Acute Heart Failure: New Therapies, New Devices, and Management Pearls

Join our host, Ohio-ACC President  Dr. Kanny Grewal, and guests Drs. Ankit Bhatia and Gregory F. Egnaczyk, both from The Christ Hospital in Cincinnati, as they discuss the practical management of acute decompensated heart failure (ADHF) - including clinical assessment, classification, acute therapies, candidacy for advanced therapies. They then review the current clinical role for left ventricular assist devices (LVADs) including patient selection and current outcomes. 

For more information, see Durable Mechanical Circulatory Support: A JACC Scientific Statement  from the ACC.

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Please subscribe to receive updated episodes automatically! Visit https://www.ohioacc.org/cardiohio-podcast/.

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Transcript

Kanny: 0:11

So welcome back to the cardio Ohio podcast. I unfortunately don't have my co fellows helping me out today, but I am honored to have a couple of excellent guests from Cincinnati, Ohio. We're going to focus today on acute heart failure. We've had some previous sessions. dealing with chronic heart failure. But I really am proud to have a couple of specialists with acute heart failure that are going to talk us through some of the key clinical points and also talk about candidacy and management of patients with device therapy as well. First, I'd like to welcome Dr. Ankit Bhatia. He is at the Christ Hospital in Cincinnati. He's a heart failure specialist. So first of all, Ankit, welcome. And second of all, do you mind just taking a minute and telling us a little bit about the path that brought you to Cincinnati and also what led you into specializing in advanced heart failure?

Ankit: 1:08

Thanks so much for having us, Kenny. Hey guys, I'm Ankit Bhatia. As, as Kenny mentioned, I work here at the Christ Hospital as an advanced heart failure transplant cardiologist. My path starts in Syracuse, New York. I'm a diehard Syracuse Orange fan. My parents were both professors there, grew up there, and then made my way to University of Chicago for med school, and then finally landed in Washington University in St. Louis for both my general cardiology and advanced heart failure fellowships. After that, made my way to Cincinnati where my wife was born and raised, and had a great experience here at the Christ Hospital. We were both in LBAD in the transplant program. And my clinic specifically focuses more on some of the genetic cardiomyopathies and hypertrophic cardiomyopathy more so, but see all sorts of patients. And it's been a great experience being here.

Kanny: 2:00

Great. Well, we're happy to have you in Ohio I'd also like to welcome actually your partner, Dr. Gregory Ignacek, who is known to a lot of clinicians in Cincinnati, also a heart failure specialist. And in fact, the medical director of advanced heart failure at the Christ Hospital. I understand you have an endowed chair as well. So Greg, welcome. And can you just tell us a little bit about your trail into Cincinnati and into your specialty as well?

Greg: 2:26

Yeah, thanks, Kenny, really much for having us here tonight and honored to be here. So, yeah, I went to medical school, did an MD PhD at University of Cincinnati. I'm actually from Connecticut originally. And then met my, my, my now wife there in Cincinnati, but I brought her out to Boston and that was just only. when it comes to taking Cincinnatians out of their home state. So fortunately I've, I've made amends and brought her back to Cincinnati after doing training in Boston and then down at Duke. And then as, as a fellow, I was really drawn to advanced heart failure. from the perspective of the complexity of the patients and really the amazing saves that we can do. We see these patients at death's door and we can find ways to kind of, you know, resuscitate them with either LVAD and or heart transplant and really make these miraculous recoveries. And that was very much attractive. And that complexity and the scientific underpinnings drew me to advanced heart failure. Now that was as a fellow, as you become an attending. Then it's your responsibility to take care of these people and that, and that's a fair, can be a fairly stressful time. It could be a time filled with different long, hard family discussions and also the palliative care, which is an important part of what we do in advanced heart failure. So I think that aspect of things in the humanity that we, we get engaged with as, as these people are nearing. End of life is really been a privilege, and I think it's been a good balance between the amazing science and therapies that we can deliver, but also really Being part of these families lives after they're after we care for them. So thank you for inviting us here tonight.

