For advanced heart failure patients, collaboration holds the key to finding the best therapeutic option, says Teresa De Marco, M.D., director of the Advanced Heart Failure and Pulmonary Hypertension programs and medical director of the Heart Transplant Program at UCSF Medical Center.

"It's important for us to individualize care through collaboration with interdisciplinary teams that consider both physical and psychosocial factors, and to effectively co-manage our patients with the referring physicians to assure optimal outcomes."

She says the teams should include specialists, referring physicians, nurses, pharmacists, dietitians, social workers and physical therapists. The breadth of knowledge is what fosters the best choice from a full spectrum of approved therapies, including pharmacotherapy, electrical and mechanical circulatory devices, heart transplantation and combined organ transplantation.

Complex Patients Require Options

De Marco says that when patients are referred early, these expert teams can sometimes delay disease progression with state-of-the-art treatments or experimental pharmacological and device trials that may not be available at other centers. "And when the disease advances to late-stage heart failure, we can draw on specialized experience and expertise to make sure each patient continues to get the best therapeutic option for their needs," she continues.

The programs available at UCSF include:

• A unique Pulmonary Hypertension Program, where cardiologists work as part of an interdisciplinary team to manage patients with advanced heart failure and pulmonary hypertension using the full spectrum of approved pharmacologic and device-based therapies as well as investigational strategies.
• A choice of electrical devices, including implantable cardioverter defibrillators, cardiac resynchronization therapy (CRT) devices, CRT defibrillators (CRT-Ds) and heart failure monitoring devices.
• A comprehensive mechanical circulatory support program that includes the full range of short-term devices, including those used for extracorporeal membrane oxygenation (ECMO), and experience with such long-term devices as Thoratec's HeartMate II and the recently FDA-approved HeartWare device.
• A dedicated team of surgeons and mechanical circulatory specialists available 24/7 to provide assistance for the cardiogenic shock patient who may need ECMO cannulation before transport to UCSF.
• A dedicated critical care bed for the cardiogenic shock patient, available 24/7.
• A heart transplantation program with one-year patient and graft survival rates that exceed the national averages.
• Strong experience with combined organ transplants, including heart-kidney and heart-lung.

Expanding the Use of Mechanical Circulatory Support

Multidisciplinary care and technical advances make mechanical circulatory support a viable option for an increasing number of patients as a short-term bridge to recovery, as a longer-term bridge to transplant or as destination therapy. This is especially so where teams have experience in nearly all FDA-approved devices and so can skillfully recommend the right approach and device for each patient. The HeartWare pump expands the menu of options.

"It is smaller than any other pump, can be used on both the left and right sides of the heart and is easier and faster to implant than other devices," says Georg Wieselthaler, MD, surgical director of the Cardiac Transplantation and Mechanical Circulatory Support Program, who has implanted over 60 HeartWare devices. Wieselthaler co-invented this device and has performed seminal research on it in Europe.

He notes that the HeartWare device also has a visual display for physicians, which aids in monitoring during examination by showing flow curve and curve of the current, and that its ability to store and download data for up to 30 days facilitates diagnosis.

Heart Transplant Program

When transplant becomes an option, an academic medical center like UCSF offers the advantages of experience, enhanced access to organs and novel devices, state-of-the-art genetic testing and a full range of imaging modalities.

"The key, however, is referring early enough to give these patients a chance," says Wieselthaler. "Anyone with a worsening heart condition that might ultimately require cardiac transplant should be referred for consultation as soon as possible."

To contact our 24/7 physician-to-physician hotline, call (415) 514-8866.

Indications for Heart Transplant or Mechanical Assistance

All of the following:

• NYHA class III/IV heart failure stage
• Worsening renal function
• Intolerance of ACE inhibitors and beta-blockers due to hypotension or renal insufficiency
• Two recent hospitalizations for heart failure

Plus one or more of the following:

• LVEF <35 percent
• Cardiogenic shock
• Refractory ventricular arrhythmias
• Severe restrictive cardiomyopathy

A Leading Program

The UCSF Advanced Heart Failure Evaluation and Therapies Program has some of the best outcomes in the nation.

• Each year, surgeons in the program perform 15-20 heart transplants, with more than 260 patients transplanted to date — including 10 heart-lung and 20 heart-kidney transplants.
• Recent national data compiled by the Scientific Registry of Transplant Recipients found that the one-year survival rate for adult heart transplant patients at UCSF was 96 percent, compared with an average national rate of 90 percent.
• UCSF has one of the lowest readmission rates for heart failure patients in the nation, with an average all-cause, 30-day readmission rate of 11 percent and 90-day readmission rate of 26 percent.
• Inpatient and 30-day postdischarge mortality rates for acute decompensated heart failure patients are also lower than the national averages.

 

Heart & Vascular Center News, Winter 2013 Index