HEART FAILURE CONDITION

Patients with advanced heart failure having left ventricular dysfunction and a normal or mildly impaired right ventricle can undergo LVAD implantation. Patients with severe right ventricular dysfunction are not suitable candidates for LVAD (heart transplant can be done in patients with any degree of right ventricular impairment). Patients with heart failure and high lung pressures can undergo LVAD too.
In patients with rare blood groups where a chance of getting organ donor is less, heart transplant LVAD is preferred.

The risks of delaying the decision in heart failure therapy are:

  • Patients who come at late stages of heart failure have higher risk of adverse events than the ones who come early.
  • They can also be inoperable.
  • Hospital stay is longer in patients who are late leading to higher cost. In addition to these, statistically, loss of life is higher in patients who come late.

The two main surgical options available for patients with heart failure are:

  • Heart transplantation
  • LVAD (Left ventricular Assist Device)

However, if a patient’s condition deteriorates rapidly and heart transplant and LVAD are not immediately available, the following can be used as temporary measures:

  • EMCO
  • Temporary LVAD

Patients who are on these temporary measures will require permanent therapy (heart transplant or LVAD) at the earliest.

Patients who are undergoing inotropic therapy continuously can receive the treatment at home, however they have to be under regular medical supervision. They should stay at a place close to the health care facility, in case of any emergency and to monitor their state to decide the further course of action.

Usually condition of many patients with heart failure worsen after being stable on medicines for some time (months to years).

Worsening of patients status is reflected by one of the following features:

  • Breathlessness on mild exertion or at rest that is not improving with medicines.
  • Decrease in urine output less than 500 ml/day or worsening of kidney function.
  • Swelling of face, legs, and abdomen.
  • Repeated collection of fluid in abdomen and chest.

In this situation, starting an inotrope (drugs that increase the heart function) will help the patients.

The features of an Inotropic therapy are:

  • Drugs are given as continuous injections using infusion pumps.
  • Attempts are made after few days to decrease and stop these injections.
  • Some patients may require their therapy at regular intervals.

Inotropic therapy and optimization of drug can help the kidney recover. Early surgery (transplant/LVAD) have also proven to help the kidney. However once the kidney fails, they may need to be on regular dialysis.

1. Once the patient has kidney disease and passes lesser urine, more and more fluid is retained inside his body leading to worsening of his condition.
2. Increased risk during the surgery (transplant/LVAD) because of kidney dysfunction.
3. May or may not tolerate the immunosuppression therapy post heart transplant.

Patients with heart failure can have poor kidney function due to one of the following reasons:

  • They can have a primary kidney disease.
  • Inadequate supply of blood to the kidney can cause secondary complications.

The patient may know about his heart failure when he has the symptoms (breathlessness, swelling, fatigue) for the first time. Once they are evaluated and diagnosed to have heart failure, they are put on drugs.
Depending from patient to patient, upon treatment, they may remain symptom-free or may have minimal symptoms for months or years if they are on regular medication. Some may recover also.
If they don’t recover from medical therapy, they are required to be hospitalized. From this point, if their condition deteriorate, further therapy (transplant/ LVAD) cannot be done.
Hence it is advised to contact the hospital that can perform transplant/LVAD immediately once their symptoms start to worsen.

A. Medical options

1. Medical therapy:
Different classes of drug are used in this therapy. It leads to improvement of symptoms and some patients can even recover, but in most cases, as the disease progress, symptoms can worsen.

2. CRT (Resynchronization therapy):
Suitability of the patient for this therapy is often decided after the evaluation, as not every patient qualifies for this treatment. It has a high improvement rate.

B. Surgical options

1. Heart transplantation:
In this procedure, patient’s heart is removed and replaced with a normal heart from a brain dead donor. Here too, suitability of the patient for heart transplant is decided after evaluation.

2.. Ventricular assist device:
Artificial pump is inserted into the body to pump the blood. Patients can lead a normal life after the surgery. In this case as well, suitability of the patient is decided after evaluation.

Usual precautions they should follow are:

  • Regular medication
  • Restrict the fluid intake
  • Monitor his/her urine output
  • Consult the doctor when symptoms worsens.

The common complains of patients with heart failure are:

  • Shortness of breath (or) breathing difficulty
  • Fatigue
  • Swelling of legs, body
  • Recurrent collection of fluid in abdomen and thorax.

Depending upon the change in heart morphology, different types of failure are:

  • Dilated Cardiomyopathy : Grossly enlarged heart/ Ventricles functioning poorly.
  • Restrictive Cardiomyopathy : Severely impaired filling of ventricles.
  • Ischemic Cardiomyopathy: Heart muscle is severely weakened.

The reason for heart failure is diverse, most common being genetic, viral infection, coronary artery disease, valvular heart disease and metabolic disorder.

Heart failure occurs when the heart is unable to function properly and maintain sufficient blood flow to meet the body’s needs. It is characterized by shortness of breath, excessive tiredness, and leg swelling.

