Heart Failure
The NYU Approach to Heart Failure
Diagnosing & Evaluting Heart Failure
Treating Heart Failure
Our Heart Failure Specialists
Patient Stories
HEART FAILURE
Heart failure is a life-threatening condition in which the heart muscle grows progressively weaker and cannot pump enough blood to meet the body's needs for oxygen and nutrients. Many people confuse heart failure with sudden cardiac death, where the heart stops abruptly, without warning signs or symptoms. In heart failure, in contrast, the heart gradually weakens but continues to beat, if ineffectively.
As heart failure progresses, blood backs up into the vessels around the lungs. This causes fluid to seep into the respiratory tract, congesting the lungs and making breathing difficult. (Thus, heart failure is sometimes called congestive heart failure.) Other symptoms of heart failure are fatigue, swelling of the legs, rapid weight gain, loss of appetite, abdominal bloating, and difficulty sleeping. Heart failure also compromises the function of other organs, such at the kidneys, which may ultimately fail because of insufficient blood flow.
Heart failure can result from a variety of conditions. The most common cause is a heart attack (myocardial infarction) that damages the myocardium (heart muscle). Heart failure can also stem from problems with the heart's valves, rheumatic heart disease, bacterial infections, and congenital defects. Other causes of heart failure include abnormal heart rhythms (arrhythmias), diseases of the heart muscle (collectively known as cardiomyopathies), high blood pressure, and diseases involving other organs.
More than five million Americans suffer from heart failure. About 550,000 new cases are diagnosed each year. Until recently, relatively little could be done for people with this condition. Today, however, there are many effective therapies — from medicines to devices to surgery — that can substantially improve and extend the lives of those with failing hearts.
THE NYU APPROACH TO HEART FAILURE
Studies show that patients who are managed by an experienced heart failure cardiologist have superior outcomes and survival rates. At NYU, we bring the care of heart failure to the next level. Every one of our patients is managed by an expert heart failure cardiologist, who in turn is backed by a team of specialists in cardiac imaging, cardiology, interventional cardiology, cardiac surgery, electrophysiology, cardiac rehabilitation, nursing, nutrition, and social work — each with expertise in heart failure. Every effort is made to integrate these services, resulting in a seamless transition from diagnosis and treatment to recovery and follow-up.
Since heart failure often occurs alongside other medical or cardiac conditions, our team works closely with the patient’s primary-care physician, cardiologist, or cardiac surgeon in order to optimize his or her care.
With such a wide range of expertise, we are able treat patients with any form of heart failure and in any stage of heart failure. We have particular experience and success in the care of high-risk patients, such as those in their eighties and nineties, as well as patients in the advanced, severely disabling stages of the disease, known as end-stage heart failure. At most centers, such patients typically exhaust all available therapies and deteriorate quickly, with a severely limited life expectancy. What distinguishes the NYU Heart Failure Program is that we are able to offer these individuals advanced treatment options — including high-risk cardiac surgery, with backup options such as ventricular assist devices and heart transplantation, and ventricular restoration surgery— improving their prospects for survival as well as their quality of life.
DIAGNOSING & EVALUATING HEART FAILURE
The NYU Heart Failure Program employs the full range of technologies for diagnosing and evaluating heart failure, from basic electrocardiograms to state-of-the-art scanners. Among the advanced tests we offer are:
•cardiac catheterization: an X-ray exam of the heart and its arteries, which is used to assess the location and extent of arterial blockage or narrowing.
• cardiopulmonary exercise testingcardiopulmonary exercise testing: the standard stress test for measuring how the heart, lungs, and muscle respond to exercise.
• dobutamine stress echocardiogram: a nonexercise stress test, which is used to detect blockage of blood flow to the heart. This test is useful for those who cannot tolerate a standard stress test, which requires patients to use an exercise treadmill. Instead, the intravenous drug dobutamine is used to make the heart beat faster, mimicking the effects of exercise on the heart.
• transesophageal echocardiogram (TEE): a noninvasive test that uses high-frequency sound waves to visualize the heart. In TEE, images are obtained through a probe inserted into the esophagus and positioned directly behind the heart, allowing better visualization of certain heart structures than with standard echocardiography.
• 64-slice cardiac CT angiography: a noninvasive test that uses X-rays to build highly detailed three-dimension pictures of cardiac anatomy, including coronary arteries, great arteries and veins, cardiac chambers, muscle, and valves.
• cardiac magnetic resonance imaging (MRI): a scanning technology that employs noninvasive magnetic fields and radio waves (instead of x-rays) to obtain two- and three-dimensional images of the body. Cardiac MRI provides details about damage to heart muscle after a heart attack, arterial blockage, and how various parts of the heart are functioning, among other information.
