Recognizing Advanced Heart Failure and Knowing Your Options

Updated:May 14,2013

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.

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

  • 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.
  • 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.



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