Recognizing Advanced Heart Failure and Knowing Your Options

Updated:Mar 25,2016



Understanding the Medical Situation

Having advanced heart failure does not mean you have run out of treatment options. In fact, the growing selection of therapies and state-of-the-art technologies for advanced heart failure has made decision making more challenging.

This is where shared decision making helps. Your doctor knows your medical situation best and can narrow down treatment possibilities to the most appropriate options for you. Together, you sort through the options and consider how each treatment fits into your priorities and life goals.

“If patients can go through the process of what their goals are for life, especially as they approach the end of life, they can then think about how specific treatments fit into those and whether they should or should not pursue them,” said Larry A. Allen, M.D., M.H.S., heart failure specialist at the University of Colorado Anschutz Medical Center.

Implantable defibrillators are a good example, Allen said. For a patient who wants to live as long as possible, a defibrillator may reduce the risk of sudden cardiac death by shocking a fluttering heart (also known as ventricular fibrillation) back to its normal beat. But for patients who have expressed the desire to die in their sleep, a defibrillator may not be the best option.

“Working through those scenarios and identifying what the preferences are for the end of life actually helps frame the discussion around whether a defibrillator is appropriate or not,” Allen said. “Defibrillators are great, but they’re not the right answer for everybody.”

Knowing the Treatment Options
Advanced heart failure can't be cured, but it can be treated. Treatments can reduce your symptoms and help your heart pump as best it can. But with benefits come risks, which you should discuss in detail with your doctor before choosing a treatment.

Sometimes, patients don’t fully understand the possible side effects or tradeoffs of a treatment before deciding whether they actually want it, Allen said. A mechanical heart pump, for example, can help the heart pump better and relieve congestion-related symptoms such as shortness of breath. Patients may live longer and have a better quality of life as a result. But the pump, known as a left ventricular assist device, increases the risk of infection, stroke and bleeding in the gastrointestinal tract.

Even if the risks aren’t a deterrent, patients must consider that an electrical cord connects the pump to a power source worn outside the body on a belt or harness. “That, in itself, is a disease where you always have to be plugged in,” Allen said. “People need to recognize there are tradeoffs in the treatment decisions they make.” At some hospitals, palliative care specialists are called in to help patients make big medical decisions, such as whether to receive an LVAD.

Unfolding science is suggesting that cognitive and other concerns may need to be discussed and monitored as part of the treatment plan. Explore the possible benefits and risks of each therapy with your doctor and work together to decide what treatment you need now and what you may need in the future.

Treatment Options for Advanced Heart Failure

Major Interventions

  • Open-heart surgery: For patients with advanced heart failure that is somewhat stable, surgery may be an option. Open-heart surgeries require stopping the heart and using a heart-lung machine to circulate and oxygenate blood until the heart is restarted after the procedure. It is still unclear whether these major surgeries are effective in treating advanced heart failure, Allen said. “Since we don’t yet know what the right answer is, one of the questions that should weigh into a patient’s decision is, ‘Do I want to be aggressive or do I not want to take a chance?’”
    High-risk surgeries for advanced heart failure include:
    • Coronary artery bypass graft: If heart failure is caused by coronary artery disease, bypass surgery may be an option. Using arteries or veins taken from other parts of the body, called grafts, blood flow to the heart is rerouted around one or more blocked heart arteries.
    • Valve surgery: Heart valves control the one-way flow of blood through the heart. In advanced heart failure, the mitral valve may leak if the muscles around the valve stretch and become too weak to allow the valve to close tightly. In other cases, heart failure may be caused by stiffness, or stenosis, of the aortic valve. When the aortic valve doesn’t open completely, less blood is pumped from the heart to the body. Surgeons can repair a damaged valve or replace it with a new, artificial valve.
    • Pericardiectomy: The pericardium is the thin sac that surrounds and protects the heart. Long-term inflammation of the pericardium causes it to become stiff and thick with scar tissue, a condition called constrictive pericarditis that essentially squeezes the heart and prevents it from beating normally. During a pericardiectomy, also called pericardial stripping, most of the stiff sac is removed to relieve constriction of the heart.
  • Percutaneous interventions: Percutaneous interventions are non-surgical procedures performed on a beating heart. Unlike open-heart surgery, the heart is accessed with special tools threaded through a small opening in the groin. A percutaneous procedure may be considered in advanced heart failure patients who are not candidates for surgery. Options include:
    • Percutaneous valve intervention: A narrowed valve may be repaired using a balloon to widen the valve opening. For a leaky valve, a clip device can clamp the valve flaps to reduce the leak. A faulty valve can be replaced with an artificial valve that is implanted through a catheter. There are different procedures for different types of valve defects.
    • Percutaneous coronary intervention: A blocked heart artery can be opened using an inflatable balloon. Artery-clogging plaque is pushed against the blood vessel wall, thus restoring blood flow through the artery. A small mesh tube called a stent is sometimes placed in the artery to keep it open. Percutaneous coronary intervention, or PCI, is also known as coronary angioplasty. View an animation of angioplasty.
  • Pacemaker: Advanced heart failure may cause delayed contractions of the right and left ventricles, the heart’s main pumping chambers that normally contract at the same time. When a pacemaker coordinates the electrical signaling between the ventricles to allow them to pump together, it is called cardiac resynchronization therapy, or CRT.
    View an animation of CRT.
    Watch an animation of a pacemaker.

