VI Reunión Anual de la Sección de insuficiencia Cardiaca y Trasplante 26 y 27 de Junio de 2009 Actividad acreditada por el comité de Acreditación de la Sociedad Española de Cardiología
Manejo de la IC avanzada o refractaria. Dr. Nicolas Manito
1. Dr. Nicolás Manito Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco Hospital Universitario de Bellvitge MANEJO DE LA IC AVANZADA O REFRACTARIA
5. REGISTRO ESPAÑOL DE TRASPLANTE CARDÍACO 1984-2007 Supervivencia actuarial por periodos. Grado de recomendación I, nivel de evidencia C. ESC 2008
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7. Lietz K. J Am Coll Cardiol 2007;50:1282–90 Improved Survival of Patients With End-Stage Heart Failure Listed for Heart Transplantation Status 1 Status 2
8. Mechanical ventilation 2.13 (1.68–2.71) 0.001 Valvular CM 1.93 (1.17–3.19) 0.01 UNOS status 1A 1.92 (1.57–2.35) 0.001 Serum creatinine >1.5 mg/dl 1.77 (1.47–2.12) 0.001 IABP 1.63 (1.29–2.06) 0.001 Age at listing 60 yrs 1.42 (1.16–1.74) 0.001 Intravenous inotropes 1.41 (1.14–1.75) 0.002 Body weight ≤ 70 kg 1.35 (1.11–1.64) 0.002 PCWP > 20 mm Hg 1.29 (1.07–1.54) 0.006 ICD at the moment of listing 0.79 (0.65–0.96) 0.001 Multivariable Analysis of Risk Factors for Death Within 2 Months After Listing of UNOS Status 1 Candidates for Heart Transplantation: U.S. Scientific Registry for Transplant Recipients:Years 2000 to 2005 (n 5,451) Lietz K. J Am Coll Cardiol 2007;50:1282–90 P RISK RATIO (95%CI)
9. Restrictive CM 3.94 (1.92–8.09) 0.001 Intravenous inotropes 2.95 (1.89–4.61) 0.001 Congenital heart disease 2.83 (1.24–6.46) 0.01 Secondary dilated CM 1.86 (1.12–3.11) 0.02 Serum creatinine > 1.5 mg/dl 1.70 (1.20–2.41) 0.003 PCWP 20 mm Hg 1.66 (1.20–2.28) 0.002 Blood group B 0.63 (0.45–0.90) 0.01 Multivariable Analysis of Risk Factors for Death Within 2 Months After Listing of UNOS Status 2 Candidates for Heart Transplantation: U.S. Scientific Registry for Transplant Recipients:Years 2000 to 2005 (n: 6937) P RISK RATIO (95%CI) Lietz K. J Am Coll Cardiol 2007;50:1282–90
10. Class I: 1. An ICD for secondary prevention should be always considered ( Level of Evidence: A ). 2. An implanted or wearable ICD should be provided for Status 1B patients who are discharged home given that the wait for transplantation remains significant (Level of Evidence: C). 3. Amiodarone should be used as the agent of choice when anti-arrhythmic therapy is necessary to prevent recurrent atrial or symptomatic ventricular arrhythmias despite its numerous side effects (Level of Evidence: A). 4. Re-synchronization therapy in advanced heart failure patients should be considered together with a defibrillator (Level of Evidence: B). Class IIa: 1. It is reasonable to consider placement of a defibrillator in patients with Stage D failure who are candidates for transplantation or LVAD destination therapy (Level of Evidence: C). Heart Rhythm Considerations in Heart Transplant Candidates : International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates—2006 Gronda E et al. J Heart Lung Transplant. 2006; 25:1043-1056
13. BOMBAS AXIALES IMPLANTABLES 1998 Micromed Nasa de Bakey Jarvik 2000 Heart Mate II 2002 Incor VENTAJAS : - Sin valvulas - Menos accidentes tromboembolicos - Menor tamaño y peso - Menos infecciones - Mejor duracion mecánica - Implantacion mas facil “ FLUJO CONTINUO NO ES PERJUDICIAL “