Kanny: 4:06

Yeah, great So welcome to both of you So as I mentioned at the beginning, we've had a podcast, with some great heart failure doctors talking about chronic Heart failure in terms of state of the art medical management. So we really wanted to focus today on, especially from the standpoint of the general cardiologist, because, as you know, we have an audience of general cardiologists, cardiac specialists, but it's also quite a few advanced practice providers and fellows in training. Obviously, it doesn't matter what specialty or area of cardiology practice you encounter acute heart failure on a daily basis. You don't have to be a subspecialist to see a lot of heart failure, especially working as a consultant in a hospital. So, from that perspective, Ankit, I thought I would just start by asking you. When you, as a consultant, approach a patient with either, confirmed acute heart failure or a suspected heart failure, or even undefined, hypotension or shock, going into an evaluation like that, what's the kind of classification that you're trying to categorize these patients into to kind of, get an initial assessment and start to think about therapy?

Ankit: 5:16

Thanks, Kenny. And it's a great question because really, many times we're seeing patients that are relatively undifferentiated. And, heart failure, we consider kind of a catch all term for the inability of the heart to adequately pump blood flow to the body or having to do so at the expense of high filling pressures and kind of broadly kind of summarizing. I know most folks will know this already. We break it up as half path for basically heart failure preserved ejection heart failure with deduced ejection fraction even below 40 percent and then mid range if in between. And the reason we break that up is that really our therapeutic approaches vary and the evidence as to what works between the various types of heart failure does vary as well. So when I'm seeing a new patient, first I want to characterize that in my mind. What kind of heart failure do they have? And for the purposes of our discussion, we'll focus more on the heart failure with systolic dysfunction, since that's where a lot of the evidence lies in terms of advanced heart failure therapies. So when I first see a patient, I want to know first, is this a new diagnosis I'm seeing, or is this a patient that's on chronic medical therapy? If it's a new diagnosis and they're treatment naive, I'm much more willing in those circumstances to start them on good guideline directed medical therapy, the meds that we know have been proven to make patients with systolic dysfunction live longer and give them quality of life. Those are, just to review for everyone, beta blockers ACE inhibitors, ARBs, or now ARNI medications, including Entresto, which has come standard of care in that class, mineralocorticoid receptor antagonists, and finally, now most recently, SGLT2 inhibitors. And I'll try to get them on these therapies if they're able to tolerate it. Well, that's first off, but and so, so beyond defining kind of new versus chronic I then want to know in the moment, assessing them, what is their volume status? How are they doing clinically? Do they appear well compensated or not? And there's two parts of that to what I consider. I consider first their perfusion. Do we, do I feel like they're adequately perfusing their organs or not? As, as sort of a marker of low output or not. And then secondly, do I feel like their volume status is adequate for not? And that's going to help to define therapy there. And that can, in terms of further kind of elucidating that, we can look at end organ markings of perfusion, we look at things like LFTs, we look at creatinine to help us define that, and we think about the patient's history as well. And then from there, we kind of develop a management strategy. But that's kind of how I approach it is, is this de novo or is this chronic? Do we think they have a chance at medical therapy or do we think they're failing medical therapy at that point? And then finally assessing the situation clinically, how are they doing in terms of their current compensation status? And are they adequately perfusing or not? And that's about that's the way I can define what the urgency is and the next step forward to taking care of them.

Kanny: 8:11

That's great. Thanks. Now, as an image and specialist myself, you know, obviously, I know imaging plays a critical role in that initial assessment, especially as you're trying to categorize. The patient Greg, maybe you can just summarize, you know, how do you, how do you use echocardiography to help, confirm or classify that initial decompensated patient? And is there any other imaging, that would really be relevant in that very acute phase of assessment?

Greg: 8:42

Yeah, echoes is the echocardiography is definitely the mainstay, and we can certainly. Besides the ejection fraction, which kids told us, told you all how it classifies our heart failure, it also can help hemodynamically in terms of filling pressures by diastolic parameters, it can help us understand if there's interventions for these patients. Once we kind of stabilize them again, decongestant is their valvular disease that we can intervene on. We have great percutaneous therapies now, both for the valve mitral valve, and then as it's evolving the tricuspid valve as well. And so then it also helps us know about the right ventricle and we know some of the worst outcomes that we see in any patient population, be it preserved or reduced ejection fraction, common patients that have significant RV dysfunction and with its correlate pulmonary hypertension. So I think you can glean a lot that helps you know the right direction and take your patient in by the echocardiogram.

