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Don’t Forget لا تنسوا أقصانا. Refractory Heart Failure. Prof. A. ABU-HASHEM (M.D. Cardiology) Zagazig, Egypt. “In these hearts …… their reserve force lost and with it the power of meeting the demands in maintaining the circulation during severe exertion”……. (Osler, 1892). - PowerPoint PPT Presentation
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Don’t ForgetDon’t Forget
تنسوا تنسوا ال ال أقصاناأقصانا
Prof.Prof. A. ABU-HASHEMA. ABU-HASHEM(M.D. Cardiology)(M.D. Cardiology)
Zagazig, EgyptZagazig, Egypt
““In these hearts …… their reserve In these hearts …… their reserve
force lost and with it the power of force lost and with it the power of
meeting the demands in maintaining meeting the demands in maintaining
the circulation during severe the circulation during severe
exertion”…….exertion”…….
(Osler, 1892).(Osler, 1892).
“ “ A pathophysiological state in which an A pathophysiological state in which an
abnormality of cardiac function is abnormality of cardiac function is
responsible for the failure of the heart responsible for the failure of the heart
to pump blood at a rate commensurate to pump blood at a rate commensurate
with requirements of the metabolizing with requirements of the metabolizing
tissues”tissues”
(Braunlwald, 1986).(Braunlwald, 1986).
Most cases of CHF respond favorably to Most cases of CHF respond favorably to
pharmaco and non-pharmaco therapies.pharmaco and non-pharmaco therapies.
Some do not improve or suffered from Some do not improve or suffered from
rapid recurrence despite optimal therapy rapid recurrence despite optimal therapy
and have symptoms at rest or minimal and have symptoms at rest or minimal
exertion, can not perform daily activities, exertion, can not perform daily activities,
frequently suffering from anasarca and frequently suffering from anasarca and
cachexia and require repeated cachexia and require repeated
hospitalization; hospitalization; Refractory HFRefractory HF. .
EPIDEMIOLOGYEPIDEMIOLOGY
CHF is major cause of mortality and CHF is major cause of mortality and morbidity especially among elderly and is morbidity especially among elderly and is considered a serious health problem.considered a serious health problem.
4-7 million is USA have CHF.4-7 million is USA have CHF.
400,000 new cases every year.400,000 new cases every year.
CHF is the 1ry cause of death in 40,000 / CHF is the 1ry cause of death in 40,000 / year.year.
CHF is the most frequent cause of CHF is the most frequent cause of hospitalization in medicare population.hospitalization in medicare population.
RHF accounts for 5% of symptomatic RHF accounts for 5% of symptomatic HF.HF.
Incidence of RHF increases with age Incidence of RHF increases with age and is more in males.and is more in males.
Risk of death in mild CHF is 5-10% Risk of death in mild CHF is 5-10% annually.annually.
This increases much in RHF up to This increases much in RHF up to 50%.50%.
EPIDEMIOLOGYEPIDEMIOLOGY
The burden associated with RHF is The burden associated with RHF is
expected to increase due to :expected to increase due to :
I.I. Ageing of the population.Ageing of the population.
II.II.Increase numbers of elderly with CAD and Increase numbers of elderly with CAD and
HPN.HPN.
III.III.Improved diagnosis e.g echo.Improved diagnosis e.g echo.
EPIDEMIOLOGYEPIDEMIOLOGY
ETIOLOGY ETIOLOGY
Ischemic (extensive CAD, multiple MI).Ischemic (extensive CAD, multiple MI).
Non-ischemic CM (younger, some with Non-ischemic CM (younger, some with
family history).family history).
Hypertension. Hypertension.
Valvular.Valvular.
Viral myocarditis.Viral myocarditis.
Precipitating (Aggravating) FactorsPrecipitating (Aggravating) Factors..
1.1. Cardiac :Cardiac : arrhythmias, M.I. arrhythmias, M.I.
2.2. Non cardiac :Non cardiac : anemia, pul.embolism, anemia, pul.embolism,
infections, other illness.infections, other illness.
