Health Related Quality of Life Outcomes and Functional Status after Transcatheter Aortic Valve Replacement

Abstract

Background: Chronic inotropic therapy is used to manage advanced heart failure (HF) either as a bridge to heart transplant (HT) or left ventricular assist device (LVAD) implantation. When used as palliative therapy in patients with end-stage HF, median survival time is limited to about one year. Here we report a case of a patient with Stage D HF surviving longer than 2 years on palliative home milrinone therapy, without a single admission for HF. Case: Our patient is a 77 year old man diagnosed in February 2014 with heart failure with reduced ejection fraction (HFrEF) due to wild-type transthyretin (ATTRwt) cardiac amyloidosis, with ejection fraction 20-25% and NT proBNP 5778 pg/ mL at diagnosis. Imaging findings were suggestive of amyloidosis, and diagnosis was confirmed through endomyocardial biopsy and genetic testing. He progressively declined on standard therapy, and 1 year after diagnosis he was admitted with cardiogenic shock (cardiac index of 1.42 L/min/m 2 ), needing continuous intravenous (IV) milrinone to sustain adequate cardiac output. An unsuitable candidate for HT or LVAD given advanced age and disease, he declined hospice and elected to try palliative home milrinone. He also declined placement of an implantable cardioverter defibrillator. He was discharged on continuous home IV milrinone. Two years later (3 years after initial diagnosis), he continues to remain stable within Class III-IV Stage D HF, with an acceptable quality of life. Discussion: Small studies investigating outcomes in patients with cardiac amyloidosis who undergo HT or LVAD placement have found 1-year survival rates of about 85% and 55% respectively (Fig. 1). Despite being associated with worse long-term outcomes, inotropic agents provide symptomatic and likely survival benefit in patients with advanced HF who are not candidates for LVAD or HT. This case highlights the successful use of palliative home milrinone for our patient with cardiac amyloidosis to improve quality and quantity of life, and it should be considered prior to adopting hospice.