Congestive Heart Failure: Update 2002

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Congestive Heart Failure Update 2002

• Bruce D. Hettleman, MD
• DHMC
• December 2, 2002

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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.

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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.

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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.

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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

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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

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Potassium Level
8
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

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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
• Randomized, controlled, double-blinded
• 93 of patients on ACEIs
• Superimposable survival curves
• 25 reduction with Dig on first CHF
  hospitalization

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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 (Pcombined risk of death and hospitalization by
30-35 (PTreatment, CONSENSUS, and V-HeFT II trials
Garg and Yusuf, 1995.
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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
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Improved survival with aldactone in advanced
CHF--Rales Trial
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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.

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Cardiac Resynchronization Therapy for Heart
FailureMechanisms, Clinical Outcomes,Patient
Selection, and Implant
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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 stresscompromising
  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 2000211211-1214
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Animation Ventricular Dysynchrony
Click to Start/Stop
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Cardiac Resynchronization
Click to Start/Stop
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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 198979845-853. 2 Xiao, HB, Lee CH,
Gibson DG. Br Heart J 199166443-447. 3 Xiao
HB, Brecker SJD, Gibson DG. Br Heart J
199268403-407. 4 Yu C-M, Chau E, Sanderson JE,
et al. Circulation. 2002105438-445.
19
Proposed Mechanisms Improved Intraventricular
Synchrony
Improved Intraventricular Synchrony1,2
? dP/dt 1,3,4 ?EF1,5 ? Pulse Pressure 3,4
? SVCO1, 2
? MR1
? LVESV1
? LA Pressure1
1 Yu C-M, Chau E, Sanderson J, et al.
Circulation 2002105438-445 2 Søgaard P, Kim W,
Jensen H, et al. Cardiology 200195173-182 3
Kass D Chen-Huan C, Curry C, et al. Circulation
1999991567-73 4 Auricchio A, Ding J, Spinelli
J, et al. J Am Coll Cardiol 2002391163-1169 5
Stellbrink C, Breithardt O, Franke A, et al. J Am
Coll Cardiol 2001381957- 65
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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 2002143412-417 2 Shenkman H, McKinnon
J, Khandelwal A, et al. Circulation 2000102(18
Suppl II) abstract 2293 3 Schoeller R, Andresen
D, Buttner P, et al. Am J Cardiol.
199371720-726 4 Aaronson K, Schwartz J, Chen T,
et al. Circulation 1997952660-2667 5 Farwell D,
Patel N, Hall A, et al. Eur Heart J
2000211246-1250
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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 N5517
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LBBB N1391
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 2002143398-405
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Proposed Mechanisms of Cardiac Resynchronization
Yu C-M, Chau E, Sanderson J, et al. Circulation
2002105438-445
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Summary of Proposed Mechanisms
Yu C-M, Chau E, Sanderson J, et al. Circulation
2002105438-445
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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
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CRT Improves Quality of Life Score and NYHA
Functional Class
QoL NYHA PATH-CHF1 (n41) InSync
(Europe)2 (n103) InSync ICD (Europe)3
(n84) MUSTIC4 (n67) MIRACLE5
(n453) MIRACLE ICD6 (n364)
Statistically significant improvement with
CRT (p ? 0.05) ? Not statistically
significant or No statistical analysis performed
on dataBlank Indicates
test neither performed nor reported
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CRT Improves Exercise Capacity
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CRT Improves Cardiac Function/Structure
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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 20024311-320 2 Auricchio A. Stellbrink C,
Sack S., et al. J Am Coll Cardiol
2002392026-2033 3 Linde C, Leclercq C, Rex S,
et al. J Am Coll Cardiol 200240111-118
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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

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Step 2 Perform Venograms
Varying Patient Anatomy 1,2,3
1. Potkin et al. Am J Cardiol 1987601418-1421
2. Neri et al. Europace 2000I D95 Abstract 88/2
3. Hill et al. Europace 2000ID238 Abstract
167/2
Photos Courtesy of Dr. Daniel Gras
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Cardiac Venous Anatomy
Step 2 Perform Venograms
Great
Postero-lateral
CS Os
Antero- lateral
Lateral
Middle
Anterior
Posterior
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Lead in Lateral Cardiac Vein
Step 2 Perform Venograms
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Step 4 Place LeadAttain OTW Model 4193
Click to Start/Stop
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Step 4 Place LeadAttain OTW Model 4193
Courtesy ofDr. Daniel Gras
Click to Start/Stop
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LAO View Tracking Over the Wire
Courtesy ofDr. Daniel Gras
Click to Start/Stop
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Step 4 Place Leads Attain LV Model 2187
Video compliments of Dr. Vince Paul
Click to Start/Stop
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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
• 4. Optimal medical therapy