Kanny: 9:36

So, Ankit, you mentioned about, you know, clinical assessment at the bedside. I think, obviously, we're all taught as consultants to look for, for example, signs of reduced end organ perfusion, in a cardiogenic shock patient. But do you have any pearls about, like, what specifically would indicate a very worrisome or high risk patient that may be decompensating and may be a candidate for more advanced therapy in terms of what specific, indicators of low perfusion would raise, your alarm the most? Thank you.

Ankit: 10:06

Kenny, I'm really happy to bring that up because as much as we are reliant on more advanced kind of diagnostics now, you know, bedside exams, the first thing we have, and we often have to use that more urgent situations as all we have. So, you know, when we think about perfusion, you know, I'm sure many of you guys have seen the 2 by 2 table. warm and wet versus cold and dry. The first thing I think I think about in terms of confusion is, you know, to assess them on exam, look at the, look at their physical exam. Do they feel warm or do they feel cold? And that in and of itself is not terribly specific, but a good place to start. And then looking at their volume status, looking at things like JVP, looking at for things like ascites by physical exam, lower extremity edema as as kind of a better way to determine where they lie on that table. And then in terms of symptoms, You know, low output is something that's been very humbling to me because it's kind of presented in many forms. Many times it's someone that has slowed down gradually over time. People with a cardiac index of 1. are not always you know, in cardiogenic shock, there are a lot of people sitting with low output for a long period of time as an outpatient till I get to a critical tipping point, make their way in the hospital. So have they been slowly, you kind of slowing down over time, getting more lethargic and young people, especially abdominal discomfort or nausea, vomiting can be a common sign of both hyper like hyper bulimia as well as low output as well. And we've seen multiple examples of folks in cardiogenic shock with that being the presenting symptom. So that's kind of what I go on is if I have some of these concerning symptoms that I see or an exam that's concerning, we then go straight to the diagnostics, including laboratory testing, as well as psychocardiograms to kind of better determine where that patient lies and kind of where they are in this, in kind of severity of what needs to be treated. If from there you then see indications of malperfusion by labs, which we talked about creatinine LFTs, lactate, whatnot, too. I think that's enough from there to saying that this is not just low output, but shock, which by definition requires malperfusion. And then that escalates into the need for inotropes. and potential mechanical circulatory support. So all of a sudden the severity has gone up and I think we can talk about more about how to treat

Kanny: 12:20

shock from there. Absolutely. And I'm glad you brought up therapy because, as a general cardiology consultant I think one thing that can be overwhelming at times, or at least challenging is just the decision to initiate, IV therapy with inotropes or. Vasopressors, but also the choice of therapy. So, how do you approach that decision to both start a vasoactive medication and then how would you, make that initial decision about what agent to

Ankit: 12:49

start? So when I'm thinking about a patient that's low output, another thing that can be very helpful if you have it is a right hard cath, either with a leave in swan or, you know, just a single time assessment to determine low output or not. If you if you have a clinical indication of patient is low output and At that point, the approach is you can start an inotropic medication, which can be beneficial to kind of help the patient better perfuse. And so the two options that you have are that the primarily are dobutamine and milrinone. These are both inotropic medications that work by different mechanisms. Milrinone is a medication that can. better, better produced afterload reducing effects. So a patient that's more hypertensive, for example, or a patient with elevated pulmonary vascular resistance, Milrinone may be the better choice there. But the important thing to note with Milrinone is it is cleared by the kidneys. So with patients with significant renal dysfunction, it can accumulate and become toxic and lead to worsening hypotension. So Milrinone is something that We often avoid in patients that do have fairly severe hypotension. The other option is dobutamine. Dobutamine is a pure beta agonist that has less effect on blood pressure and then more works to increase contractility. As a result, though, it's slightly more arrhythmogenic, so it may not be the best choice for a patient that has worsening ventricular or atrial arrhythmias. But those are the two inotropic choices to go on. And then If either of them are not possible or inadequate to provide adequate support to heart, that's when we consider mechanical circulatory support.

Kanny: 14:23

So as you talk about mechanical support what are, like, kind of the key clinical indicators in a decompensating patient that start to push you towards, using support more urgently? And a related question would be, in a setting that's maybe not a tertiary center, what are some of the clinical indicators that you would suggest that may be early transfer to, a tertiary center with advanced therapy capabilities would be advisable.

