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CASE STUDIES IN ADVANCED HEART FAILURE

Navin Rajagopalan, MD

Director, Congestive Heart FailureMedical Director, Cardiac Transplantation

Gill Heart Institute Cardiovascular MedicineGill Heart Institute, Cardiovascular Medicine

DISCLOSURESDISCLOSURES

NOTHING TO DISCLOSENOTHING TO DISCLOSE

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OBJECTIVESOBJECTIVES

Discuss the different diuretic regimens Discuss the different diuretic regimens th t il bl f ti t ithth t il bl f ti t iththat are available for patients with that are available for patients with decompensated heart failuredecompensated heart failure

Discuss methods for monitoring fluid Discuss methods for monitoring fluid status in patients with chronic systolicstatus in patients with chronic systolicstatus in patients with chronic systolic status in patients with chronic systolic heart failureheart failure

CASE #1CASE #1

34 year old male diagnosed with 34 year old male diagnosed with i h i di th i 2008i h i di th i 2008nonischemic cardiomyopathy in 2008nonischemic cardiomyopathy in 2008

–– LHC: no CADLHC: no CAD

–– LVEF 25%LVEF 25%

–– Placed on medical therapy including Placed on medical therapy including BB/ACEiBB/ACEi

In 2010 lost job/insurance and stopped In 2010 lost job/insurance and stopped all medications, physician followall medications, physician follow--upup

In late 2011 experienced increasing In late 2011 experienced increasing SOB, LE edema, orthopneaSOB, LE edema, orthopnea

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CASE #1CASE #1

PE:PE:–– P 100 BP 96/60 Weight 340 lbsP 100 BP 96/60 Weight 340 lbs

–– Morbidly obese, tachypneicMorbidly obese, tachypneic

–– Clear lungsClear lungs

–– CV CV –– RR, S3 gallopRR, S3 gallop

–– 3+ LE edema3+ LE edema3+ LE edema3+ LE edema

BNP 700BNP 700

Cr 1.8Cr 1.8

ECHOCARDIOGRAMECHOCARDIOGRAM

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OPTIONSOPTIONS

Initiate intravenous diuresisInitiate intravenous diuresis–– IV bolus diuretic therapy IV bolus diuretic therapy

–– IV diuretic dripIV diuretic drip

UltrafiltrationUltrafiltration

ULTRAFILTRATIONULTRAFILTRATION

UNLOAD randomized 200 patients hospitalized with UNLOAD randomized 200 patients hospitalized with CHF to UF versus standard diureticsCHF to UF versus standard diureticsCHF to UF versus standard diureticsCHF to UF versus standard diuretics–– UF group: no diuretics; UF up to 48 hoursUF group: no diuretics; UF up to 48 hours

–– Standard group: IV diuretics at a dose twice that of home doseStandard group: IV diuretics at a dose twice that of home dose

–– Primary endpoint: Weight loss and objective dyspnea at 48 hrsPrimary endpoint: Weight loss and objective dyspnea at 48 hrs

Patient characteristics:Patient characteristics:–– NYHA III/IVNYHA III/IVNYHA III/IVNYHA III/IV

–– 70% LVEF < 40%70% LVEF < 40%

–– Cr 1.5 Cr 1.5 ±± 0.50.5

–– Home Lasix dose 120 mg / dayHome Lasix dose 120 mg / day

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ULTRAFILTRATIONULTRAFILTRATION

UF group experienced significant weight loss at 48 hours compared to standard care

Fewer pts in UF group received vasoactive drugs at 48 hours (NTG, nesiritide, inotropes)

No difference in changes in creatinine

No change in LOS

Oral diuretic dosage was less in the UF group at discharge (p = 0.058) and at 10 days post-discharge (p 0.049)

ULTRAFILTRATIONULTRAFILTRATION

UF group experienced significantly lower CHF rehospitalization rate at 90 days as well as fewer ER visits and unscheduled clinic visits

Possibly related to lower diuretic dose in UF group

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ULTRAFILTRATIONULTRAFILTRATION

Mechanism for the decrease in rehospitalization is Mechanism for the decrease in rehospitalization is unknownunknownunknownunknown

Promising new therapy for volume removal in Promising new therapy for volume removal in decompensated CHF patientsdecompensated CHF patients

Economic analysis of UF has not been studiedEconomic analysis of UF has not been studied

CASE #1CASE #1

Right heart catherization:Right heart catherization:–– CVP 38 mm HgCVP 38 mm HgCVP 38 mm HgCVP 38 mm Hg

–– RV 65/37RV 65/37

–– PA 65/42 (mean 51 mm Hg)PA 65/42 (mean 51 mm Hg)

