Referring Patients for Heart Failure Management & Treatment

Our experts can assist in managing complicated heart failure patients, including heart failure with reduced and preserved ejection fraction. A comprehensive review of patient history can provide further insight regarding etiologies, current and potential therapies for both anticipated and unanticipated events, disease trajectory/prognosis and advanced care planning.

When to Consider a Referral

• Persistent NYHA functional class III-IV symptoms
• Need for chronic IV inotropes
• Symptomatic hypotension
• Persistent hyponatremia
• Worsening renal function
• Inability to tolerate optimally-dosed neurohormonal blockade
• Increasing diuretic requirements
• Recurrent heart failure readmissions (>/= two in the last year)
• Repetitive ICD shocks

CardioMEMS is a wireless monitoring system that consists of a tiny pressure sensing device inserted into a distal branch of the pulmonary artery (PA) during a right heart catheterization procedure. It communicates via an external pillow antenna that transmits the PA pressure reading to a secure website that can be immediately accessed by clinicians.

• Pressure readings monitored at least twice a week by heart failure nurses
• Medications titrated as necessary to manage pressure changes or other symptoms
• Decreases the chance of heart failure hospitalization

When to Consider a CardioMEMS Referral

FDA-approved for:

• NYHA Class III (symptomatic) heart failure AND
• Admission to the hospital for heart failure within the last year

Other clinical considerations:

• eGFR>25 (small amount of contrast required for implant)
• Antithrombotic therapy required after implant:
• DAPT for 1 month and then aspirin indefinitely OR
• Continue pre-existing therapeutic anticoagulation

Non-clinical considerations:

• Willing and able to transmit daily 18-second recordings via a non-invasive sensor
• Access to a cellular, wifi, or landline phone connection

The CDAc provides same-day assessment and treatment by board certified cardiologists for patients with cardiac symptoms that are non-life threatening but require prompt attention. Appropriate patients can bypass the ED, but must be referred by a physician.

Services include:

• Urgent diagnostic testing including stress testing and echocardiography
• Extended hours on weekdays (8 am –11 pm)
• Overnight evaluation in an observation unit staffed 24 hours a day

Consider a CDAc referral if your patient presents with:

• Volume overload without unstable vital signs or significant hypoxia (more than 2-3L nasal cannula requirement)

Additional considerations include:

• Concern for malignant syncope
• Anginal chest pain needing to be ruled out for MI (Please note: patients with ST elevations or unstable vital signs should go to the ED.)
• Rapid, symptomatic atrial fibrillation

How to Refer

Speak directly with the cardiologist on duty and start your referral by calling 617-632-7777.

BIDMC's Advanced Heart Failure Program uses continuous flow ventricular assist devices (VADs), including Heartware and Heartmate 3, to improve survival and quality of life in patients with end stage heart failure. VADs can be used as a bridge to transplant (BTT) or destination therapy (DT) in those who cannot be listed for heart transplant.

When to Consider a Referral for a Durable VAD

• Heart failure with reduced ejection fraction with NYHA class III-IV symptoms
• Inability to tolerate guideline directed medical therapy
• Need for inotropic support
• Need for temporary mechanical circulatory support

BIDMC offers a range of temporary mechanical circulatory support (MCS) devices to support single and biventricular failure. Available devices include intra-aortic balloon pump, Impella (CP, 5.0, RP), CentriMag, and extracorporal membrane oxygenation (ECMO). These devices support patients through acute critical illnesses as a bridge to recovery or to permanent therapies, such as durable ventricular assist device (VAD) or organ transplantation.

When to Consider a Temp MCS Referral

Typical candidates for temporary MCS have been admitted to an ICU or are receiving care in an emergency setting, cardiac catheterization laboratory or operating room. Patients should be considered for temporary MCS referral if they have:

• Refractory shock despite initial resuscitative efforts
• Patient currently supported by and dependent on temporary MCS
• Worsening hypoxia and/or hypercarbia despite intubation and efforts to maximize oxygenation and ventilation (e.g. optimization of ventilator settings, inhaled pulmonary vasodilator agents)

In a close collaboration with BIDMC Interventional Cardiology and Echocardiography, BIDMC’s Advanced Heart Failure team evaluates patients with severe mitral regurgitation to determine whether patients are candidates to undergo a minimally invasive repair of the valve with the MitraClip. The MitraClip device is FDA-approved for this condition.

Since 2014, BIDMC has performed the most MitraClip procedures in the New England region.

When to Consider a MitraClip Evaluation Referral

• LVEF 20-50%
• Ischemic or non-ischemic cardiomyopathy
• Moderate to severe or severe mitral regurgitation
• NYHA class II-IV symptoms