Spotlight On: Treatments for Heart Failure

What therapies are available for heart failure?

John Kern, M.D., a cardiac surgeon with the UVA Heart Center, answers questions about a new FDA-approved therapy for heart failure. 

Heart failure occurs when the heart muscle becomes too weak to pump the blood needed by the body’s vital organs. Symptoms can vary but often include, fatigue and severe shortness of breath even with minimal exertion, swelling of the ankles and legs, and unexplained weight gain (due to fluid retention). With severe heart failure, fluid builds up in the lungs and results in difficulty breathing when lying flat and a cough that produces frothy, and possibly blood-tinged, sputum. 

Heart failure has many causes. Most commonly in older individuals, it is the end result of coronary artery disease (often after multiple heart attacks), untreated, long-standing valvular heart disease (leaky or stenotic heart valves), or certain congenital heart problems. Less commonly, heart failure is caused by a viral infection (such as the flu). Sometimes, the cause is idiopathic or unknown. 

What are the medical and surgical treatment options for heart failure? 

Treatment of heart failure depends to some degree on the cause. Medications (such as diuretics to help get rid of the excess fluid) are almost always used to help the heart beat more effectively. 

The mainstay of heart failure treatment is optimal blood pressure management, dietary changes, avoiding excess salt, smoking cessation, and other lifestyle changes and proper exercise. 

If a correctible cause is identified (such as a bad heart valve), surgery may help, or a special pacemaker may be needed to help the heart beat more effectively.  Despite these therapies, heart failure may progress and patients may require more aggressive therapy with intra-venous medications to help the heart beat stronger. Some patients may even need to consider the possibility of heart transplantation or the placement of a left ventricular assist device (LVAD). 

I've heard LVADs mentioned in the news lately. What are they and how are they used to treat heart failure?

An LVAD is an implantable mechanical blood pump that “takes the place” of the heart’s failing left ventricle—the heart’s main pumping chamber. Most forms of heart failure affect the left ventricle. 

There are many different types of LVADs, but probably the most commonly used is the Thoratec Heartmate II. This pump is about the size of a small yogurt cup and fits easily inside the chest of even smaller individuals. The pump is connected to a power source through a small flexible “driveline” (about the size of a small pencil) that exits the body through the upper abdominal wall. The driveline connects to either a permanent power source, or batteries that allow for a great degree of freedom and patient mobility. 

Most LVADs are placed as a “bridge to transplant”, meaning the patient is able to be stabilized, recover and gain enough strength to undergo a heart transplant. Less commonly, an LVAD may be placed as a “bridge to recovery”, such as for patients with a viral cardiomyopathy and in whom recovery may be possible. 

More recently, and most excitedly, the Thoratec Heartmate II has been FDA approved as “destination therapy”, meaning this blood pump may now be used as the definitive treatment for many heart failure patients who are not candidates for heart transplantation. This approval provides a potential new treatment option for thousands of patients who may have had no other option previously. 

What is UVA’s experience with this new technology? 

UVA began implanting the new Heartmate II about one year ago. Before then, we were using the first generation LVAD (Heartmate XVE), which was significantly larger, difficult to implant and only suitable for larger individuals, meaning mostly men. Up until then, we were implanting about 5 to 6 LVADs a year, all as a bridge to transplant. 

Over the past 13 months, we have implanted 33 LVADs (all Heartmate II) and have been able to treat an equal number of men and women. Our survival rate for LVAD implants is around 93 percent over the past 4 years, remarkable when considering these patients are the sickest of the sick and often confined to a bed in the intensive care unit with significant end-organ dysfunction prior to surgery. 

After LVAD placement, patients are rapidly able to get out of bed and begin their recovery. Most patients are discharged home within a few weeks and go on to enjoy active lives. 

Of great significance, our LVAD program was recently certified by the Joint Commission as a destination therapy site for LVAD therapy. This is because of our comprehensive and collaborative approach to patient care and our excellent outcomes. The Joint Commission certification, in conjunction with the recent FDA approval of the Heartmate II as a destination therapy device, means UVA now has the ability to offer definitive treatment to many more patients with heart failure than ever before. 

How do LVADs improve outcomes and quality of life in patients with heart failure? 

They restore life. Patients go from having no functioning left ventricle, often on the verge of death, to having a device that can pump as much blood to the body that is needed. Without an LVAD, many patients would not be able to survive long enough to undergo a heart transplant because of the significant lack of organ donors. With the LVAD, patients are able to get out of bed, get off their IV medications, avoid dialysis, participate in physical therapy, eat and gain strength and muscle mass, leave the hospital, and in general, have a normal life again. While most patients will still go on to have a heart transplant, now many patients will continue to live with their LVAD.