Heart%20failure%20-%20chronic Treatment

Device-based Therapy

Cardiac Resynchronization Therapy (CRT)

• May be performed in patients >40 days post-MI and with reasonable expected survival of >1 year
• Recommended if NYHA Class II-IV symptomatic patient is in sinus rhythm with a QRS duration of ≥150 msec, left bundle branch block (LBBB) and LVEF ≤35% despite optimal GDMT for at least 3-6 months; CRT provides high economic value     
• Should be considered in NYHA Class II-IV symptomatic HF patient in sinus rhythm with LVEF ≤35% and QRS duration of ≥150 msec and non-LBBB pattern or QRS duration of 120-149 msec and LBBB pattern despite optimal medical therapy   
• CRT with a pacemaker is recommended (instead of a right ventricular pacing) in patients with HFrEF regardless of NYHA class or QRS width with an indication for ventricular pacing for high-degree AV block, bradycardia, and AF   
• Consider an upgrade to CRT in patients with LVEF ≤35% who have received a conventional pacemaker or an ICD and subsequently experience worsening HF despite optimal medical therapy and who have a significant proportion of right ventricular pacing  
• To improve symptoms and quality of life and to reduce hospitalizations and total mortality, CRT may also be considered in the following patients: 
  • With high-degree or complete heart block and LVEF of 36-50%
  • In sinus rhythm NYHA Class III-IV with a QRS duration of 120-149 msec, non-LBBB and LVEF ≤35% on GDMT
  • With ischemic cause of HF, in sinus rhythm NYHA Class I with a QRS duration of ≥150 msec, LBBB and LVEF ≤30% on GDMT
  • On GDMT with LVEF ≤35% and undergoing placement of a new or replacement of a device implant with anticipated requirement for significant ventricular pacing

Implantable Cardioverter-Defibrillator (ICD)

• Primary prevention or prophylactic ICD implantation to decrease the risk of sudden cardiac death may be done in a NYHA Class II-III symptomatic patient with an LVEF ≤35% or NYHA Class I symptomatic patient with an LVEF ≤30% despite optimal GDMT for at least 3-6 months and:
  • Without an MI in the prior 40 days 
  • With dilated ischemic cardiomyopathy 
  • With reasonable expected survival of >1 year
• A transvenous ICD is of high economic value in the primary prevention of sudden cardiac death 
• ICD may be done for secondary prevention in the following patients to improve survival:
  • Cardiac arrest survivors (expected survival rate of >1 year with good functional status) from ventricular fibrillation or with hemodynamic instability caused by documented ventricular dysrhythmia
  • Those with symptomatic CHF and LVEF ≤35% who experience syncope of unclear etiology  
  • With previous MI and LVEF ≤40% with non-sustained ventricular tachycardia and ventricular tachycardia or ventricular fibrillation that is inducible and sustained during an electrophysiological study   
• Consider an ICD implantation in patients with genetic arrhythmogenic cardiomyopathy with high-risk features of sudden death and EF of ≤45% to decrease sudden death

Left Ventricular Assist Device (LVAD)

• A mechanical circulatory support used as a bridge to transplantation or to recovery  
• Should be considered in select NHYA Class IV patients who are deemed dependent on IV inotropes or temporary mechanical circulatory support
• May be used long-term as a transplantation alternative in patients with end-stage HF not eligible for heart transplantation (destination therapy) or as a bridge to candidacy or heart transplantation  

Surgery

Coronary Revascularization

• Eg coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)  
• Considered in patients with HF with LVEF ≤35% and suitable coronary anatomy to relieve persistent angina symptoms despite optimal GDMT including anti-anginal agents 

Valvular Surgery

• Mitral valve repair or replacement may be considered after optimization of GDMT in patients with LV systolic dysfunction and severe mitral regurgitation who will undergo surgical coronary revascularization  
  • Mitral valve repair may be done in symptomatic patients with HF, severe mitral regurgitation and LVEF <30%
    • A MitraClip may be considered in select patients with HFrEF to decrease mitral regurgitation 
    • In symptomatic patients with chronic moderate-severe to severe mitral regurgitation despite GDMT at optimal doses, a transcatheter mitral valve edge-to-edge repair may be considered if ineligible for surgery and not requiring coronary revascularization
  • Mitral valve replacement may be considered in symptomatic patients with LVEF <30% and/or LV end-systolic diameter >55 mm unresponsive to medical treatment, with comorbidities, and with low likelihood for successful surgical outcome
  • Balloon mitral valvuloplasty (BMV) can be considered in patients with mitral stenosis with suitable valve anatomy
  • Percutaneous mitral commissurotomy (PMC) may be considered in symptomatic patients with mitral stenosis with valve area >1.5 cm² with suitable valve anatomy at high risk or with contraindications for surgery
    • Should be considered in asymptomatic patients with high thromboembolic risk and/or high risk of hemodynamic decompensation without contraindications to PMC
• Aortic valve replacement may be considered for patients with aortic stenosis or aortic regurgitation
  • Recommended for symptomatic patients irrespective of LVEF value
  • Should be considered in symptomatic patients with LVEF ≤50%, LV enlargement with LV end-diastolic diameter >70 mm, or LV end-systolic diameter >50 mm
  • Transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI) may be considered in patients with high-risk aortic stenosis or patients not fit for surgery
• Aortic valve repair or valve-sparing surgery should be considered in patients with pliable noncalcified tricuspid or bicuspid valves with type I or type II aortic regurgitation

Heart Transplantation

• Considered in eligible patients with poor prognosis, advanced or end-stage HF and severe symptoms who have failed or are refractory to optimal GDMT or device therapy/surgery, and without absolute contraindications
• Significantly increases patient’s survival and quality of life