3. Increasing Severity
Class I
• Cardiac disease
• No symptoms
• No limitation in
ordinary physical
activity
Class II
• Mild symptoms
(mild shortness of
breath and/or
angina)
• Slight limitation
during ordinary
activity
Class IIIa and IIIb
• Marked
limitation in
activity due to
symptoms
• Comfortable only
at rest
Class IV
• Severe
limitations
• Symptoms even
while at rest
• Mostly bedbound
patients
NewYork Heart Association Functional Classification of Heart Failure
4.
5.
6. (Strength of Evidence = A)
• ACE inhibitors
• ARBs
• Warfarin
• In patients with atrial fibrillation,
pulmonary embolism, orTIA
• Beta Blockers
• Aldosterone Antagonists
• Hydralazine and Isosorbide
Dinitrate
• Loop Diuretics Lindenfeld, J, et al.
J Card Failure
2010; 6, 486-491
7. Strength of Evidence = B
• Antiplatelet agents (Aspirin)
• Ischemic etiology of HF
• Digoxin
• In stage II and III HF
• Thiazide diuretics
• Warfarin
• MI patients with LV thrombus
Strength of Evidence = C
• Digoxin
• In stage IV HF
• Metalazone
Lindenfeld, J, et al.
J Card Failure
2010; 6, 486-491
8. Inotropes
• Commonly used on an outpatient basis for stage IIIb – IV heart failure
• Milrinone and Dobutamine are the only FDA approved drugs for
outpatient use
• Not recommended for acute heart failure exacerbations in ischemic
patients
• Probable benefit in non-ischemic exacerbations
• OPTIME-CHF JAMA
2002; 287:1541-7
10. Implantable Cardiac Defibrillators
• Ischemic Etiology
(Strength of Evidence = A)
• Non-ischemic Etiology
(Strength of Evidence = B)
• Primary prevention of ventricular
arrhythmias
• LVEF <35%
Lindenfeld, J, et al.
J Card Failure
2010; 6, 486-491
11. Decreased end organ perfusion
• Renal function
• Liver function
• Pulmonary function
We need more support!
12. Ventricular Assist Device (VAD)
Long-Term LVAD Short-Term LVAD
A mechanical circulatory device used to partially or completely
replace the function of either the left ventricle (LVAD); the right
ventricle (RVAD); or both ventricles (BiVAD)
13. ANY
• Rule out any contraindications toVAD support?
• End-stage lung, liver, or renal disease
• Metastatic disease
• Medical non-adherence or active drug addiction
• Active infectious disease
• Inability to tolerate systemic anticoagulation (recent CVA, GI bleed, etc.)
• Moderate to severe RV dysfunction
• What are our other issues in this particular patient?
14. Lietz and Miller
Curr OpinCardiol
2009, 24:246–251
INTERMACS SCORE
Interagency Registry for Mechanically Assisted Circulatory Support
Long-Term LVAD
Ideal candidates are
INTERMACS classes 3-4
Short-Term LVAD
Candidates are
INTERMACS classes 1-2
Not a LVAD Candidate
INTERMACS 1 or those with
multisystem organ failure
16. Long-term placement :Terminal heart failure
DestinationTherapy (DT)
• Not a heart transplant candidate
• NYHA IV
• LVEF <25%
• Maximized medical therapy >45
of 60 days; IABP for 7 days; OR
14 days
• Functional limitation with a peak
oxygen consumption of less than
or equal to 14 ml/kg/min
• Life expectancy < 2 years
Bridge toTransplantation (BTT)
• Patient is approved and currently
listed for transplant
• NYHA IV
• Failed maximized medical therapy
20. Pump Speed (RPM) – How quickly
the pump rotates
Pump Power (Watts) – Measure of
motor voltage and current
Pump Flow (L/min) - Estimated
value of the volume running
through the pump
Pulsitility Index –The measure of
the left ventricular pressure during
systole
27. • Utilized for LV support only; not appropriate to
use with RV failure
• Impella 2.5 can be inserted through the femoral
artery during a standard catheterization
procedure; provides up to 2.5 L of flow
• Impella 5.0 inserted via femoral or axillary
artery cut down; provides up to 5L of flow
• The catheter is advanced through the
ascending aorta into the left ventricle
• Pulls blood from an inlet near the tip of the
catheter and expels blood into the ascending
aorta
• FDA approved for support of up to 6 hours
28. • Used for LV support; not
appropriate in RV failure
• Cannulas are inserted
percutaneously through the
femoral vein and advanced across
the intraatrial septum into the left
atrium
• The pump withdraws oxygenated
blood from the left atrium and
returns it to the femoral arteries
via arterial cannulas
29. • Can be used for LV and/or
RV support
• Cannula are typically
inserted via a midline
sternotomy
• Capable of delivering flows
up to 9.9 L/min
• Can be used for up to 30
days
30. • Used for patients with a
combination of acute cardiac
and respiratory failure
• A cannula takes deoxygenated
blood from a central vein or the
right atrium, pumps it past the
oxygenator, and then returns
the oxygenated blood, under
pressure, to the arterial side of
the circulation