Ankit: 14:57

So, you know, broadly talking about that definition of shock. If a patient is in cardiogenic shock, I view inotropes as a temporary means to help stabilize the patient. And if a patient really is having indications of end organ perfusion, especially theförmative Determined by right heart catheterization and by their, and by their labs, I would consider at that point starting an inotrope and then considering transfer to a center that can provide mechanical circulatory support or placing it where you are there. We've seen too many examples, unfortunately, of patients that get temporarily supported on dobutamine, but then have an arrhythmia and then are further decompensated. But for folks that are failing, failing inotropes. Or require a more permanent, a more durable long term form of mechanical support as we consider the next option, whether that be LVAD or transplant or anything along those lines, we got a couple options. So first off, and most conventionally, you've got the balloon pump. And, and that, that can take a couple forms that can go into a femoral vessel or an axillary vessel. And that provides, you know, a smaller amount of cardiac output, conventionally, you know, 0. 5 to 1 liter. but has been shown to be much more effective in chronic heart failure. So a patient that's had chronic heart failure for a long time and is now decompensated, kind of going to slow simmer or burn of cardiogenic shock, that is an option if a patient requires, if you think a patient requires more cardiac support beyond what a balloon company will provide, which is oftentimes the case in cardiogenic shock another approach is an impella, which is basically a peripheral LVAD in that way that kind of sits in the left ventricle and, and directly supplies blood crossing the aortic valve to the aorta. And that comes in a couple of forms. The most common forms used in shock are the impella CP, and which can be placed by both femoral as well as axillary approach. And then finally, The most common device that we use at Christ specifically because of its durability and the amount of flow it can provide, is the Impella 5. 5, which is a device that can deliver over 5 liters of cardiac output and is surgically placed to axillary. And that's been our main device that we use when considering patients for LVAD and transplant that requires stabilization, but that varies from center to center. Finally, in a patient with severe cardiogenic shock, where it's clear that the other forms of mechanical circulatory support would be inadequate, we can consider VA ECMO. And you know, this is something that you consider in a circumstance, but not necessarily want to push towards because it's something that has its own cadre of associated complications that can come with it. But it is the most. Robust form of mechanical circulatory support that we have to support a patient in the most severe form of shock.

Kanny: 17:45

Great. That's helpful to know. So just so our listeners know, Greg did have to drop off to attend to an urgent patient matter. We hope to have him back soon. But in the meantime, I'd get, just to transition in our last 10 minutes we have, to talk in more detail about durable, left ventricular assist devices. Most of us are familiar with LVADs. Some of us are fortunate to work at centers where LVADs are implanted. Others maybe not. I think a lot of us have kind of a more traditional view of what patients will benefit from LVADs, but I know that's evolved a lot in recent years. So what specifically, especially, let's start with the acutely decompensated patient who's maybe recovering, but it's still unstable. What kind of clinical scenarios or indicators would then lead you to think that, a more durable assistive device. Could be either a bridge to a recovery or, ultimately transplant.

Ankit: 18:48

So, yeah, Kenny, that's a great question. And when I think about I really think about the patient journey. Oftentimes, many times these patients are diagnosed. They're put on good guideline directed medical therapy. They might get a mitra clip. They might get a CRT. And then eventually over time, you start to see that many of these patients begin to fail those therapies, they start getting hospitalized, they start getting hypotensive with inability to tolerate their medical therapy, their ejection infections go down. So when I'm seeing a patient that's coming in for a decompensated heart failure admission, even if they're not in shock, I'm thinking about that as an escalation or worsening of severity of their illness. We know that one heart failure hospitalization is roughly a 30 percent one year mortality. Three heart failure hospitalizations in a year is roughly 50 percent one year mortality. So when you're starting to see a patient that's failing medical therapy and beginning to get admitted. Thank you. For it. That's the time to be thinking about L bad. And then on the on the on the other side, as you mentioned, the patient that is that is presenting with cardiogenic shock, meaning that they're not their heart is not able to provide adequate blood flow to their organs, and they need potentially a form of mechanical circulatory support, like a balloon pump or an impella to to guide their therapy. The first thing you want to consider there, again, is do you think it's a recoverable phenomenon? Do you think, was this an ischemic insult that we expect some improvement? Was this myocarditis that we expect to get better? But if that's not the case, and they're failing medical therapy, that is the time to think about LVAD or transplant. And that is a decision that maybe we won't go get into too much, but What we do know about LVAD specifically is that it's been proven to make patients with advanced heart failure who are failing medical therapy live longer and give them better quality of life. And sometimes I worry that our messaging for LVAD isn't all that clear as to how good patients can feel and how well they do. Because it's, you know, kind of seen as this, this mechanical device you got to carry around batteries and whatnot. But it's really, what we know is that it does make people feel better and live longer, and it's something that we need to kind of look at more when a patient's otherwise failing medical therapy.