  • Open-heart surgery: For patients with advanced heart failure that is somewhat stable, surgery may be an option. Open-heart surgeries require stopping the heart and using a heart-lung machine to circulate and oxygenate blood until the heart is restarted after the procedure. It is still unclear whether these major surgeries are effective in treating advanced heart failure, Allen said. “Since we don’t yet know what the right answer is, one of the questions that should weigh into a patient’s decision is, ‘Do I want to be aggressive or do I not want to take a chance?’”
    High-risk surgeries for advanced heart failure include:
    • Coronary artery bypass graft: If heart failure is caused by coronary artery disease, bypass surgery may be an option. Using arteries or veins taken from other parts of the body, called grafts, blood flow to the heart is rerouted around one or more blocked heart arteries.
    • Valve surgery: Heart valves control the one-way flow of blood through the heart. In advanced heart failure, the mitral valve may leak if the muscles around the valve stretch and become too weak to allow the valve to close tightly. In other cases, heart failure may be caused by stiffness, or stenosis, of the aortic valve. When the aortic valve doesn’t open completely, less blood is pumped from the heart to the body. Surgeons can repair a damaged valve or replace it with a new, artificial valve.
    • Pericardiectomy: The pericardium is the thin sac that surrounds and protects the heart. Long-term inflammation of the pericardium causes it to become stiff and thick with scar tissue, a condition called constrictive pericarditis that essentially squeezes the heart and prevents it from beating normally. During a pericardiectomy, also called pericardial stripping, most of the stiff sac is removed to relieve constriction of the heart.
  • Percutaneous interventions: Percutaneous interventions are non-surgical procedures performed on a beating heart. Unlike open-heart surgery, the heart is accessed with special tools threaded through a small opening in the groin. A percutaneous procedure may be considered in advanced heart failure patients who are not candidates for surgery. Options include:
    • Percutaneous valve intervention: A narrowed valve may be repaired using a balloon to widen the valve opening. For a leaky valve, a clip device can clamp the valve flaps to reduce the leak. A faulty valve can be replaced with an artificial valve that is implanted through a catheter. There are different procedures for different types of valve defects.
    • Percutaneous coronary intervention: A blocked heart artery can be opened using an inflatable balloon. Artery-clogging plaque is pushed against the blood vessel wall, thus restoring blood flow through the artery. A small mesh tube called a stent is sometimes placed in the artery to keep it open. Percutaneous coronary intervention, or PCI, is also known as coronary angioplasty. View an animation of angioplasty.
  • Pacemaker: Advanced heart failure may cause delayed contractions of the right and left ventricles, the heart’s main pumping chambers that normally contract at the same time. When a pacemaker coordinates the electrical signaling between the ventricles to allow them to pump together, it is called cardiac resynchronization therapy, or CRT.
    View an animation of CRT.
    Watch an animation of a pacemaker.

