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Defining what is End-Stage CMP
1. What is not end-stage
2. What is clearly end-stage
3. Dissecting the ambulatory high risk
Modern Era Mortlity
Primary Endpoint: CV death or HF Hospitalization
N Engl J Med 2014; 371:993-1004
Where do we draw the line?
INTERMACS PROFILES AND OTHER CLASSIFICATION SYSTEMS
Profile # Description NYHA Class Time to MCS therapyAHA/ACC
Stage
INTERMACS 1 Crashing and burning IV Within hours D
INTERMACS 2 Progressive decline on inotropic support IV Within a few days D
INTERMACS 3 Stable but inotrope dependent IV Within a few weeks D
INTERMACS 4Recurrent advanced heart failure;
resting symptoms at home on oral therapyAmbulatory IV Within weeks to months D
INTERMACS 5 Exertion intolerant Ambulatory IV Variable D
INTERMACS 6 Exertion limited or walking wounded Ambulatory IV Variable C-D
INTERMACS 7 Advanced NYHA III IIIB Variable C
Prognosis and Peak VO2
Patients were subdivided into quartiles according to peak VO2 (P1:<13.0 ml/kg/min, P2:13.0-16.5 ml/kg/min, P3:16.6-21.6 ml/kg/min, P4: >21.6 ml/kg/min). Their respective Kaplan-Meier survival curves were significantly different ( p<0.0001). Mortalities at 24 months were 48%, 32%, 12%, and 4% respectively.
Francis DP, Shamim W, Davies LC, Ponikowski P, Anker SD, Coats AJS.European Heart Journal 2000 21: 154-161
VE/VCO2 (rate of increase ventilation per carbon dioxide production
Patients were separately subdivided in quartiles according to VE/VCO2 slope (V1:<27.7, V2:27.7-34.5, V3:34.6-42.1, V4: >42.1), whose Kaplan-Meier Survival curves were again distinct from each other (Figure 3, p<0.0001). Mortalities at 24 months were 3%, 17%, 26% and 49% respectively.
Francis DP, Shamim W, Davies LC, Ponikowski P, Anker SD, Coats AJS.European Heart Journal 2000 21: 154-161
Combined Post and Pre Capillary PH
• DPG > 7 mm/h
• PVR > 3 W
European Heart Journal doi:10.1093/eurheartj/ehv317
“Fixed PAH”
• TPG >15 mmHg
• DPG (defined as diastolic PAP − mean PAWP) appears to best approach the characteristics required to determine pulmonary vascular disease. (ESC 2015 guidelines)
European Heart Journal doi:10.1093/eurheartj/ehv317
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