TREATING HEART FAILURE
General considerations
Therapies for heart failure
Since heart failure has many possible causes, there is no single remedy. While some patients respond well to medication, many also need an interventional or surgical procedure. In most cases, a combination of therapies is required.
In managing a patient with heart failure, we focus on four areas:
• optimizing cardiac performance with medications
• minimizing or removing behavioral factors that can aggravate heart failure (e.g., smoking, a high salt diet)
• identifying and treating the underlying disease processes (e.g., a faulty heart valve)
• treating the consequences of heart failure (e.g., fluid retention, breathing difficulties)
Many patients with heart failure will benefit from an interventional or surgical procedure of one type or another. Typically, patients are stabilized first with medications and an interventional procedure (e.g., angioplasty or pacemaker implantation), and then treated surgically, if symptoms progress. Certain conditions are best treated surgically early in the course of the disease, when the patient is stronger and the risk of surgery lower. In some cases, surgery should not be delayed, for example, when the underlying cause is a faulty mitral valve. This condition cannot be definitively treated with medication, and to delay surgery is to risk further, and possibly irreversible, damage to the heart muscle.
Minimally invasive heart surgery
Fortunately, heart surgery is much less traumatic than it was only a decade ago. Recent advances have made it possible to repair the heart with minimally invasive procedures, in which the operation is performed without splitting the breast bone. Compared to conventional open-heart surgery, minimally invasive surgery is much less traumatic to the patient. It not only requires smaller incisions, but also leads to fewer blood transfusions, less postoperative pain, and shorter hospital stays, and quicker recoveries.
Catheterization procedures
Electrophysiology procedures
Surgical Procedures
Investigational Procedures
• Angioplasty (percutaneous coronary intervention): procedure for opening a clogged artery, using a small balloon-tipped catheter that is inserted into the coronary arteries and then inflated to flatten the blockage.
• Pacemaker implantation: surgical insertion of a small electrical device that sends electrical signals to the heart muscle, restoring normal cardiac rate and rhythm. Additionally, pacemakers are used to treat patients who suffer from chronotropic incompetence, a condition in which the patient has the symptoms of heart failure either at rest or during activity because of inappropriately slow heart rates.
• Cardiac resynchronization therapy (biventricular pacing): implantation of a specialized pacemaker that resets the timing of contractions of the left and right ventricles, improving heart’s pumping efficiency.
• Cardioverter defibrillator implantation: surgical insertion of a small electrical device that monitors the heart’s rhythm and quickly identifies dangerous and potentially life-threatening arrhythmias, which are immediately terminated by an electrical shock. A defibrillator is sometimes combined with a biventricular pacemaker in patients with severe heart failure.
• Radiofrequency ablation: a procedure that involves the identification and mapping of abnormal areas of electrical activity that are responsible for arrhythmias (abnormal, less efficient, and potentially dangerous heart rhythms). This is followed by application of radiofrequency heat to these areas, via a special catheter, either in the catheterization laboratory, or at the time of open heart surgery, eliminating the stimulus for the arrhythmia.
• Ablation of atrial fibrillation: a specific application for radiofrequency ablation for patients with either short-term or long-lasting atrial fibrillation, a type of abnormal heart rhythm.
Coronary revascularization
Mitral valve repair
Atrial fibrillation surgery
Septal myotomy (for hypertrophic cardiomyopathy)
Surgical ventricular restoration
Ventricular assist devices
Cardiac transplantation
High-risk cardiac surgery
Investigational procedures
Coronary revascularization, also known as coronary artery bypass grafting (CABG), is a procedure in which blood is rerouted around one or more clogged coronary arteries in order to improve blood flow to the heart muscle. The new connections are established using arteries and/or vein grafts taken from the patient's body.
Coronary revascularization is typically recommended for heart failure patients who have left main coronary artery disease; narrowing of at least three of the major coronary arteries, including the left anterior descending artery; decreased ventricular function (as indicated by the size of the heart or ejection fraction); or diabetes mellitus.
In many cases, cardiac function will improve dramatically after CABG. In patients with blockages in at least two major vessels, CABG has been shown to be more effective than angioplasty in reducing symptoms, long-term mortality, need for re-intervention, and long-term health-care costs.
Many hospitals do not perform CABG on patients with severely compromised left ventricular function, considering the risks too high. However, many of the risks can be significantly reduced by using off-pump and minimally invasive surgical techniques, which are available at NYU.
