Chapters Transcript Video What One Should Know about LVADs Dr. Amin Yehya reports on the current state of mechanical circulatory support post-transplant allocation with a focus on Sentara's experience. Good afternoon everyone. And uh I want to take a minute to thank our vendors for being here and supporting the program. It's a great turnout and great to see familiar faces and thanks for joining us today. Uh Basically, these are disclosures um is that gonna be the outline and this slide we show it and every time we update it, there's a lot of patients with heart failure, around 6.8 million have a heart failure, um adults in the United States, this number is expected to increase further and the total mortality of putting all heart failure patients together in five years around 50%. And so we're gonna go straight into the talk today. Um This is what happens usually with patients when diagnosed with heart failure. Um when on the initial diagnosis, uh basically, they have poor quality of life and they get diagnosed. You put them on GDMT, which are the four pillars of GDMT as we all know. Now, uh secu sarin as you have two inhibitors, be it sin or dapagliflozin, uh Mr A beat aone or spinal lactone and a beta blocker, be it Carol Biol or mel sain. So, after you put them on the medical therapy, patients feel better. But they're gonna be a point in time when the patients start to decompensate. And, uh, because as we know heart failure is a progressive disease and when patients start to decompensate and have multiple hospitalizations, their kidney function gets worse or you pull out medications because their blood pressure on the low side or they don't respond to diuretic. This is a nice time and a great time to refer them to advanced heart failure center. And we're gonna know why. And these are the points that I always like to show. It's called I need help. It's a mnemonic that we tell our referring providers whenever you see, uh, any of the patients that you take care of that, um, need aros patients who are resistant to diuretic and you go up on diuretics patients, ny A class four patients with worsening and organ dysfunction, be adrenal or hyponatremic patients who get I CD shocks, recurrent heart hospitalizations, hypertensive, refer these patients to advanced heart failure center. And we're gonna see why it's important to refer to advanced heart fail center because these patients tend to be taken care of by a multidisciplinary team and the team is made of Social worker finance, um and also a palliative care because it's important to try to uh prepare the patients for that, you know, what might come and have, have them, make sure their advanced directive taken care of also an advanced heart failure center. We provide therapies that are not available elsewhere. We can provide patients with uh being participating in clinical trials. We can provide uh remote monitoring for patients. Be it cardio MS or others. We can do other investigative therapies or uh maneuvers such as biopsies for patients. Put do cardio pul exercise testing for them to determine their functional capacity and among many others. And when patients decompensate and when medical therapy stops working or not as effective, we refer patients to be evaluated for advanced heart failure, surgical options, be it LVAD or transplant. And sometimes patients elect not to be not to be part of transplant or a vet, they just want quality of life or for patients who do not qualify for a vet or transplant being on ANP support has you know, can provide patients with good quality of life, does not improve survival. As we can see here from prior data. Also, patients with heart transplant are the ideal treatment modality for patients with end stage heart failure. As we can see here, patients with transplant, they have immediate survival at least 13 years and that's perfect. But again, there are not much hearts available. You can get hearts like you know, off the shelf, there are limited available donor availability. But we start noticing because of the rise of the opioid pandemic and epidemic in the states, more hearts became available. And now we're doing a little bit more hearts than before. And we're gonna see what, what were also in other initiatives led to more transplants. So, again, ideal treatment modality for patients with end stage heart fit is a transplant but not many transplants available. So what are all the options for patients who don't qualify for transplant or are too sick to get a transplant? VADs? Basically, or ventricle devices came in and revulsion basically made a big revolution in managing patients with advanced heart failure. And as we can see here on the first generation VADs which heart made XVE. And um at that time with the rematch trial for those who were involved with it, you know, Brenda was part of that too here at, you know, patients used to live maximum a year, around 50% of patients made it a year on the XVE compared to 20% of patients on medical therapy and a two year survival was less than 20%. And as you can see here, other devices too, as you can see, they are very bulky, they are very, you know, had a lot of complications and required a lot of support. Um the third generation um beds, as you can see here were heart made three, which is the device that we only use nowadays. And the one on top was HVD. Um basically HVD is not more available, it was pulled out of the market because of the increased uh C VA strokes and cardiovascular uh pump failure from it too. So currently we use the heart made three device as the uh as a device of choice. So there are around 19,000 patients who would benefit from therapies for advanced heart fair surgical options. And as you mentioned, only around 2500 to 3500 heart transplants available. So less than 10% of patients receive the treatment that they need to receive. And um and that would be maybe a vet Vito Grais device. So in 2018, there was a transplant allocation system. It was all changed at that time because we were trying to get more patients transplanted. We were trying to get the sicker patients transplanted and we were trying to get patients on the transplant list transplanted earlier. So we changed the hierarchy of um the listing on the transplant list. We had one A one B two and seven before now, we have 123456 and seven. So as you can see here, as you go from 1 to 7, the acuity and the severity of the illness it goes down. So um multiple centers started using this new uh it's we're adopting this new transplant allocation again. So more patients were getting transplanted because now we can put them in the IC U, put a balloon pump in them or an impala support. Um And if they need some hemodynamics, they can get transplanted quicker than getting them. Putting having a vat in these patients and we keeping them on the transplant list and they might not get transplanted as fast as they used to in the past. So how did the transplant allocation affected the vet uh implants? There was um in 2020 there was drop in around 17% in the vat implant uh nationwide. And this is the data uh published