non pharmachological treatment of hf

8/3/2019 Non Pharmachological Treatment of HF

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Non pharmachological treatment of

heart failure


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Heart Failure

Venezia, 5-6 November 2009

Jessup M, Brozena S. N Engl J Med 2003;348:2007-18.

The clinical syndrome of heart failure is the final pathway for

myriad diseases that affect the heart.


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Heart Failure


Therapeutical targets

Jessup M, Brozena S. N Engl J Med 2003;348:2007-18


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Non pharmachological approaches



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Cardiac Resynchronization Therapy


Elevated ventricular end-diastolic pressure

can lead to wall stretch causing atrialfibrillation or delays in ventricular conduction

and bundlebranch

block.

Left bundle-branch block is a significant

predictor of sudden death and a common

finding in patients with myocardial failure.Left ventricular contraction is

dyssynchronous, with the interventricular

septum contracting before the left ventricular

free wall.

Delayed opening and closure of the mitral

and aortic valves, and abnormal diastolicfunction

Dyssynchronous contraction is mechanically

inefficient, leading to decreases in the left

ventricular ejection fraction (LVEF) and

cardiac output.


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INDICATIONS

Dilated cardiomyopathy (ischemic or nonischemic)

LVEF of 35 percent or less

QRS interval of at least 120 msec

NYHA class III or IV heart failure despite

optimal medical therapy

most candidates for biventricular pacing are also

candidates for a defibrillator.

GREY ZONE AND UNCERTAINITIES

Mild heart failure (NYHA class II)

QRS interval as best criterion for benefit from CRT.

Possible role of echocardiographic evidence of

ventricular dyssynchrony Atrial fibrillation

Ablation of the atrioventricular node performed to

ensure complete control of ventricular activation.

REFERENCES

Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE2002 guideline update for implantation of cardiac pacemakers

and antiarrhythmia devices: summary article: a report of the

American College of Cardiology/American Heart Association

Task Force on Practice Guidelines (ACC/AHA/NASPE

Committee to Update the 1998 Pacemaker Guidelines).

Circulation 2002;106:2145-61.

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COMPLICATIONS

Coronary sinus dissection or perforation

Hemopericardium and tamponade

Pneumothorax

Complete heart block

Asystole

Dislodgment of the left ventricular pacing lead

PITFALLS

Lead failure

Device infection in PMK pocket

Atrial dysrhythmias, with device tracking of the atrial

rate

inability to implant the left ventricular because ofunfavorable coronary venous anatomy.

Proximity to the left phrenic nerve, and the resulting

uncomfortable diaphragmatic stimulation during pacing

External electromagnetic fields

REFERENCES

McAlister FA, Ezekowitz JA, Wiebe N,et al. Systematic

review: cardiac resynchronization in patients with

symptomatic heart failure. Ann Intern Med 2004;

141:381-90.


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Most candidates for biventricular pacing are alsocandidates for a defibrillator.


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Surgical Strategies


Heart failure subsequent to ischemic or non ischaemic

disease often leads to functional mitral regurgitation dueto LV dilation worsening prognosis

Mitral valve repair or replacement (MVR)could have a

dramatic effect on cardiac function unloding the heart

and improving ejection fraction and optimizing oxygen

consumption

MVR procedures can be combined with surgical

revascularization with improved resultsTechniques for minimally invasive MVR have been

developed


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Surgical Strategies


Surgical ventricular reconstruction

DOR procedure allows ventricular reshaping

in case of ventricular dilation

Several techniques have been developed for

ventricular reconstruction

The procedure can be associated to MVR in

order to improve valve function as well

Surgical ventricular reconstruction is

performed in selected patients,usually in

conjunction with CABG


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Surgical Strategies


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Ventricular Assist Device


Ventricular assist devices are mechanical pumps that take over the function of the

damaged ventricle and restore normal hemodynamics and end-organ blood flow.

These devices are useful in two groups of patients.

1. Patients who require ventricular assistance to allow the heart to rest and recover its

function.

obtain complete drainage of the ventricle

unload the ventricle

Diminish myocardial work

maximize subendocardial perfusion.

2. Patients with myocardial infarction,

acute myocarditis,or end-stage heart diseasewho are not expected to recover adequate

cardiac function and who require

mechanical support as a bridge to transplantation


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Available ventricular assist device


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INDICATIONS FLOW CHART


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ValvularHeartDisease

Patients with preexisting mitral stenosis or aortic

regurgitation may require correction of the

valvulopathy before implantation of the device

CoronaryArteryDiseasePatients with inoperable coronary artery disease

sometimes continue to have angina without adverse

hemodynamic effects while being supported by a left ventricular assist device. However, right

ventricular ischemia and myocardial injury soon after implantation of the device can cause

right-sided heart failure, resulting in decreased flow to the left ventricular assist device.