Mitral valve regurgitation can be either a cause or a consequence of heart failure. In mitral valve regurgitation, the valve on the heart’s left side doesn’t close completely, allowing blood to leak backward from the ventricle to the atrium. This condition forces the heart to work harder. Over time, the heart weakens and enlarges, which in turn worsens the regurgitation, further stressing the heart — an increasingly debilitating, and ultimately fatal, downward spiral.
In most patients with mitral valve regurgitation, the cause is unknown. Some cases are due to hereditary connective tissues disorders (e.g., Marfan syndrome, Ehlers-Danlos syndrome, adult polycystic kidney disease, and Ebstein's anomaly) that weaken the mitral valve. Mitral valve prolapse can also result from damage to the heart muscle induced by a heart attack.
Mitral valve prolapse is common, occurring in about 4 percent of men and 7 percent of women. However, only a small portion of people with the condition experience any symptoms. When symptoms do appear, they are usually mild, including an irregular heartbeat, fatigue, lightheadedness, dizziness, difficulty breathing or shortness of breath (especially during exercise), and chest pain.
People with mitral valve prolapse should have regular checkups to monitor the progression of the disease. Those with signs and symptoms are generally advised to have surgery to repair or replace the leaky valve. At NYU, our approach is to repair the valve before obvious problems emerge, particularly if the patient shows signs of significant valve leakage or heart enlargement (determined by echocardiography). We believe an aggressive approach is warranted because our surgeons can repair most mitral valves, and most of these repairs can be performed minimally invasively. (Some patients with valve disease also have coronary artery disease, in which case both conditions are treated at the same time using traditional open-heart surgery.)
Another treatment option with functional mitral valve regurgitation (a form of the disease due to changes in size or shape of the left ventricle) is implantation of the Coapsys device, now undergoing trials at NYU. This device consists of two pads that are placed on opposite sides of the heart. The pads are connected by a cord that passes through the left ventricle. By drawing the two pads together, the heart is reshaped, in theory reducing leakage from the mitral valve.
Atrial fibrillation is a type of arrhythmia in which the heart’s two upper chambers (the atria) quiver instead of beating in an organized fashion, reducing the amount of blood flowing into the left ventricle.
Atrial fibrillation can cause heart failure, but more often it is a coexisting condition that worsens the prognosis of heart failure and complicates its treatment.
Medicines are commonly used to control arrhythmias. However, medical treatment of atrial fibrillation can cause significant problems in patients with heart failure. An alternative treatment is ablation, in which small incisions are made in each of the atria. When the lesions heal, scar tissue forms, interrupting the electrical circuits that cause the heart to beat abnormally. Ideally, the procedure is performed via cardiac catheterization. However, a surgical approach is warranted when catheter-based ablation fails or when the patient requires other surgery for another heart problem.
Septal myotomy (for hypertrophic cardiomyopathy)
Some cases of heart failure are due to hypertrophic obstructive cardiomyopathy, a disease of unknown origin that causes the heart muscle to thicken and the septum (the muscular wall separating the right and left ventricles) to stiffen, limiting the heart’s ability to pump blood. Patients with this condition are at increased risk for atrial fibrillation (a type of arrhythmia) and sudden cardiac death, among other complications.
Treatment usually begins with calcium-channel blockers or beta-blockers, which slow the heart rate and relax blood vessels, thereby improving blood flow.
A surgical procedure called septal myomectomy should be considered for patients who do not respond to medical therapy or who have left ventricular outflow tract obstruction, a blockage of the blood exiting from the heart. In a septal myotomy, the surgeon removes a portion of the septum. This eases the obstruction, which relieves symptoms and often slows the progression of disease.
Surgical ventricular restoration
Surgical ventricular restoration (the Dor procedure) is a new treatment option for patients with ischemic cardiomyopathy — heart failure caused by a heart attack. After a heart attack, portions of the left ventricle may become scarred, causing the muscle to thin and bulge out, a condition known as a ventricular aneurysm. Once an aneurysm forms, the heart must work harder in order to pump enough blood throughout the body. Eventually, the heart weakens and enlarges, resulting in heart failure.
In ventricular restoration surgery, the surgeon removes the dysfunctional areas of the left ventricle and “remodels” the heart, restoring its normal size and shape. The procedure is often performed in combination with coronary revascularization or mitral valve repair.
Surgical ventricular restoration has been shown to slow the progression of heart failure, reduce clinical symptoms, delay the need for transplantation, and improve long-term survival in many patients. Furthermore, the combination of ventricular restoration and CABG (coronary artery bypass grafting) has been shown to have better outcomes than CABG alone.
NYU is currently participating in the Blue Egg trial, which is testing a new sizing device for determining the appropriate size and shape of the left ventricle during ventricular restoration surgery. “Blue Egg” refers to size and shape of the silicone device.
