Issues in Advanced Heart Failure

The AHA/European Society of Cardiology Joint Session, “Advanced Heart Failure,” addressed several topics, including classifications of advanced heart failure (HF), hemodynamic monitoring, implantable devices, and heart transplantation.

Mariell Jessup, MD, University of Pennsylvania, Philadelphia, PA, first described the staging system for HF. Dr. Jessup said that the New York Heart Association (NYHA) classification of advanced (or severe) HF is based primarily on the presence of symptoms. In contrast, the American College of Cardiology/American Heart Association (ACC/AHA) classification guidelines, updated in 2005, focus more on underlying disease and the need to treat early in the disease process, before overt symptoms of HF are present [Hunt et al. Circulation 2005].

Christopher M. O'Connor, MD, Duke University, Durham, NC, noted the importance of clinical and hemodynamic monitoring, emphasizing that serial clinical assessment remains an important cornerstone of surveillance. Dr. O'Connor said that the use of implantable hemodynamic monitoring systems have significantly reduced HF-related events. He also discussed several studies that have shown that biomarker-guided therapy is a less-invasive approach that may add significantly to the management of patients with advanced HF. Specifically, HF therapy that is guided by brain natriuretic protein (BNP) levels has reduced cardiovascular events and mortality in small studies. Dr. O'Connor added that a definitive large-scale, multicenter, randomized, controlled trial of BNP-guided HF therapy is needed.

Several guidelines have established criteria for the use of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices in patients with advanced HF [Zipes et al. Circulation 2006; Dickstein et al. Eur Heart J 2008; Epstein et al. Circulation 2008]. However, the overall use of these devices is low, especially among female and black populations, said Angelo Auricchio, MD, PhD, Fondazione Cardiocentro Ticino, Lugano, Switzerland. Dr. Auricchio noted that all national and international scientific societies recommend CRT for patients with advanced HF, reduced left ventricular ejection fraction, sinus rhythm, and QRS duration of at least 120 ms who remain symptomatic despite the use of optimal tailored drug therapy. Additional patient groups may now be considered for CRT, added Dr. Auricchio, including HF patients in whom permanent pacing or frequent dependence on ventricular pacing is expected and patients with chronic atrial fibrillation who eventually undergo atrioventricular junction ablation.

Ventricular assist devices (VADs) and heart transplantation are therapeutic options for patients with severe HF, and there are several important factors to note when considering either of these approaches. James Young, MD, Cleveland Clinic, Cleveland, OH, described several contraindications for VADs, which he classified into categories of technical, hemodynamic, pulmonary, peripheral vascular, active systemic infection, irreversible endorgan dysfunction, and psychosocial issues that may affect compliance.

Unlike the case with implantable devices, there are no comprehensive guidelines for the care of heart transplantation candidates, said Mandeep R. Mehra, MD, University of Maryland School of Medicine, Baltimore, MD. Dr. Mehra discussed several important questions to ask when deciding to perform heart transplantation:

• Is the patient sick enough?

• Will the patient tolerate a heart transplant?

• Are there comorbidities that will influence outcome?

• Are absolute contraindications really relative contraindications?

Dr. Mehra also noted that transplant listing should be dynamic; patients who are listed for transplantation must be re-evaluated at 3-month intervals to determine response to therapy and should be removed from the list if they have improved.