GENERAL PRINCIPLES FORVAD APPLICATION

CARDIAC FACTORS

Arrhythmias

Atrial and ventricular arrhythmias continue to occur after implantation of the device.Atrial fibrillation hinders right ventricular filling but is reasonably well tolerated in recipients of left

ventricular assist devices.CongenitalDefects

Intracardiac septal defects should be repaired at the time of implantation of the device to avoid the right-

to-left shunt and subsequent oxygen desaturation that would be created by the sudden reduction in left

filling pressures


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GENERAL PRINCIPLES FORVAD APPLICATION

EXTRACARDIAC FACTORS

Functional compromise of end-organs

Irreversible major neurologic deficits

Severe obstructive or restrictive pulmonary disease is a contraindication, because

these patients often have oxygen desaturation in the perioperative period that can

result in hypoxic pulmonary vasoconstriction and right-sided heart failure.

Hepatic insufficiency and coagulopathy needs to be corrected aggressively

Dependence on hemodialysis is a contraindication but moderate renal insufficiency

does not preclude VAD implantation

Arterial and aortoiliac disease of the lower extremities complicates transfemoral

institution of cardiopulmonary bypass, which is sometimes necessary at the time of

removal of the device.

Patients with type O blood and for patients with a positive panel-reactiveantibody titer

for whom prospective crossmatching is required may be candidate to BRIDGING



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Available ventricular assist device


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Extracorporeal Pulsatile

Abiomed BVS 5000This is a short-term mechanical system that can provide left, right, or biventricular support

for patients whose hearts have failed but have the potential for recovery.

The device can also be used as a bridge to definitive therapy.

The pump houses an Angioflex membrane

and two proprietary tri-leaflet valves.

The AB5000 can provide flow rates of up to 6 lit

per min

The console recognizes which blood pump

is connected and automatically ensures

proper system function.

Although the left and right sides of the pump

work independently of each other, the console

automatically adjusts heart rates and

flows accordingly.


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Extracorporeal Pulsatile

ThoratecOne or two Thoratec VADs can be used to provide left, right, or biventricular support.

The blood pump is positioned outside the body (extracorporeally) and connected to tubes

(cannulas) inserted into the heart.

The pump has a rigid plastic case that contains a flexible pumping sac.

Blood is ejected from the pump when the pumping sac is

compressed by air from the external control console.

Within the inflow and outflow conduits, mechanicalvalves control the direction of blood flow.

The Thoratec VAD has a stroke volume of 65 milliliters

It can be operated at up to 100 beats per minute

(blood flow rates of up to 7 liters per minute)

3 different modes of operation:

asynchronous mode (pumping occurs at a preset rate)

synchronous mode (pumping is synchronizedwith the patient's heart rate)

volume mode (pumping is adjusted according

to the left ventricular filling volume).


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TandemHeartTandemHeart Percutaneous Ventricular Assist Device (pVAD)

can be inserted either by cardiovascular surgeons in the operating room or by cardiologists in the

cardiac catheterization laboratory.

The TandemHeart has been used in postcardiotomy cardiogenic shock patients (those who have

developed heart failure as a result of heart surgery or a heart attack) and as a bridge to a definitive

therapy.

The TandemHeart pVAD provides short-term support from a few hours up to 14 days, giving the heart

time to strengthen and potentially regain native function.

The TandemHeart pVAD is a continuous-flow centrifugal assist device placed

outside the body (extracorporeally).

Cannulas are inserted percutaneously through the femoral vein and advancedacross the intraatrial septum into the left atrium.

The pump withdraws oxygenated blood from the left atrium,

propels it by a magnetically driven, six-bladed impeller through

the outflow port, and returns it to one or both femoral arteriesvia arterial cannulas.

The pump weighs 8 ounces

The pump is capable of delivering blood flow up to 5.0 liters/minute.

Extracorporeal Non Pulsatile


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Implantable Pulsatile

Thoratec HeartMate IP LVAS (implantable pneumatic)

The pneumatic (air-driven) LVAS is a titanium alloy pump that weighs 570 grams and

consists of a blood chamber, an air chamber, a drive-line, and inflow and outflow

conduits.