Kanny: 21:03

Yeah, and just as an aside, the, the JACC did put out a scientific statement this year in the Journal of the ACC regarding LVADs. And durable devices, and it's an excellent review, by the way, and I'm going to put the link to that in the notes to this session. But they did point out that, the most recent outcome data with heart made 3 showed, you know, 87%. Survival that was basically on par with heart transplant, and I'm not sure, if all clinicians really Understand how much the survival has improved. Do you think that's because of technique or reduction in adverse events or better patient selection?

Ankit: 21:45

I think it's all the above, you know, with the most recent HeartMate 3 pump, many of the complications that we've seen with traditional pumps prior to this, which included, you know, pump thrombosis with the older HeartMate 2s and HVADs, ischemic stroke. Those have significantly improved with the most recent heart made three device. We still we still run into complications, including G. I. Bleeding, given the fact that these patients do need anticoagulation right heart failure and infection that have occurred at similar rates versus prior. But on the whole, what we know with the most recent heart made three pump in the data that was prevented in the momentum three trial Is that mortality has improved substantially and so is quality of life. We just got five year data that shows a 60 percent five year, five year survival, which is astounding as to where we were and comparing to what these patients would otherwise have living with advanced heart failure.

Kanny: 22:41

Yeah. So having said that, do you think the candidacy of patients who will qualify for LVADs is gonna, is expanding or has expanded or, or, and do you see that broadening in the future, you know, in terms of. Who would be a candidate for a durable therapy?

Ankit: 22:59

So what we know is when we're thinking about advanced heart failure therapies, right now, heart transplant has a finite number that can be provided hearts that can be provided to patients. So that's a number that's relatively static, and it may increase with other means of obtaining organs, but. That's going to be relatively stable, but we are seeing a larger number of patients presenting with advanced heart failure as our population ages here. And so, what I'd say is, is that the best an LVAD patient can do is if they go into the OR as optimized as possible. And given the advances that we have in mechanical circulatory support and other means of stabilizing patients. We can optimize them better than we have before so that they can do better. And even over the course of my relatively young medical career at this point, I've seen us begin to push the limits in terms of implanting patients that are older, that have more comorbidities just because we have the ability to stabilize them better. I think the other thing we're also doing better is on the post VAD side, we've come to realize the importance of a team approach. We have a an amazing team here at Christ of LVAD coordinators that are training families and educating facilities on best practices, and that's helping to prevent things like driveline infections, adherence to medication, and we all know these things are very important. So, to answer your question, yes, I do think we're beginning to push the limit and expand the pool of what we consider to be a candidate just because we have, we've had so many advances in this space.

Kanny: 24:31

Great. So Greg welcome back. Yeah.

Greg: 24:34

Sorry about that. I appreciate it. We'll see when you, you hire young, smart physicians, like I'm kid, I just can sit back and listen and learn. So it's but get back in the conversation

Kanny: 24:45

here too. Yeah, you don't want to let a podcast recording get in the way of good patient care. So, but we were talking about LVADs Greg, but one question I had for you in your practice at Christ is, just in general, what's the distribution of implants now between patients where you generally feel that, you want to get them to a transplant versus what you would consider, just durable therapy with the LVAD?