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17. INTERMACS: Jun 23, 2006 – Mar 30, 2007 Prospective Patients: n=156 Months after Device Implant % Survival All Others n=28, deaths=4 Event: Death Critical Cardiogenic Shock n=67, deaths=18 Prog Decline n=61, deaths=10 p= .07 Patient Profile at Implant 80% vs 60% Survival at 3 months 0 10 20 30 40 50 60 70 80 90 100 0 1 2 3 4 5 6
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19. Severity of Heart Failure Modes of Death MERIT-HF Study Group. LANCET. 1999;353:2001-07. 12% 24% 64% CHF Other Sudden Death n = 103 NYHA II 26% 15% 59% CHF Other Sudden Death n = 103 NYHA III 56% 11% 33% CHF Other Sudden Death n = 27 NYHA IV
22. N= 217 (13%) EF LVEDV low BP IHD Diabetes 6 min W OPT vs CF III
23. N= 217 (13%) OPT: HF death of 39% CFIII and 48%CFIV
24. 1 er AÑO T.MED. OP. TRC TRC+D TCO CF IV 44% 36% 30% 20% 2º AÑO CF IV 62% 45% 55% 25% IC refract. 29% 26% 41% MS 25% 16% 9% Lindenfeld J et al. Circulation . 2007;115:204-208 ESTUDIO COMPANION - CF IV (NYHA) Supervivencia
25. FUNCTIONAL CLASS IV HEART FAILURE PATIENTS TREATED WITH CARDIAC RESYNCHRONIZATION THERAPY M.A. Castel et al. H. Clínic . Barcelona . Europace. Berlin 2009 38 patients with NYHA Class IV Age, yrs, mean ±SD 65.31 ± 11.67 Male, n (%) 26 (74.3) Aetiology, n (%) Ischemic Idiopathic 22 (59.4) 14 (37.8) Atrial fibrillation, n (%) 19 (51.4) AICD, n (%) 18 (48.6) Upgrade, n (%) 12 (32.4) Inotropic treatment, n (%) 16 (43.2)
26. M.A. Castel et al. H. Clínic . Barcelona. Europace. Berlin 2009 FUNCTIONAL CLASS IV HEART FAILURE PATIENTS TREATED WITH CARDIAC RESYNCHRONIZATION THERAPY Variable Baseline 6-months p NYHA class 4 2.8±1.1 <0.001* QRS 168.2 ± 29.8 145.5± 22.3 0.001* QoL (points) 66.4±19.4 34.9±23.8 0.004* 6MWT (m) 0 (17 pat) 144.8±27 (4 pat) 349.5 ±31.2 325±25 <0.001* Ns LVEF (%) 21.1 ± 7.4 25.7±7.4 0.008* LVEDD (mm) 73.5±8.0 74.1±6.8 Ns LVESD (mm) 58.2±8.2 60.6±10.4 Ns Creatinine (mg/dl) 1.6±0.6 1.61±0.6 Ns Sodium (mmol/L) 130.8±5.8 136.2±4.6 0.001* Haemoglobin (g/dl) 11.8 ± 1.9 12.8±1.8 Ns Cholesterol (mg/dl) 139.6 ± 51.4 157.8±52.2 Ns BNP (pg/ml) 926.8 ± 1101.2 758.6±823.4 Ns
27. Follow up: 11.7 ± 9.8 months 12 Events at 6 m: 8 HF, 2 SD, 1 HTX, 1 CVA 17 Total Events: 12 HF, 2 SD and 3 HTx Six months mortality: 32% Twelve months mortality: 42% Responders at 6 months: 36.4% ● Univariate analysis: baseline sodium and low QRS reduction after CRT were associated with increased mortality. ● Multivariate Cox regression showed that a QRS shortening of <12.5% from baseline QRS was an independent predictor of mortality (HR 4,5 (95% CI: 0,96-20,8) p =0,038). FUNCTIONAL CLASS IV HEART FAILURE PATIENTS TREATED WITH CARDIAC RESYNCHRONIZATION THERAPY M.A. Castel et al. H. Clínic . Barcelona. Europace. Berlin 2009
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Notas del editor
Interestingly, most patients who suffer from sudden cardiac death (64%) are the patients who are minimally symptomatic with Class II heart failure. The sickest, most symptomatic patient (Class IV) experience heart failure deaths (56%) from pump failure, rather than sudden cardiac death (33%). It is important to remember that although it can be said that a heart failure patient in NYHA Class II may have a higher risk of SCD, their relative annual risk of dying is less than the other NYHA classes. The SCD-HeFT Trial (Sudden Cardiac Death in Heart Failure Trial) which enrolled NYHA Class II and III patients, hopes to answer whether patients in these classes are truly at a higher risk for SCD and need protection.
Key Message: The benefits of CRT were similar across subgroups.
Las dosis más bajas no aumentaban la frecuencia cardiaca
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