More information about the Blue Egg trial and ventricular restoration surgery.
Ventricular assist devices (VADs) are mechanical pumps that assist, or take over, the function of a weakened heart. VADs are used for emergency as well as short-, intermediate-, and long-term support.
VADs are commonly used to sustain patients for a brief period, from days to weeks, allowing time for the heart, and other vital organs, to recover. This is called a “bridge to recovery.” Most often, VADs are used as a life-support system for patients who need a heart transplant but who are unlikely survive the wait for a donor heart (which averages almost six months). This is referred to as a “bridge to transplant.” More and more, VADs are being used as a “destination therapy,” a permanent solution for patients with end-stage heart failure who have exhausted all other therapies but are not considered candidates for transplant.
The newest application of VADs is as an emergency support for patients undergoing high-risk catheterization procedures. In the case of an emergency, such as acute heart failure (see below), an assist device can be quickly inserted via a catheter, allowing enough time for the patient to be brought to the operating room for a more definitive operation or for placement of a longer-term assist device.
The Heart Failure Program at NYU currently offers a complete selection of FDA-approved VADs for all patients and clinical scenarios. Our team has extensive experience in the management of patients with VADs, including both inpatient and outpatient care.
Acute heart failure
VADs have also proven useful for patients with acute heart failure, or cardiogenic shock, in which the heart has been damaged so much that it cannot supply enough blood to the body. Acute heart failure occurs in about 8 percent of patients who experience a heart attack and in about 1 percent of patients who undergo cardiac surgery. It can also occur in patients with viral infections of the heart and in those with chronic cardiac conditions.
Acute heart failure requires immediate in-hospital emergency treatment. Blood flow to the heart must be restored immediately, either with a catheter-based intervention or coronary revascularization surgery. A small percentage of patients will require more aggressive intervention, namely the implantation of a VAD. Many patients supported with a VAD recover heart function within days or weeks, at which point the device can be safely removed. If the damage is too severe for the heart to recover, VADs are used as a bridge to heart transplantation or as a permanent solution, or “destination therapy.”
Heart transplantation remains the “gold standard” treatment for patients with end-stage cardiac failure. Although transplantation is a high-risk procedure, the vast majority of patients survive the operation, and most have a high quality of life. The median survival for heart transplant recipients is 11 years.
Since the supply of donor hearts is extremely limited, heart transplantation is usually reserved for patients under age 65 who require intensive medical therapy or mechanical support, have no other medical conditions that would limit life expectancy or complicate recovery from transplant, and have a life expectancy less than 70 percent at one year.
For heart failure patients who do not require intensive medical therapy or mechanical support, and who can be managed as outpatients, medical therapy directed by expert heart-failure teams appears to provide outcomes similar to that of cardiac transplantation.
NYU does not perform cardiac transplantation on site. When appropriate, patients are referred for transplant to our clinical partners a local transplant center. Our surgeons and cardiologists have extensive experience evaluating and managing transplant candidates, ensuring a seamless transition of care.
Our staff specializes in the surgical care of patients with advanced, or end-stage, heart failure. Many of these patients have structural heart defects that can be repaired with surgery, often with tremendous improvements in cardiac function and quality of life. However, these patients are high-risk surgical candidates, requiring a comprehensive, multidisciplinary approach to care.
A major challenge in managing high-risk patients is distinguishing between those who might benefit from surgery and those who might not have enough residual cardiac function to survive the operation. The first step in this process is to assess the patient’s cardiac reserve (the heart’s ability to function beyond what is required under normal circumstances).
The next step is to evaluate and optimize any associated or unrelated medical conditions, minimizing the chance of complications or cardiac failure. This may require early admission to the intensive care unit for pre-operative cardiac support. For patients with chronic heart failure, specialists in cardiac imaging, electrophysiology, cardiac rehabilitation, psychiatry, social work, and nutrition may be involved in pre-operative evaluation and management.
Although most high-risk patients do well with this approach, a reassuring and unusual feature of our program is our ability to offer several backup options — including ventricular assist devices and heart transplantation — should patients not have sufficient cardiac function immediately after the operation or in the days and weeks that follow. As part of the preoperative assessment, patients are considered for temporary or permanent assist device placement or for cardiac transplant. Such contingency plans are based on the evaluations of the care team and discussions with the patient and family.
Patients who fail to respond to standard therapy may be candidates for investigational treatments under study at NYU. Our cardiologists and cardiac surgeons play leadership roles in several important national and international trials of new devices and surgical techniques.
OUR HEART FAILURE SPECIALISTS
Gregory A. Crooke, M.D.
Greg H. Ribakove, M.D.