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. • 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?

• 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

• 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?

• 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?

• 1. No worries, mate • 2. One week ( big worries, mate) • 3. Four weeks • 4. Three months

Potassium Level 2 1 0 8 7 4 3 6 5 JNRY 15 JNRY 25 20-Feb 1-Apr Potassium

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

•

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

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.

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

Improved survival with aldactone in advanced CHF--Rales Trial

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.

Cardiac Resynchronization Therapy for Heart Failure

Mechanisms, Clinical Outcomes, Patient Selection, and Implant

Ventricular Dysynchrony and Cardiac Resynchronization

• Ventricular Dysynchrony 1 –

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

Animation – Ventricular Dysynchrony

Click to Start/Stop

Cardiac Resynchronization

Click to Start/Stop

Clinical Consequences of Ventricular Dysynchrony

• • • • • • Abnormal interventricular septal wall motion 1 Reduced dP/dt Reduced pulse pressure 4 3,4 Reduced EF and CO 4 Reduced diastolic filling time 1,2,4 Prolonged MR duration 1,2,4 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 Improved Intraventricular Synchrony 1,2

 

dP/dt 1,3,4



EF 1,5 Pulse Pressure 3,4



SV&CO 1, 2



MR 1



LVESV 1



LA Pressure 1

1 Yu C-M, Chau E, Sanderson J, et al.

Circulation

2002;105:438-445 2 S øgaard P, Kim W, Jensen H, et al.

Cardiology

2001;95:173-182 3 Kass D Chen-Huan C, Curry C, et al.

Circulation

4 Auricchio A, Ding J, Spinelli J, et al. 1999;99:1567-73

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

General HF Population 1,2 Moderate to Severe HF Population 3,4,5

IVCD >30% IVCD 15%

1 2 3 4 5 Havranek E, Masoudi F, Westfall K, et al. Am Heart J 2002;143:412-417 Shenkman H, McKinnon J, Khandelwal A, et al. Circulation 2000;102(18 Suppl II): abstract 2293 Schoeller R, Andresen D, Buttner P, et al. Am J Cardiol. 1993;71:720-726 Aaronson K, Schwartz J, Chen T, et al. Circulation 1997;95:2660-2667 Farwell D, Patel N, Hall A, et al. Eur Heart J 2000;21:1246-1250

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 * HR = Hazard Ratio

20 15 HR * 1.70

(1.41-2.05) 16.1

All patients N=5517 LBBB N=1391 10 5 0 11.9

HR * 1.58

(1.21-2.06) 7.3

5.5

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 Improved Intraventricular Synchrony Cardiac Resynchronization Improved Atrioventricular Synchrony Improved Interventricular Synchrony

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

Summary of Proposed Mechanisms Cardiac Resynchronization Intraventricular Synchrony Atrioventricular Synchrony Interventricular Synchrony



(



dP/dt,



EF,



CO Pulse Pressure)



MR



LA Pressure



LV Diastolic Filling



RV Stroke Volume



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

• 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 Atrial Lead Left Ventricular Lead Right Ventricular Lead

CRT Improves Quality of Life Score and NYHA Functional Class QoL NYHA

PATH-CHF 1 (n=41) InSync (Europe) 2 (n=103) InSync ICD (Europe) 3 (n=84) MUSTIC 4 (n=67)

+ + + + + + +

MIRACLE 5 (n=453)

+ +

MIRACLE ICD 6 (n=364)

+

 Blank

+ +

Statistically significant improvement with CRT (p  0.05) Not statistically significant or No statistical analysis performed on data Indicates test neither performed nor reported 1 Auricchio A. Stellbrink C, Sack S., et al.

J Am Coll Cardiol

2002;39:2026 2033 2 3 Gras D, Leclercq C, Tang A, et al.

Eur J Heart Failure

Kuhlkamp V.

JACC

2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al.

J Am Coll Cardiol

2002;4:311-320 2002;40:111-118 5 Abraham 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 Exercise Capacity 6 Min Walk Peak VO 2 Exercise Time

PATH-CHF 1 (n=41) InSync (Europe) 2 (n=103) InSync ICD (Europe) 3 (n=84) MUSTIC 4 (n=67) MIRACLE 5 (n=453) MIRACLE ICD 6

+

 Blank (n=364)

+ + + + +



+



+ + + +

Statistically significant improvement with CRT (p  0.05) Not statistically significant or No statistical analysis performed on data Indicates test neither performed nor reported 1 Auricchio A. Stellbrink C, Sack S., et al.

J Am Coll Cardiol

2002;39:2026 2033 2 3 Gras D, Leclercq C, Tang A, et al.

Eur J Heart Failure

Kuhlkamp V.

JACC

2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al.

J Am Coll Cardiol

2002;4:311-320 2002;40:111-118 5 Abraham 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 LVEF MR Other

PATH-CHF 1 (n=41) + LVEDP + LV dP/dt max InSync (Europe) 2 (n=103)

+

+ Filling Time InSync ICD (Europe) MUSTIC 4 (n=67) 3 (n=84)

+

  + Filling Time   LVEDD,LVESD Filling Time MIRACLE 5 (n=453) MIRACLE ICD 6

+

 Blank (n=362)

+



+ +

+ LVEDD, + LVEDV, LVESV + LVESV, + LVEDV Statistically significant improvement with CRT (p  0.05) Not statistically significant or No statistical analysis performed on data Indicates test neither performed nor reported 1 Auricchio A. Stellbrink C, Sack S., et al.

J Am Coll Cardiol

2002;39:2026 2033 2 3 Gras D, Leclercq C, Tang A, et al.

Eur J Heart Failure

Kuhlkamp V.

JACC

2002;39:790-797 4 Linde C, Leclercq C, Rex S, et al.

J Am Coll Cardiol

2002;4:311-320 2002;40:111-118 5 Abraham 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 NYHA QoL 6 Minute Walk Peak VO 2 InSync European and Canadian Study 1 (n=67, followed to 12 months) PATH-CHF Study 2 (n=29, followed to 12 months) MUSTIC Study 3 (n=42 in sinus rhythm group, n=33 in atrial fibrillation group followed to 12 months) + + + + + + + + + +



+

 Statistically significant improvement with CRT (p  0.05) No statistically significant improvement with CRT Blank Indicates test neither performed nor reported 1 Gras D, Leclercq C, Tang A, et al.

Eur J Heart Fail

2002;4:311-320 2 Auricchio 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

•

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 Varying Patient Anatomy

1,2,3

Photos Courtesy of Dr. Daniel Gras

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.

Europace 2000;I:D238 Abstract 167/2

Step 2: Perform Venograms CS Os Middle Posterior Great Postero-lateral Antero lateral Lateral Anterior Cardiac Venous Anatomy

Step 2: Perform Venograms Lead in Lateral Cardiac Vein

Step 4: Place Lead Attain OTW Model 4193

Click to Start/Stop

Step 4: Place Lead Attain OTW Model 4193

Click to Start/Stop

Courtesy of Dr. Daniel Gras

LAO View: Tracking Over the Wire

Click to Start/Stop

Courtesy of Dr. Daniel Gras

Step 4: Place Leads Attain LV Model 2187

Click to Start/Stop

Video compliments of Dr. Vince Paul

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