Mr M was 60 years old and looking forward to retirement. He had worked hard all his life and raised his family well. A slim, fit and healthy man, he never needed to see a doctor, did not smoke or drink alcohol, and had a well-balanced diet. However, he seemed to be more out of breath in recent days. Climbing the stairs at home became something he would avoid, preferring to spend his time on the ground level. He felt lethargic and did not have the energy to play with his grandchildren, even though that was what he had wanted to focus on after retiring. One night, he woke up gasping for breath and he feared for his life. His wife was very worried and called the ambulance straight away.
At the hospital, he received the diagnosis that he had “Congestive Cardiac Failure”. His heart was very weak. It could not pump enough blood around his body, and blood-flow slowed down on the left side of the heart, leading to congestion of the lungs. He could not lie flat as he would become very breathless. His legs and abdomen were swollen due to fluid retention. He had thought it was part of getting old, but now realised it was all due to a weak heart. His vital organs including his kidneys could not receive enough blood-flow. As his kidneys could not function properly, he could not excrete enough fluid and hence his body swelled up.
The doctor prescribed medication to get rid of the excess fluid, and other medication to improve his heart function. Detailed heart scans using Echocardiography (a form of Ultrasound) and Coronary Angiography were performed to find out why he had a weak heart. Echocardiography showed that his heart was only functioning at a quarter of normal strength - LVEF 15% (normal LVEF is 60%). The result of Coronary Angiography was surprising as it showed that the blood vessels of his heart were normal with no blockages. Blocked arteries are the most common cause of heart disease and heart failure in men, but there are also other causes. It is likely that Mr M. had a viral infection some months ago that affected the heart, and gradually caused the heart to weaken to its current state.
Mr M. felt better after a couple of days in hospital and was discharged with some medications and an appointment to see the heart specialist (cardiologist). However, the symptoms returned soon after he was discharged. He felt breathless, the leg swelling returned, and he could not lie flat. He went back to hospital and received the same treatment, and was discharged after a few days. The cycle repeated itself a few times, and Mr M. wondered why he wasn’t getting better. He became depressed and his wife also stopped smiling. The sounds of laughter around the house also ceased as his grandchildren went to the in-laws to be cared for. Mr M. was too weak to look after the grandchildren, and his wife had to look after him.
When I saw Mr M. for the first time, he had already been through this ordeal for 6 months, and had lost hope of recovering. All the years of hard work appeared to have no reward for him. Just by chance, the ambulance brought him to my hospital for the first time. Just like previous times, he responded to medication to clear the excess fluid (diuretics). However, constantly repeating this cycle is not recommended as repeated use of high-dose diuretics may lead to diminishing effect in the body. The doctors at the other hospital did not give him the wrong medication. The problem was that Mr M.’s heart failure was more severe than the majority of patients. Without sufficient clinical experience, they could not be blamed for just using the standard therapies.
As part of my Cardiology Training, I completed a full year’s Fellowship in Heart Failure and Cardiac Transplantation at the world-renowned Cleveland Clinic in Ohio, USA. It is recognized as the top hospital in the USA for treating heart problems, and has received this award for the last 19 years consecutively since 1994. It does many Heart Transplants and Left Ventricular Assist Device (LVAD) implantations every year, and shapes clinical practice around the world by the research it performs and publishes. Doctors and hospitals around the USA and also the world refer their sickest patients to the Cleveland Clinic. Even prestigious hospitals in the USA send patients to the Cleveland Clinic when they realize they can offer nothing more. I had the opportunity to participate in the care of the sickest patients, and often witnessed their miraculous recovery from almost certain death.
I immediately recognised that Mr. M had End-Stage Heart Failure, and the routine treatment was not strong enough to support his heart and vital organs. To confirm this, I performed a Right Heart Catheterization and Study to obtain objective measures of his cardiac function, including his Cardiac Output. This is the Gold Standard in measuring cardiac function. He was indeed in a critical state – his heart was only pumping about 2 litres of blood every minute. A normal person at rest would pump between 4 to 6 litres every minute. His organ function was compromised and his blood test showed reduced kidney function. He had trouble concentrating and was no longer the clear-headed thinker that he was all his life. This was because his brain, the most sensitive organ in the body, was also suffering from reduced blood flow.