HEART TRANSPLANT

Patient can lead a  near-normal life once they undergo heart transplant, such as:

  • Can go to work
  • Can participate in activities with physical exertion (swim, run, cycling).
  • Can drive motor vehicles, travel by air.

However, they have to be on regular medicines and be cautions in avoiding infection.

Body has an inherent tendency to refuse/ reject anything foreign to it. New heart (donor heart) is at risk of being rejected (damaged) by the patient. To prevent this, drugs (immunosuppressive therapy) are given. The patient needs to take them for their life time. These drugs can have side effects and need to be adjusted accordingly to the individual patient. Also the patient has to be on regular follow up to review their condition.

Main complications associated with heart transplant are infection and other complications of a major heart surgery. There is a risk of rejection of the new heart by patient. The risk of complications depends upon the profile of individual patient.

Heart transplant is considered as a therapy of choice for patients with heart failure. Survival rate is 85%.

Postoperative stay is typically as follows:

  • Few days in ICU, strict isolation till the patient is off ventilator and all injections. Once they start walking, they are shifted to step down unit.
  • Step down unit (few days) isolation, mobilization, physiotherapy and close monitoring.
  • Ward Room (two weeks) – this period is for optimizing post-transplant drug therapy and watch for any other pending issues.

During the surgery,

  • The patient is put on an artificial circulation (cardiopulmonary bypass).
  • His native heart is removed.
  • New heart (donors) will be stitched in the place.
  • Artificial circulation is slowly discontinued and switched to normal heart and circulation.

Heart transplant has all of the risks associated with a major heart surgery. However, it can be done safely in majority of patients. Patients presenting themselves late have higher risk than the ones presenting early. All the risks associated will be counseled in detail and in person once the patient is ready for transplant.

The main precautions that should be taken are:
1. Availability and being ready for the transplant: Once a patient is in the top of the organ donation waiting list he/she should be in the city the process can happen anytime on any day. Delay from the patient’s side may cause him/her to lose a chance to get a donor organ.
2. Keep fit for transplant and have regular follow up.

Allotment of organs is done by the government. The waiting period for getting an organ cannot be specified. In most cases, it takes 1 to 3 months to find a suitable donor. Chennai, Tamil Nadu has the highest number of donors.

Once the patient is advised heart transplant and all the necessary tests are done, he is enlisted in the government’s waiting list of recipients for organs from brain dead donors.
The list is maintained by the state government in association with a trust. The allocation of organ from a brain dead donor is according to the win. However patients who are very sick can request the government for consideration for an early organ allotment.

The following investigations are required to come to a decision:

  • Basic investigations (Blood report, ECG and X-ray)
  • ECHO
  • VO2 max
  • Cardiac cath

All the above can be done in a day or two, provided the patient is fit enough to undergo the tests. Patients who are not fit may need to be optimized before the tests.
Once heart transplant (by both the doctor and patient) is decided upon, further tests are required to see the status of immunoreactivity. These tests are mandatory according to government norms before anyone is listed for transplant.

Once the patient come to the hospital, necessary tests to evaluate the severity of disease are done. They may be advised for heart transplant depending upon the severity of the disease, severity of symptoms and test results. If a patient has been hospitalized for more than 2-3 times in a year, he/she may be have to go for heart transplant.

Once the patient is advised heart transplant and all the necessary tests are done, he is enlisted in the government’s waiting list of recipients for organs from brain dead donors.
The list is maintained by the state government in association with a trust. The allocation of organ from a brain dead donor is according to the win. However patients who are very sick can request the government for consideration for an early organ allotment.

LVAD

LVAD is a permanent therapy, but if the patient’s native heart recovers it can be removed.

  • Patients waiting for LVAD have the risk of secondary complications to heart failure.
  • The procedure of LVAD carries all risks associated with any other major heart surgery.
  • The risk of complications depends upon the individual patient’s profile.
  • All the risks will be counseled in detail and in person once the patient is for LVAD.
  • Since the blood can clot in LVAD, patients are to be on anticoagulation medications.

Patients with LVAD can lead:

  • Normal life style
  • Do their job normally
  • Can participate in activities like running and cycling (however, they cannot swim)
  • Drive motor vehicles.
  • They have to take care of the equipment.
  • They have to take medicines (blood thinners) regularly.
  • They should be on regular follow up.

The hospital stay after LVAD is as follows:
Pre-operative (few days) – This is for work up, optimizing before shifting.

Post-operative ICU (few days) – Till the patient is off ventilator and injections.

They are made to walk (mobilized) before surgery.

Step down care (few days) – This phase requires the patient to be actively mobilized and receive supportive care and information about the device.

Ward (10 days – 2 weeks) – Actively mobilized, educated thoroughly about the device and its functions, their immediate family members are also trained.

 

Patients with critical pre-operative status and who present late can have a prolonged hospital stay.

LVAD implantation is a surgical procedure. The pump of LVAD is placed in close proximity with the heart and then it is connected so that it gets the blood from left ventricle and pumps it back into the main blood vessel (aorta).