–– PCWP 41 mm HgPCWP 41 mm Hg

–– Maintained cardiac outputMaintained cardiac output

Hemodialysis line placed in right IJ veinHemodialysis line placed in right IJ veinHemodialysis line placed in right IJ veinHemodialysis line placed in right IJ vein

Ultrafiltration initiated and titrated up to 250 mL/hour fluid Ultrafiltration initiated and titrated up to 250 mL/hour fluid removalremoval

Successful 10 L diuresis over 3 days with improvement Successful 10 L diuresis over 3 days with improvement in serum creatinine (1.8 to 1.3)in serum creatinine (1.8 to 1.3)

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CASE #1CASE #1

Patient transitioned to IV diuretics, then oral diureticsPatient transitioned to IV diuretics, then oral diuretics–– Discharged on oral Bumex 2 mg bidDischarged on oral Bumex 2 mg bidDischarged on oral Bumex 2 mg bidDischarged on oral Bumex 2 mg bid

Chronic HF therapy optimized including ACEi, BB, and Chronic HF therapy optimized including ACEi, BB, and aldosterone antagonistaldosterone antagonist

6 months later:6 months later:N b t h it li tiN b t h it li ti–– No subsequent hospitalizationsNo subsequent hospitalizations

CASE #2CASE #2

41 year old with dilated cardiomyopathy (LVEF 15%) in 41 year old with dilated cardiomyopathy (LVEF 15%) in setting of HIV (dx 1994) referred by his cardiologist forsetting of HIV (dx 1994) referred by his cardiologist forsetting of HIV (dx 1994) referred by his cardiologist for setting of HIV (dx 1994) referred by his cardiologist for advanced heart failure optionsadvanced heart failure options

NYHA class IIINYHA class III--IV symptomsIV symptoms

Echo: LV moderately dilated (6.3 cm LVEDD); moderate Echo: LV moderately dilated (6.3 cm LVEDD); moderate MRMR

Rx: carvedilol 3.125 mg bid, lisinopril 2.5 mg qday, lasix Rx: carvedilol 3.125 mg bid, lisinopril 2.5 mg qday, lasix 40 mg qday and HAART40 mg qday and HAART40 mg qday, and HAART40 mg qday, and HAART

Admitted to periods of noncomplianceAdmitted to periods of noncompliance

Told me HIV viral load was “in the millions” and CD4 Told me HIV viral load was “in the millions” and CD4 count was “less than 50”count was “less than 50”

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CASE #2CASE #2

Other hx included several AIDS defining illnesses:Other hx included several AIDS defining illnesses:–– PCP pneumoniaPCP pneumoniaPCP pneumoniaPCP pneumonia

–– MACMAC

–– CMV pneumonitisCMV pneumonitis

PE:PE:–– P 110 BP 100/60 Weight 130 lbsP 110 BP 100/60 Weight 130 lbs

–– Chronically ill appearing, cachectic; in wheelchairChronically ill appearing, cachectic; in wheelchair

–– HEENT: JVP 12 cm H20HEENT: JVP 12 cm H20HEENT: JVP 12 cm H20HEENT: JVP 12 cm H20

–– Lungs ClearLungs Clear

–– CV: tachycardic with S3 gallop and 2/6 MR murmurCV: tachycardic with S3 gallop and 2/6 MR murmur

–– Abdomen: mild hepatomegalyAbdomen: mild hepatomegaly

–– Ext: 2+ pitting edemaExt: 2+ pitting edema

QUESTIONS TO CONSIDERQUESTIONS TO CONSIDER

Are HIV/AIDS absolute contraindications to heart Are HIV/AIDS absolute contraindications to heart transplantation and/or VAD placement?transplantation and/or VAD placement?transplantation and/or VAD placement?transplantation and/or VAD placement?

Is upIs up--titration of medical therapy and ICD placement his titration of medical therapy and ICD placement his only option?only option?

How much is noncompliance playing a role in his poor How much is noncompliance playing a role in his poor functional status, failure to thrive?functional status, failure to thrive?

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LVAD IN HIV PATIENTSLVAD IN HIV PATIENTS

Sims DB et al. J Heart Lung Transplant 2011;30:1060-4

HEART TX IN HIV PATIENTSHEART TX IN HIV PATIENTS

Uriel N et al. J Heart Lung Transplant 2009;28:667-9

All patients had negative HIV viral load at time of transplant

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CASE #2CASE #2

Decided to obtain right heart catheterization as Decided to obtain right heart catheterization as outpatientoutpatientoutpatientoutpatient

Before RHC was obtained, patient presented with Before RHC was obtained, patient presented with decompensated heart failure and transferred to UKdecompensated heart failure and transferred to UK