Ideally, he should receive a heart transplant to restore normal heart function. Patients who receive successful heart transplants live on average 10 years more. Some live more than 20 years. However, as the donated heart is considered “foreign” to the patient’s body, the patient’s body will try its best to get rid of it, which is called “rejection”. This will lead to the transplanted heart weakening and the patient will eventually not survive. To prevent this, strong medication to suppress the patient’s immune system has to be taken every single day without fail. This medication also brings a whole host of other potential side-effects. In addition, one must wait for a transplant, as it cannot be ordered, and relies on another person dying to provide this gift of life. There may also be religious and philosophical issues to consider.
Alternatively, he could get a Left Ventricular Assist Device (LVAD) implanted. This is basically a mechanical pump that takes over the heart’s pumping action to deliver blood-flow to the body. There have been heart pumps for more than 50 years now, but it is only in recent times that a durable, reliable, small pump has been developed. Heart pumps have 2 main problems – blood clots developing in the pump, and infection of the pump. These have been minimised to manageable levels with the Thoratec HeartMate II LVAD. Since 2005, there have been more than 15,000 implants worldwide. The longest a patient has had this pump is now more than 8 years. The pump is implanted into the heart internally, and there is a power cable that comes out of the patient’s abdomen and is connected to a battery supply. You could walk past someone with this LVAD along the street and not know that they actually have a heart pump implanted. The major hurdle is that it is extremely costly.
I discussed the options with Mr M. and his family. For the first time in months, he felt a glimmer of hope. I didn’t want to give false hope, so I made sure he knew all the possible risks as well. He wanted to give himself a chance to live a normal life again, and so agreed to consider a heart transplant. He was evaluated by the Heart Transplant Team, and placed on the transplant list. However, what happens in the meantime while he waits for a donor?
We had worked out previously that his heart was so weak that he would soon be back to hospital with the same symptoms. With a constant intravenous infusion of a medication to make the heart beat stronger, he would feel better temporarily. This medication is called an “Inotrope”, and he was thus “Inotrope”-dependent. Why not give him this medication constantly, and avoid a risky heart transplant or an expensive heart pump? This same question was asked by doctors some years ago and many studies were done to confirm what seemed like a good idea.
Unfortunately, the results were completely different from what the doctors had hoped to see. Patients who were put on Inotropes (such as Dobutamine or Milrinone) felt better temporarily, but had a higher risk of dying. The simple explanation was that the heart was truly weak. Using a medication to stimulate the heart to beat stronger may provide a short-term improvement in heart function, but actually stresses the heart more. This leads to higher incidence of serious irregular heartbeats, heart attack, and sudden death.
Thankfully, research has progressed since then and a new type of medication that works differently from the old Inotropes is now available. Although it is an “Inotrope”, it does not work by stressing the heart more. It increases the heart muscle’s sensitivity to calcium, which is essential for the heart to pump. It is therefore called a “Calcium-Sensitiser”.
Mr M. was hospitalised again with Congestive Cardiac Failure. This time, he wanted to try something to help him avoid having to be hospitalised so frequently. We discussed it and he agreed to undergo Right Heart Catheterization and then infusion of the Calcium-Sensitiser called Levosimendan. As it is a strong medication, it needs to be infused in the intensive care unit with continuous monitoring using the Gold Standard of measuring cardiac function. It can be administered from 1 to 3 days. I prescribed 24 hours of the Levosimendan infusion. It can sometimes result in irregular heartbeats. Thankfully, everything went smoothly and Mr M. was discharged after a few more days.
I saw him again in clinic a few months later. He was very happy and had started to enjoy life again. There was no more swelling. He was looking after himself and was taking all the prescribed medications. However, there was one major difference – he had not been admitted to hospital again since the Levosimendan infusion!
One year later, Mr M. was taken off the transplant list as he had no symptoms of heart failure at all. He was walking everywhere without breathlessness. A repeat echocardiogram of his heart showed it was still “weak”, pumping only 15% to 20% of blood, whereas the normal is 60%. However, his heart had adapted to its weakened state with the help of the optimal medication regime. But I have no doubt that the most important factor was the Levosimendan infusion that made all the difference. Mr M. still needs to take his medication everyday, and have regular medical check-ups. But his life no longer revolves around being admitted to hospital. He can now look forward to the plans he made for his retirement. Most importantly, he can now play with his grandchildren and enjoy their laughter at his home.
If you have breathlessness or chest pain, or are concerned about the health of your heart, do consult your doctor without delay.
Dr Daniel Yeo
30 March 2014