgically
• Can be used as bridge to
transplant or as destination
therapy
Heartmate II
• Pros:
– Excellent flow device
– Very durable
– Easily implantable
– Has excellent long term efficacy and
data
• Cons:
– Difficult to explant
– Need chronic anticoagulation
– Device does have defined lifespan
– Patient must be of a certain size to
accommodate device
The Future
•Heartware
•Impella RP
outflow
inflow
Heartware
• Continuous axial flow pump
• Connects LV apex to Aorta
• Bypasses blood flow from the left
ventricle
• Only has exteriorized driveline connected
to external monitor and power source
• Must be placed surgically
• Can be used as bridge to transplant or as
destination therapy
• Small device can be placed in any body
habitus
• Can be used for biventricular long-term
support
• Currently on trial
Impella RP
• Catheter-based percutaneous
VAD (22 Fr pump mounted on
a 11 Fr catheter)
• Treatment: Right ventricular
dysfunction
• Flow: > 4 L/min
• Duration of support: up to 14
days
• Pump Inflow: Inferior Vena
Cava (IVC) Pump Outflow:
Pulmonary Artery (PA)
outflow
inflow
Thank You!!
Contact Information
Dr. Moghbeli
Einstein Advance Heart Failure Program
Location
5501 Old York Road
Philadelphia, PA 19141
To talk to one of our team, call the Heart
Failure Hotline at 215-292-1958
Dr. Shah
Salil G. Shah
215-456-8543
5501 Old York Road
Klein 409
Philadelphia, PA