3.3. Treatment-related:Treatment-related: poor compliance, poor compliance,
NSAID, steroids, B.B.NSAID, steroids, B.B.
The vicious circle of The vicious circle of pathophysiology pathophysiology
Chamber Chamber dilatationdilatation
Vent-Vent-Dysfunction Dysfunction
Wall stressWall stress
Renal Renal Vasoconstriction Vasoconstriction
HH22o and Na o and Na
retentionretention
Toxic effects Toxic effects
(Apoptosis, myocyte loss)(Apoptosis, myocyte loss)
Vasoconstriction Vasoconstriction (afterload)(afterload)
HR, ArrhythmiaHR, Arrhythmia Neuro-Neuro-hormoneshormones
Vent. Remodeling Vent. Remodeling
More functional deterioration More functional deterioration
Changes in geometry ( from prolate ellipse to Changes in geometry ( from prolate ellipse to more spherical shape), volume and architexturemore spherical shape), volume and architexture
Impairment of skeletal muscle metabolism.Impairment of skeletal muscle metabolism. TNF… muscle atrophy.TNF… muscle atrophy.Resulting in cachexia, and exercise intolerance Resulting in cachexia, and exercise intolerance
Changes is the biology and volume of myocytes Changes is the biology and volume of myocytes and non-myoctes components of the myocardiumand non-myoctes components of the myocardium
Symptoms of RHFSymptoms of RHF
1.1. Dyspnea III or IV .Dyspnea III or IV .
2.2. Orthopnea,PND,exertional and nocturnal Orthopnea,PND,exertional and nocturnal
dry cough.dry cough.
3.3. Fatigue, weakness.Fatigue, weakness.
4.4. Dizzy spells or palpitations due to Dizzy spells or palpitations due to
frequent tachyarrhythmias .frequent tachyarrhythmias .
5.5. Fluid retentions, LL edema, ascites….Fluid retentions, LL edema, ascites….
Physical exam.Physical exam.
1.1. Increased JVP with prominent V-wave.Increased JVP with prominent V-wave.
2.2. Generalized anasarca.Generalized anasarca.
3.3. Cardiac dilatation, galloping and Cardiac dilatation, galloping and
murmurs.murmurs.
4.4. Fine lung crepitations.Fine lung crepitations.
5.5. Tender hepatomegaly.Tender hepatomegaly.
Functional evaluationFunctional evaluation1.1. NYHA classification (insensitive, subjective)NYHA classification (insensitive, subjective)
2.2. Six-minute walk (<305 met. in 6 min. Six-minute walk (<305 met. in 6 min. bad bad prognosis).prognosis).
3.3. Peak maximal oxygen utilization (MVOPeak maximal oxygen utilization (MVO2 2 < 10 < 10
ml/kg/min in high risk pt.).ml/kg/min in high risk pt.).
4.4. Exercise testing: modified Bruce or Naughton Exercise testing: modified Bruce or Naughton protocols (reduced speeds and slow protocols (reduced speeds and slow increments).increments).
5.5. Metabolic equivalents and work capacity Metabolic equivalents and work capacity (METs) are reduced.(METs) are reduced.
Diagnostic investigationsDiagnostic investigations
1.1. Confirm the clinical diagnosis.Confirm the clinical diagnosis.
2.2. Identify an underlying causes.Identify an underlying causes.
3.3. Identify precipitating factors.Identify precipitating factors.
4.4. Guide therapy.Guide therapy.
5.5. Determine prognosis.Determine prognosis.
ECGECG
Nonspecific ST- T changes.Nonspecific ST- T changes.
Chambers enlargement.Chambers enlargement.
Old MI.Old MI.
BBB and other conduction defects.BBB and other conduction defects.
Tachyarrhythmias: AF, A fl, VPCs, VT….Tachyarrhythmias: AF, A fl, VPCs, VT….