Each conduit is a titanium cage

that contains a 25-mm porcine (pig)valve within a woven Dacrongraft.

A flexible polyurethane diaphragm

separates the blood chamber

and the air chamber.

Textured surfaces within the

blood chamber promote the

development of a cellular lining.

IPLVAS can provide flow rates of

up to 12 liters per minute.

The system can operate in three modes: automatic mode, fixed-rate

and external (synchronous) mode.


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Implantable Non Pulsatile

Thoratec HeartMate II LVAS

High-speed, axial flow, rotary blood pump producing non pulsatile action

12 ounces (about 375 grams) 1.5 inches (4 cm) in diameter and

2.5 inches (6 cm) long, so it is suitable for a wider range of patients,

including small adults and children.

The internal pump surfaces are asmooth, polished titanium.

A magnet is within the rotor

The pump speed can vary from

6,000 rpm to 15,000 rpm

(10 liters per minute).

The pump can run in two modes:In fixed-speed mode: constant speed,

which can be adjusted via the

system monitor.

In auto-speed mode: the pump speed varies in response to different levels of patient or

cardiac activity.


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Implantable Non Pulsatile

Jarvik 2000 Heart

The device is a valveless, electrically powered axial flow pump that fits

directly into the left ventricle and continuously pushes oxygen-rich

blood throughout the body

The Jarvik 2000 Heart is an axial flow blood pump that uses electrical power to rotate a vaned

impeller

The device is 2.5 cm wide, 5.5 cm long,and weighs 85 grams.

The impeller is a

neodymium-iron-boron magnet, which

is housed inside a welded titanium

shell.

A small cable, which exits the body

through the abdominal wall,delivers power to the impeller.

All of the blood-contacting surfaces

are made of highly polished titanium.

The normal operating range for the control system is 8,000 to 12,000 revolutions per minute,

which will generate an average pump flow rate of 5 liters per minute.


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Patients who develop heart failureafter heart surgery

and who have not responded to standard

medical therapy.

The system is designed to provide

immediate support and restore

hemodynamic stability for a period of up

to 7 days.The microaxial pump gives up to 4.5 liters per minute at a speed of 33,000 rpm.

Miniaturized impeller pump located

within a catheter.

IMPELLA



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AbioCor implantable replacement heart is the first completely self-

contained total artificial heart

Criteria

end-stage heart failure.life-expectancy of less than 30 days.

not eligible for a natural heart transplant.

no other viable treatment options.

Patients are not tethered to a large, air-pumping console nor do they have wires or

tubes piercing their skin.



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COMPLICATIONS

BleedingPerioperative hemorrhage due to hepatic dysfunction, poor nutritional status, and

antibiotic therapy; cardiopulmonary-bypassinduced thrombocytopenia and platelet

dysfunctionA recent study documented the presence of sustained thrombin generation and

fibrinolysis in patients with low-grade disseminated intravascular coagulopathy.

Absorption of tissue macrophages that express tissue factor by the surface of thedevice may be the trigger that generates this systemic procoagulant state. This may

account for reduced risk of clinically important thromboembolism.Thromboembolismandairembolism

Rightsidedheartfailure

Usually cytokine mediated (IL1, IL6, TNF, IL10)

Associated with perioperative hemorrhage and the need for blood transfusion

Infection

NOSOCOMIALpatients prolonged hospitalization, immobilization, endotracheal

intubation, suboptimal nutritional status, and need for multiple intravascular and bladder

catheters

DEVICE-RELATEDAbdominal pocket, leads exit site


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Devices can be operated either in

FIXED RATE MODE

AUTOMATIC MODE

more closely resembles normal physiologic conditions.

the device ejects when the pump is 90 percent full or when it senses a

decreased rate of filling.

As the patients activity increases,the pump fills faster and the rate (or stroke

volume) automatically increases, resulting in an increase in pump output. With a

decrease in activity pump filling and output decrease.

Because the aortic valve rarely opens when the heart is being supported by a

left ventricular assist device, pump output is synonymous with cardiac output

The development of long-term implantable devices that allow patients to be

discharged to their homes has imposed the need to assess a patients ability to

manage the device before implantation can be offered. The presence of a

constant companion, though desirable, is no longer required.

Interactions between the Patientandthe Device


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Heart Transplantation

Last therapeutical option

Long waiting list

Number of patients whoreceive heart transplants is

still relatively low (around2,200 each year)

85 percent of patients livefor more than a year aftertheir operations



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non pharmachological treatment of hf

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