Did well with diuresis, but hospitalization complicated by Did well with diuresis, but hospitalization complicated by mental status changes, elevated LFTs, and mental status changes, elevated LFTs, and thrombocytopenia (20K)thrombocytopenia (20K)

CASE #2CASE #2

RHC:RHC:–– CVP 10 mm HgCVP 10 mm HgCVP 10 mm HgCVP 10 mm Hg

–– RV 38/10RV 38/10

–– PA 38/22 (28 mm Hg)PA 38/22 (28 mm Hg)

–– PCWP 20 mm HgPCWP 20 mm Hg

–– CO 4.2 L/min; CI 2.4 L/min/m2CO 4.2 L/min; CI 2.4 L/min/m2

Conclusion: Relatively compensated HFConclusion: Relatively compensated HFConclusion: Relatively compensated HFConclusion: Relatively compensated HF

Plan: outpatient f/u with titration of medical therapyPlan: outpatient f/u with titration of medical therapy

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CASE #2CASE #2

Patient started to improve over next 2 monthsPatient started to improve over next 2 months–– More compliant with HAARTMore compliant with HAART –– improving CD4 count andimproving CD4 count andMore compliant with HAART More compliant with HAART improving CD4 count and improving CD4 count and

dropping viral loaddropping viral load

–– Improving appetite and muscle strength (started to gain weight)Improving appetite and muscle strength (started to gain weight)

–– Remained class III HF but less problems with LE edemaRemained class III HF but less problems with LE edema

–– Baseline HR improved to 80s (from 100s) and was able to tolerat Baseline HR improved to 80s (from 100s) and was able to tolerat upup--titration of beta blockertitration of beta blocker

Another RHC obtained with similar results as previousAnother RHC obtained with similar results as previous

Eventually was able to lower his diuretic from lasix 80 Eventually was able to lower his diuretic from lasix 80 mg bid to 40 mg bidmg bid to 40 mg bid

HOWEVER….HOWEVER….

One month later…(around New Years..)One month later…(around New Years..)–– Felt fatigued and had a few episodes of nausea/emesisFelt fatigued and had a few episodes of nausea/emesisFelt fatigued, and had a few episodes of nausea/emesisFelt fatigued, and had a few episodes of nausea/emesis

–– Noted lower urine output and increased his lasix from 40 bid to Noted lower urine output and increased his lasix from 40 bid to 80 bid80 bid

–– Fatigue worsened and some orthostatic symptomsFatigue worsened and some orthostatic symptoms

Seen in clinic and appeared drySeen in clinic and appeared dry

Labs: Sodium 119; BUN 50; Cr 2.2Labs: Sodium 119; BUN 50; Cr 2.2

Admitted to hospital for IV hydration with improvement in Admitted to hospital for IV hydration with improvement in BMPBMP

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NEXT STEP?NEXT STEP?

HF appeared to have stabilized to point where LVAD HF appeared to have stabilized to point where LVAD was not neededwas not neededwas not neededwas not needed

Despite patient education/instruction, he seemed Despite patient education/instruction, he seemed particularly prone to episodes of fluid overload and particularly prone to episodes of fluid overload and dehydration with need to adjust diuretic therapydehydration with need to adjust diuretic therapy

Complicating matters was his increasing weight due to Complicating matters was his increasing weight due to improvement in muscle mass, appetiteimprovement in muscle mass, appetite

Is there another way to track his fluid status?Is there another way to track his fluid status?

Ritzema J et al. Circ 2007;116:2952-9

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LA PRESSURE MONITORINGLA PRESSURE MONITORING

LA pressures can be LA pressures can be transmitted totransmitted totransmitted to transmitted to clinician dailyclinician dailyAdjustments can be Adjustments can be made to made to medications before medications before clinical symptoms clinical symptoms ariseariseariseariseSafety/utility seen in Safety/utility seen in pilot study of 8 pilot study of 8 patientspatients

Ritzema J et al. Circ 2007;116:2952-9

LAPTOPLAPTOP--HFHF

LAPTOPLAPTOP--HF is a prospective, multiHF is a prospective, multi--center, randomized center, randomized study assessing benefit of LA pressure monitoring study assessing benefit of LA pressure monitoring y g p gy g p gsystemsystem

Randomization 1:1 toRandomization 1:1 to–– sensor implanted providing ongoing LAP readings to the hand held sensor implanted providing ongoing LAP readings to the hand held

along with physician prescribed medication recommendations along with physician prescribed medication recommendations OROR

–– no sensor implant but a handno sensor implant but a hand--held device for medication remindersheld device for medication reminderspp

UK is a participating institution and actively enrollingUK is a participating institution and actively enrolling

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Navin Rajagopalan, MD

University of Kentucky

Office (859) 323-3705

nra224@uky.edu

Transplant referral: 1-800-456-5287