Greg: 25:11

Yeah, that's a great question, Kenny. So really what's happened since the allocation systems changed that the indication for bridge to transplant has really almost disappeared. And with that, we're, most of the times that we're doing it, LVADs are for a bridge to candidacy, where at the current time when we see these patients in the hospital or out of the hospital they're, they're not a candidate for the transplant. It might be a contraindication that's modifiable. It might be something like tobacco abuse, and they need to spend some time, or it might be something like pulmonary hypertension. with an LVAD that comes down, or obesity, or it can be just concern about psychosocial risk factors for, so we do you know, probably 50%, I would say, are, are these bridged to candidacy, that we think they're going to be a candidate, but right now, in this moment in time, they're not. And then the other 50 percent end up being this sort of, this, their, the destination therapy category, where they will spend the rest of their lives with the device. And these are often the older patients. The ones that have significant, you know, kidney disease and lung disease and other issues that we think they're probably not going to get to the point of transplantation. And so that's the usual breakdown. Now, I know there's a lot of interest in the indication of bridge to recovery, and in real world, that's a pretty low percentage of where people actually get to the point of explanting the pumps, but there's certainly a lot of research and single center experiences when you. take a very selected group of patients. We can increase that single center. I'm sorry, that real data number of 1 percent to 2 percent recovery to explant to maybe 10 percent or even higher. So I think those kind of would I give you sort of a general sense of the indications for when we use the LVAD.

Kanny: 26:52

Sure, sure. And just in our last couple of minutes here, Greg For those of us, obviously, that don't directly participate in implanting or caring for the LVAD patients, as you think about patients, and we all have success stories, I think, in our practices or at our institutions of patients that have gone, you know, several years with a device and for the most part stayed out of the hospital. Do you have a sense about, like, what specific Is it mostly clinical factors that would predict a good response like that, or is it social support, or is it, you know, a potpourri of factors that go into your decision making as to, this particular patient is probably, at least has a good chance of surviving several years with their device?

Greg: 27:37

Yeah, it's a really complex. sort of decision making that requires a team like Ankit said, but we, we have this pump that we have now, the heartbeat three is very forgiving and their survival data is improving. We're now getting out to, you know, 55 percent survival for five years. So. These people are living longer. They're living with great quality of lives and fewer advance adverse events. And so really, as we evaluate these patients, if we get to a patient that is really all the other organ systems look pretty well intact. And that they have and so that we look as we evaluate these patients, we look at other end organs and making sure there's no irreversible damage there. We, and we look at their frailty, how strong they are to get through a procedure. And really what we've seen is, which is part of the way we're pushing the envelope is that we're taking these patients that are sicker and more frail. And actually pre rehabilitating them before the surgery with these percutaneous pumps, especially the impella five fives, just has really changed the landscape for us in terms of its durability, its ability to have people on the support for weeks leading up to the LVAD or even transplant to the point that we can get these people stronger. And then that's chance watch them and see if that frailty, which is such a. difficult thing to assess. And there's lots of research in terms of how and being more objective about it. But can we start seeing those frailty domains improve while we take care of a patient in the ICU to the point that we think we can get them through the surgery? Then that final component evaluation is the psychosocial, which is, is challenging too. And it may be as these pumps become less for, you know, become more forgiving that we can take patients that can be more independent and live by themselves and not have caregivers. As as intimately involved as before, so I think that's another place where we see all that therapy expanding is people being a little bit more independent in their in their lives. Afterwards.

Kanny: 29:38

That's great. And then just very briefly, is there still an upper, a strict upper age cut off where you focus it more on frailty and other clinical factors to decide, you know, candidacy?

Greg: 29:48

Yeah, unfortunately, you know, I think for us, there's been kind of a soft ceiling of 80 and, Anybody over 75 really looks their age once you get them in the OR and cardiopulmonary bypass. So frailty is important and there is a chronologic age, which is biologic, but over 75 they have to look really good and over 80, we really haven't, we haven't ventured into that ground. Other places have in the world but for us, it's been kind of 80.

Kanny: 30:17

Great well, unfortunately, we're up against our recording time here. I thought it was a great discussion. I think we covered a lot in 30 minutes. I really want to thank both of you for taking time to educate us also for your contributions to the state chapter. I know you're on the faculty for our recent meeting. My only final question for you is that I'm a 50 year. Plus Ohio resident and lifelong sports fan. Do you think the Bengals can actually bring a championship to the state of Ohio before I retire?

Ankit: 30:48

Well, we're hoping on this year,

Kanny: 30:50

so we'll see. Awesome. Well, thank you both for participating and I hope to have you back soon and also in other capacities for our state chapter. Thanks again to both of you.

31:00

Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,