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Fall 2007

Early Referral for Heart Failure Improves Prognosis

UCSF physicians are encouraging referring physicians to refer heart failure patients earlier than they may have in the past. Early referral for advanced treatments can improve quality of life, as well as lead to more successful heart transplantation if needed, they say.

"We've been doing VADs (ventricular assist devices) for a long time, but what is new is our belief that we should be doing it sooner — before end-stage heart failure or before organ decline becomes irreversible," says UCSF cardiologist Eduardo Rame, M.D. "Timing is essential, as the more critically ill, decompensated patients often face greater risk of not making it to cardiac transplantation, or having poor postoperative success." UCSF physicians work with the referring cardiologists to determine optimal timing for both VAD therapy and transplantation, he adds.

The UCSF advanced heart failure/heart transplant unit takes an interdisciplinary, team approach to heart failure and provides acute right-sided heart failure care. The team includes cardiologists — Rame, Dana McGlothlin, M.D., and Kiran Khush, M.D. — and cardiothoracic surgeons — Charles Hoopes, M.D.;, and J. Donald Hill, M.D. The team also includes heart failure nurses, social workers, a VAD coordinator, dietitian, transplant pharmacist, and Heart and Vascular Center Administrative Director Karen Rago, R.N. The director of the UCSF Heart Failure Program is cardiologist Teresa De Marco, M.D.

"The important message is that we create opportunities for transplantation, rather than limiting them. Instead of excluding patients, the team evaluates to see if there are options and helps them to become transplant patients," says De Marco. "And there is great continuity of care. The patient sees the same team in both inpatient and outpatient care, so we get to know each patient and tailor their care to meet their individual needs. It's a real family atmosphere."

The prevalence of heart failure is 22 million people worldwide with an incidence of two million new cases per year, according to the World Health Organization. The American Heart Association reports five million cases in the United States and 550,000 new cases annually. The prevalence of heart failure in the United States is projected to increase to 10 million by 2037. Heart failure is the only major cardiovascular disorder that is increasing in incidence and prevalence.

UCSF had nearly 3,000 patient visits for heart failure last year and 375 new patients referred. Half of the patient population was admitted for ischemic cardiomyopathy and 40 percent for dilated cardiomyopathy (nonischemic). The remaining 10 percent were treated for adult congenital heart disease, a condition which was very rare 10 years ago and is now the fastest growing cohort for adults in their 20s and 30s.

The UCSF advanced heart failure/heart transplant center provides a full spectrum of care for patients at all stages of heart failure, from class I to class IV. Treatments range from basic disease management and pharmacologic therapy to advanced therapies such as mechanical circulatory support (VAD therapy) and cardiac transplantation. The progression of treatment includes bridge-to-bridge therapy such extracorporeal membrane oxygenation (ECMO). bridge-to-transplantation therapy such as VADs, and finally more definitive therapy such as cardiac transplantation.

The UCSF heart failure center is equipped with advanced ECMO machines, which allow patients to maintain homeostasis for up to five days — two or three days longer than with ECMO machines in most other facilities. This provides additional time for UCSF physicians and referring cardiologists to assess optimum therapy for individual patients.

UCSF physicians agree that VADs are intended not to replace the heart, but rather to maintain circulatory and organ function until a heart is available or to improve circulatory and organ function, so that the patient is in better health going into surgery. Currently, VAD technology is rapidly improving, and the devices are becoming smaller and more durable. These advanced mechanical circulatory devices should be available in the next five years.

"The devices will be much more durable than current VADs, which typically last only a couple of years," says De Marco. "There is a whole explosion in the technology of this field. With these new, smaller devices, there is no reason to wait until it's rescue therapy because these devices reduce the risk of surgery. They are easier to insert and are less prone to malfunction."

There are no standard criteria regarding the best time to refer patients to an advanced heart failure program. Timing is different for every patient. But UCSF physicians agree that patients who wait too long and are suffering from end-stage symptoms at the time of surgery don't recover as well. UCSF physicians advise that patients should not simply rest in bed prior to surgery. They must have good muscle tone and circulation, be well nourished, and have adequate renal and liver function upon entering the operating room.

"My personal belief is that patients with class III symptoms for more than six months while under medical therapy should be referred to a heart failure program and be assessed for mechanical circulatory devices, such as VADs, or transplantation," says Hoopes, head cardiothoracic surgeon. "We don't want just survival; we want patients to play tennis if they want to. It's about quality of life, so we'd like to operate much earlier."

Heart and Vascular Facts

The UCSF Heart Failure Program was initiated in 1975 and reorganized in 1989. It is one of the first centers in the United States to incorporate heart failure specialists and electrophysiological expertise in one clinical setting. UCSF pioneered vasodilator (VAD) therapy for heart failure and was the first center in the United States to implant a cardiac resynchronization therapy device.

For more information, contact the Heart Failure Clinic at (415) 353-2873.

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