last year and they, we were expecting the data from this year to come up soon. Um Again, this number continues to increase in the sense that less centers are vetting patients and more transplants. And as you can see here again, um the number dropped significantly. What about the designation vet support? Basically, patients are used to receiving vet therapy as either bridge to transplant or destination therapy or bridge to decision. As you can see in 2011, uh patients um used to receive vat 50 50 bridge to transplant or destination therapy, 2020 comes in and around 80% of patients receive the vet as destination therapy. Less centers are using that as bridge to transplant because as I mentioned now with a new transplant allocation, we can put them in the IC U. Um they can, you know, we have the IC U here manager and you can put them in the unit but its one in them, they can put them status three and whatnot and they can get transplanted earlier. So what about the bad outcomes? We're doing less VADs. Is it because the outcomes of the bad, not good, not, not true at all. Again, the bad outcomes patients who receive bad therapy, um they live longer and they feel better too. And with the recent um basically data, I was going to be showing a couple of slides down patients on vat support are living longer than before. And as you can see here, um as time goes around 50% of patients make it to five years on a therapy compared if you're gonna go being on an or just medical therapy, less than 20% of patients are alive by then, uh what are the outcomes when they certify patients based upon the data? Uh The date that they receive their ad you can see here in blue, basically, patients who were implanted between 2016 and 2020 their survival is better than the years, 2011 and 2015. And that's can be attributed to multiple reasons. One of them could be because of the new devices. The heart may 3, which has the best outcomes and also because we are more competent in managing these patients and are able to manage their out their complications. And also we are more used to managing these patients compared to in the past. So are the vets getting better or are we getting better in managing them? So, as you can see here, um one of the complication of ventri Grasses device is can cause G I bleeding and it can cause infection can cause thrombosis, but also in the recent era. And this is the data published uh by the American Thoracic Surgery Society and they show that less bleeding. We're seeing less pump thrombosis. Actually, the heart made three device, we rarely see any pump thrombosis um with these patients. So what about stroke or C va uh an infection? We're seeing less stroke and again, infection stays kind of the same because again, we're gonna have a drive line coming out from the patients to be hooked up to a controller. Um So there's always a risk for having direct um infection from outside to the um blood stream. What about hospitalization and survival and vet therapies? Still infection is the top uh complication we see in patients on vitoss device support, uh bleeding comes next bleeding. It can be for multiple reasons because we put them on aspirin anticoagulation also and warfarin. So technically, they are at high risk of bleeding, but also they can develop other um you know, acquired Von Waln disease or it can have like, you know, um acquired A V MS and multiple other reasons. So, bleeding and infection remain uh the top causes of like morbidity for these patients fluid overload because we're supporting the left ventricle, we're not supporting the right ventricle. Sometimes patients present later on with right sided failure and volume overload. And that's where we see them in clinic where the role of our nurse practitioners and providers and nurses and vet coordinators trying to see these patients early on in clinic to prevent hospitalization. I want to share with you the latest data on survival and heart make three patients. This is a patient who was published in Jama uh manuscript published in Jama. Um late last year. It's around a year now and it showed actually that the survival on vet patient vet patients with heart made 35 year survival is close to 60% 58% of patients make it to five years, which is a huge big number. And it is amazing how the therapy has uh progressed and helped, you know, provide therapies for patients who would be dead by that time. So again, this was a big um data that came out and shows that vet therapy is still a viable and excellent treatment modality for patients who do not qualify to get a transplant or do do not want to be transplanted. Again, the end point, as we can see here, the survival is better than the older device and also um event free survival. And this is more data if we can go on. So who is your vet candidate if you don't wanna transplant these patients or patients who are not candidate for transplants, who are the candidates for destination therapy vets usually patients who have smokers do not wanna quit smoking, which we have a couple of patients for that patients who are obese above our BM. I cut off threshold if there are BM I, more than 36 or 38 and they're not able to lose weight. We are closely with our dietician. Uh they have recent malignancy HIV. Um and basically high PV R or pulmonary hypertension that is not reversible. So these are patients are best candidates for vet supports because they are not candidates for transplant. So how are we doing at? So I wanna share some numbers with you and these numbers are by the inter max um data that we work now, it's called uh sts. And uh so these are numbers from October 2021 to March 2023. Our survival with V ads is 100% of destination therapy and we pride ourselves with that, especially in the last year. All VADs we implanted last year are alive and doing well. So the survival rate is as you can see 100% above the national average. What about this is from 2021 2022 or our patients that are alive and 2023 as well. So they are living. But what about the quality of life? Uh the quality of life as you can see here, our patients have excellent qual, better quality of life. The NY A classification goes down from 75% of patients from 4 to 2 or even on. So they have a not just survival but also quality of life. So these are a couple of our patients as you can see here. Um That was the first patient on the right. Uh She had a vet and then she got transplanted patient of mine and our team, this guy here, all of them consented to have their pictures. By the way, his BM I was 48 plus, he went to get gastric sleep, which is an initiative we're doing here and he's gonna be ready for being transplanted. And these are patients also of ours that are more than 10 years post transplant. And this is our team because we can't do it alone. We all do it together, our heart failure team, our nurses and coordinators and thank you so much for having me. And finally. Published October 18, 2023 Created by Related Presenters Amin Yehya, M.D. Sentara Advanced Heart Failure Center View full profile
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