The cable of the pump (which connects the pump to the battery and controller) is brought outside the patient through a small hole in the patient’s abdomen. This cable is connected to a power source and the controller.

Patients with advanced heart failure having left ventricular dysfunction and a normal or mildly impaired right ventricle can undergo LVAD implantation.

Patients with severe right ventricular dysfunction are not suitable candidates for LVAD (heart transplant can be done in patients with any degree of right ventricular impairment). Patients with heart failure and high lung pressures can undergo LVAD too.

In patients with rare blood groups where a chance of getting organ donor is less, heart transplant LVAD is preferred.

LVAD has a pump that is inserted into the patient’s body surgically and it is connected to the heart. It needs continuous power supply. A cable connects the pump inside the patient’s body to a power source from the outside. A cable is brought outside the patient’s body surgically and is connected to pump controller and power source (battery).
The patient has to carry pump controller and power source all the time – they are kept in a small bag and are hung from the patient’s shoulder. There is a charger which the patient has to carry all the time. This is used to charge batteries.

Left Ventricular Assist Device (LVAD) is an artificial pump that is inserted inside the patient and is connected to the patient’s left heart. This therapy is used in patients with advanced heart failure.The pump performs the function of the left heart that is to deliver blood to the body.

Once the patient is hospitalized, he is investigated on the necessity and fitness for LVAD (or) heart transplant based on multiple factors, such as:

Right ventricular function: LVAD therapy patients have a normal or a mildly impaired right ventricle. If the right ventricular function is severely impaired he cannot be a candidate for LVAD. Patients with severe right ventricular impairment can undergo heart transplant.

Lung pressures: Patients with high lung pressure cannot undergo heart transplant, however patients with high lung pressure can undergo LVAD (or) heart and lung transplant.

ECMO THERAPHY

Other critical conditions where ECMO can be used are:

  • Cardiogenic shock
  • As a salvage technique during cardiac arrest.
  • Patients who are waiting for lung transplantation.
  • Respiratory failure (due to severe pneumonia, ARDS)
  • Neonatal respiratory failure.

Yes, complications are there with ECMO but may not be seen in all patients. The few complications that can occur are:

  • Bleeding – This is frequently seen problem, as the patients are on anti-coagulants which prevent clotting. Thereby these patients might have bleeding from the surgical site, bleeding inside the brain etc. This complication can be minimized by careful monitoring patients clotting parameters.
  • Thromboembolism – Here a thrombus formed may get migrated from ECMO apparatus to any vital organ and can block blood supply causing ischemia.
  • Infection – Since the entry site of cannula is continuously exposed, chances of infection are also there.
  • If peripheral cannulation is used for ECMO, there may be distal limb ischemia.

Other medical supports which may be required for patients with ECMO are.

  • Ventilators.
  • Dialysis.
  • Antibiotics to treat infection.
  • Drugs to prevent blood clotting.

For ECMO therapy, hospital stay is mandatory. ECMO therapy requires continuous/round-the-clock care by doctors/nurses. ECMO machine, continuous source of oxygen, drugs administered to prevent blood clotting, test to determine clotting time, strict sterile environment and round-the-clock nursing care makes hospital admission mandatory for ECMO therapy.

The extent of benefit from ECMO therapy is variable depending on the purpose and patient’s condition. The main purpose of initiating ECMO is to give rest to the heart and lung so that they can recover. For a heart failure patient, it provides rest to the heart by taking over its action and thereby preventing the patient’s condition from deteriorating. In such patients, it also helps to buy time for initiating definitive/destination therapy. Similarly, patients suffering with certain lung disease like ARDS (still lung) will also be benefited to a large extent.

Patients can be supported with ECMO for days to weeks depending on the underlying cardiac and lung condition. Usually patients can be supported on ECMO for about 1- 3 weeks.

ECMO differs from CPB in the following ways:

  • ECMO is usually used for long term support ranging from 1 – 10 days, where as heart-lung machine is used only for few hours.
  • The main purpose of ECMO is to allow time for the recovery of lungs and heart, where as the main purpose of heart-lung machine is to provide support during cardiac surgeries.
  • ECMO is mainly applicable in ICU settings, whereas heart-lung machine is applicable in operation theatres.
  • ECMO therapy can be instituted percutaneousously (through the skin) whereas heart-lung machine requires opening of the chest wall.
  • Patients suffering from malignances (end stage disease)
  • Patients having intracranial bleed (bleeding inside the brain)
  • Patients who are not willing to undergo blood transfusion.
  • Any patient suffering from severe heart and lung failure, reversible causes, are candidates for ECMO.
  • There is no particular age barrier as neonates to elderly people can be considered for ECMO therapy.
  • End stage heart failure patient who are not responding to medical management are also eligible for ECMO which gives them time before destination therapy like heart transplant/Ventricular assist devices.

If the clinical status of the patient waiting for heart transplant/LVAD worsens in spite of inotropic therapy, he may need mechanical support devices such as ECMO and VAD.