An implantable cardioverter defibrillator, or ICD, may be used to reduce the risk of sudden cardiac death. It shocks the heart to stop a fatal arrhythmia and restore a normal rhythm. An ICD does not improve heart function or relieve symptoms of advanced heart failure. View an animation of an ICD.

  • Temporary Therapies: Short-term treatments are sometimes needed to help a patient recover from a reversible condition, such as acute kidney failure, or transition to a permanent therapy, such as a heart transplant. These treatments can, however, be needed indefinitely if a patient’s health worsens. Doctors and patients should discuss the possibility of long-term use before choosing one of the following treatments.
    • Temporary mechanical support devices: A heart attack, severe inflammation of the heart muscle (myocarditis), or another heart emergency can prevent the heart from pumping enough blood. Quick intervention may be needed to temporarily support a failing heart until it has time to recover. Temporary mechanical support devices for advanced heart failure include:
      • Intra-aortic balloon pump: A small balloon is placed inside the aorta, the major artery connected to the heart that sends blood to the body. The balloon is connected to a machine outside the body that inflates the balloon when the heart relaxes between beats and deflates the balloon before the heart pumps. This lessens the heart’s workload and increases blood flow from the heart. The balloon pump is often only needed for a few days.
      • Percutaneous ventricular assist device: A left ventricular assist device, or LVAD, helps the heart heal by taking over the workload of the left ventricle, the heart chamber that pumps blood to the body. The device may be inserted percutaneously, meaning through a small opening in the skin. A tube placed in the left atrium pulls oxygen-rich blood out of the heart and sends it into the body’s circulation. Normally, blood is sent from the left atrium to the left ventricle, where it is pumped out to the body. With an LVAD, the left ventricle does not have to work as hard. The pump and its controller remain outside the body. The device is typically used for up to two weeks.
      • Extracorporeal membrane oxygenation: Blood is sent through an extracorporeal membrane oxygenation (ECMO) machine to increase the amount of oxygen in the blood. The oxygen-rich blood is then returned to the body. ECMO is typically only needed for days or weeks.
    • Positive inotropic drugs: A positive inotropic drug is a therapy given intravenously to make the heart beat more forcefully.
    • Renal replacement therapy: Advanced heart failure can put significant strain on the kidneys, making them less able to dispose of sodium and water. If the kidneys fail, renal replacement therapy, such as dialysis, can remove waste and extra fluid from the blood.

An implanted left ventricular assist device, or LVAD, may be used as a “bridge to transplant” for patients awaiting a heart donor. When heart transplantation is not an option, an LVAD can help the heart pump blood for the rest of a patient’s life. The pump is implanted in the upper part of the abdomen and functions as a mechanical heart, pulling blood from the left ventricle and sending it to the aorta for delivery to the rest of the body. A tube attaches the pump to a battery and control system worn outside the body.

A heart transplant replaces a failing heart with a healthy donor heart. Heart failure symptoms can greatly improve or disappear, but transplant isn’t a complete fix, Dr. Allen said. “There may be aspects of transplantation that the patient doesn’t have now, which are now a new burden with new symptoms,” he said. For example, heart transplant patients must take daily medication to prevent the body from rejecting the new heart. Side effects of these immunosuppressive medications include diabetes, kidney disease and high blood pressure. Heart transplant patients are also at higher risk for infection and cancer.

Health problems not related to the heart may develop in patients with advanced heart failure. Deciding whether to undergo a non-heart procedure requires careful consideration of whether the potential benefits outweigh the risks. For example, hip surgery risks may be acceptable, whereas the possible complications of knee replacement surgery are not. In addition, routine screening tests, such as colonoscopy, mammography and prostate-specific antigen, are often not appropriate for people with advanced heart failure.



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This content was last reviewed on 04/16/2015.

Heart Failure

 

Heart Failure Questions to Ask Your Doctor

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Use these questions to ask your doctor about heart failure.

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