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Heart Failure - A Surgical Approach

NAHUSH MOKADAM, MD & DANIEL FISHBEIN, MD

Approximately five million people in the United States are affected by heart failure; around one hundred thousand of those people have end-stage heart failure.  Heart failure can be caused by a variety of diseases, but the most common cause of heart failure is coronary artery disease (a hardening of the arteries of the heart). Heart failure is also caused by high blood pressure, genetic diseases of the heart muscle or abnormalities of heart valve function.   Patients with heart failure typically have fatigue, shortness of breath at rest or with activity and lower extremity swelling. Patients with end-stage heart failure typically have severe symptoms that significantly impact their quality of life and that do not respond to medicines.  Treating these most severely affected patients requires the expertise of specialists like Dr. Daniel Fishbein and cardiac surgeons like Dr. Nahush Mokadam. Dr. Fishbein, Professor of Medicine, Division of Cardiology, Director of Congestive Heart Failure/Transplant, and Dr. Mokadam, LeRoss Endowed Professor in Cardiovascular Surgery, work together to provide lifesaving options for these patients. 

 

For most patients with heart failure, treatment with standard heart failure medications is the best option. However, patients who have limiting symptoms despite optimal medical therapy may benefit from advanced heart failure therapies including heart transplantation and mechanical circulatory support (also known as Left Ventricular Assist Device or LVAD therapy).  These patients can come to the University of Washington (UW), where our program is focused on providing the best therapies for people with advanced heart failure. Our advanced heart disease program, which began in 1985, provides state of the art therapies for these patients, with outstanding results. Heart transplant remains the gold standard for patients with end-stage heart failure, as it offers patients independence, reliability, durability and improvement in quality and quantity of life. Since 1985, over 550 transplants have been performed at UW. Half of our heart transplant patients are alive for more than fifteen years after transplant.   Patients who are not transplant candidates or too sick to wait for a heart transplant may benefit from Left Ventricular Assist Device (LVAD) therapy. An LVAD is a mechanical pump that takes blood from the heart and pumps it to the rest of the body. These devices are implanted surgically. Patients are able to leave the hospital two to three weeks after surgery and can live with these devices for years. LVAD therapy is commonly used to support patients with very severe heart failure until a suitable organ becomes available for transplant (“bridge to transplant”). Some patients with advanced heart failure may not qualify for heart transplant because of advanced age or non-heart related medical conditions. LVAD therapy can be used in these patients to treat their heart failure, improve symptoms, improve quality of life and prolong survival. Using LVAD therapy in this setting has been referred to as “Destination Therapy.” LVAD therapy can also be used to support patients with reversible heart injury. The LVAD can be removed if heart function recovers (“bridge to recovery”). Each patient is approached individually to determine whether they need a device and, if so, which of the eight different available VADs in our program will best support them.

 

Over the last decade, there has been a significant change in the use of LVADs for end-stage heart failure; the technology has become better, more reliable, easier to deploy and appropriate for a broader range of patients. In 2011, UW implanted fifty-two pumps, which was four times higher than three years ago. The UW is also broadening the options for patients with advanced heart failure. In January 2012, a Total Artificial Heart Program was started which gives an additional treatment option for bridge-to-transplant patients.  The Total Artificial Heart is used to support patients with severe left and right heart failure who cannot be adequately supported with an LVAD alone.  This spring, an ECMO (ExtraCorporeal Membrane Oxygenation) Program was started to support more critically ill patients who need emergent support before undergoing surgery. In addition, UW is participating in a national trial designed to determine whether LVADs should be implanted earlier in the course of heart failure.


Patients still face many challenges with LVAD therapy including durability, infection, blood clot formation, and the development of a totally implantable battery. Research is ongoing to address these issues with smaller, slicker, minimally invasive devices. The technical advances that are in development should result in better devices that will greatly impact patient eligibility, ease of implantation, and quality and quantity of life. 


As one of the highest implanting centers in the country, and the biggest center in the Northwest, UW is hoping to offer patients an alternative to heart transplantation that will allow patients the same potential fifteen-year survival rate. Some doctors believe that a future where we are using LVADs instead of heart transplantation is only five to ten years away. If patients have end-stage heart failure, they need to know all of the options to improve the quality of their life, and what was historically thought of as too old and too sick for advanced therapies is no longer the case.