Clinician-to-Clinician Update Clinician-to-Clinician Update

Latest Devices Offer Improved Outcomes for Advanced Heart Failure Patients

May 2015

Heart failure is a major public health concern. The lifetime risk of developing heart failure is 20% for Americans 40 years of age and over1, and heart failure significantly decreases quality of life, especially in the areas of physical functioning and vitality.2 While patients with mild-to-moderate heart failure benefit from medical therapy, the efficacy of medical therapy for patients with advanced disease (Table 1) is limited.3 Historically, the five-year mortality rate with advanced disease exceeds 50%, despite medical management.4

UMNHeartCare HeartFailure CONSULTNewsletter Table1
— Table 1. Clinical Events and Findings Useful for Identifying Patients with Advanced Heart Failure* *Adapted from American College of Cardiology Foundation/American Heart Association guidelines. Appears courtesy of ACCF/AHA.

Cardiac transplantation has long been considered the gold standard of advanced heart failure care, and survival rates are impressive: 84.5%, 78.2%, and 72.5% at 1, 3, and 5 years post-transplant, respectively. 5 For patients for whom transplantation is not indicated or donor organs not immediately available, advances in left ventricular assist device (LVAD) technology now make this an excellent treatment option. In the pivotal REMATCH trial, 68 patients with end-stage heart failure who were ineligible for cardiac transplantation received an LVAD, and outcomes were compared with those of 61 similar patients who received optimal medical management.6 The rates of survival at 1 year were 52% in the device group and 25% in the medical-therapy group (p=0.002). The device group’s quality of life was significantly improved as well. With second-generation, continuous-flow devices currently available, survival rates have improved even further, to 72% at 18 months for bridge-to-transplant patients7 and 62% at 2 years for destination therapy patients who are ineligible for transplant.8

University of Minnesota Heart Care offers a range of services for patients with heart failure, and its Advanced Heart Failure program is one of the largest in the nation. Its physicians implant more than 60 LVADs each year and perform 20 to 30 heart transplants annually, making the service line a national leader and University of Minnesota Medical Center among the top 10% to 15% of centers in the nation for cardiac transplantation. UMN Heart Care physicians enroll patients in clinical trials that explore advanced technology and other novel treatments.

References

1. Djousse L, Driver JA, Gaziano JM. Relation between modifiable lifestyle factors and lifetime risk of heart failure. JAMA. 2009;302:394-400.

2. Lesman-Leegte I, Jaarsma T, Coyne JC, et al. Quality of life and depressive symptoms in the elderly: a comparison between patients with heart failure and age- and gender-matched community controls. J Card Fail. 2009;15:17-23.

3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128:e240-e327.

4. Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence of and survival with heart failure. N Engl J Med. 2002;347:1397-1402.

5. Lund LH, Edwards LB, Kucheryavaya AY, et al. The registry of the International Society for Heart and Lung Transplantation: thirty-first official adult heart transplant report – 2014; focus theme: retransplantation. J Heart Lung Transplant. 2014;33:996-1008.

6. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345:1435-1443.

7. Pagani FD, Miller LW, Russell SD, et al. Extended mechanical circulatory support with a continuous-flow rotary left ventricular assist device. J Am Coll Cardiol. 2009;54:312-321.

8. Jorde UP, Kushwaha SS, Tatooles AJ, et al. Results of the destination therapy post-food and drug administration approval study with a continuous flow left ventricular assist device: a prospective study using the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol. 2014;63:1751-1757.

When to Refer

We strongly recommend that you refer your heart failure patients to us early in the disease course when more treatment options are available. It is not necessary to wait until the patient has advanced disease.

Patients with heart failure and any of the identifiers of advanced heart failure (see Table 1) should be referred promptly.

To schedule an appointment by phone, please contact 612-365-5000.

• “Option 1” for University of Minnesota Medical Center.

• “Option 2” for Fairview medical centers and clinics.

We offer the following services for your patients:

• Evaluation and treatment of advanced heart failure

• Cardiac rehabilitation

• Implantable cardioverter defibrillators

• Cardiac resynchronization therapy and optimization

• Ablation therapy for atrial and ventricular arrhythmias

• Cardiac surgery for high-risk patients, including off-pump coronary revascularization

• Transcatheter aortic valve replacement

• Mitral valve repair in patients with cardiac dysfunction

• MRI imaging of the heart

• Investigational drugs and devices

• Left ventricular assist devices

• Cardiac transplantation

Collaborative Care

Based on the referring provider’s preference, we will call, text, or email within 72 hours of consultation with a patient. All decisions about the treatment plan, including recommendations for LVAD use or transplantation, are made in conjunction with the referring physician. In the event that a patient receives an LVAD, our LVAD coordinators will inform and educate EMS professionals located near the patient’s residence, as needed, to ensure appropriate emergent care is readily available to the patient. Coordination of care between our providers and facilities close to the patient is very important to us. We strive to minimize stress and time lost to travel for the patient. We invite all referring providers to come and visit our hospitals and centers. To schedule a physician meeting, contact Brendan Cassidy, cardiovascular outreach manager. Phone: 651-269-2634; email bcassid1@fairview.org

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