Chest x-rayChest x-ray
Upper lobe congestion.Upper lobe congestion.
Interstitial edema.Interstitial edema.
Kerley’s A and B lines.Kerley’s A and B lines.
Pleural effusions.Pleural effusions.
Echo Doppler Echo Doppler
Dimensions, volumes, wall thickness.Dimensions, volumes, wall thickness.
Function: EF, FS, diastolic dysfunction.Function: EF, FS, diastolic dysfunction.
Valvular structure and function.Valvular structure and function.
Pressures: m PAP, RVSP.Pressures: m PAP, RVSP.
Spont. echo contrast, masses, thrombi.Spont. echo contrast, masses, thrombi.
Pericardial diseases.Pericardial diseases.
TEETEE
Inadequate TTE.Inadequate TTE.
Suspected IE.Suspected IE.
Prosthetic valve functionProsthetic valve function
LAA thrombi.LAA thrombi.
Echo Echo (cont.)(cont.)
DSE:DSE: at low dose for detection of at low dose for detection of
viable myocardium.viable myocardium.
Myocardial tissue contrast:Myocardial tissue contrast: to detect to detect
ischemia and viability.ischemia and viability.
Radionuclide scintigraphy Radionuclide scintigraphy
Non diagnostic echo studyNon diagnostic echo study
RV functionsRV functions
Viable myocardiumViable myocardium
PET is more sensitive than Thallium- PET is more sensitive than Thallium-
201 study.201 study.
Cardiac magnetic resonanceCardiac magnetic resonance
The most accurate for volumes, The most accurate for volumes,
thickness and masses.thickness and masses.
Detection of myocardial necrosis, Detection of myocardial necrosis,
perfusion and function.perfusion and function.
Quantitative biochemical information: Quantitative biochemical information:
myocardial energetics.myocardial energetics.
Other testsOther tests
Routine laboratory: Routine laboratory: ESR, anemia, ESR, anemia,
serum iron, thrombocytopenia. serum iron, thrombocytopenia.
Electrolyte: NaElectrolyte: Na++, k, k++, Mg, Mg++++ . .
Liver and kidney function tests.Liver and kidney function tests.
Thyroid function.Thyroid function.
Viral study (serum or myocardial Viral study (serum or myocardial
biopsy).biopsy).
Serum ANP or urinary proatrial Serum ANP or urinary proatrial
natriuretic peptide (N-ANP) or (N-BNP).natriuretic peptide (N-ANP) or (N-BNP).
Spirometry and respiratory function Spirometry and respiratory function
tests in selected cases.tests in selected cases.
Other testsOther tests
Invasive testsInvasive tests
Usually not required, but may be Usually not required, but may be
needed to elucidate the cause of RHF.needed to elucidate the cause of RHF.
Coronary angiography.Coronary angiography.
Hemodynamic monitoring.Hemodynamic monitoring.
Endomyocardial biopsy.Endomyocardial biopsy.
Diagnostic criteria of RHFDiagnostic criteria of RHF
Major :Major :
1.1. Resting LVEF < 30%.Resting LVEF < 30%.
2.2. NYHA III or IV.NYHA III or IV.
3.3. Peak VOPeak VO22<14ml/kg/min on symptom limited <14ml/kg/min on symptom limited
testing (4-5 METs).testing (4-5 METs).
Minor :Minor :1.1. No or minimal response after at least 3m of full No or minimal response after at least 3m of full
standard therapy (ACEI,digoxin, diuretics) .standard therapy (ACEI,digoxin, diuretics) .
2.2. Serum Na < 130 mq./L. in pt. not treated with Serum Na < 130 mq./L. in pt. not treated with ACEIs.ACEIs.
3.3. Plasma norepinephrine > 900 pg/ml.Plasma norepinephrine > 900 pg/ml.
Contributing :Contributing :1.1. More than one hospitalization for worsening HF More than one hospitalization for worsening HF
in the past 6 ms.in the past 6 ms.
2.2. Cardiac cachexia.Cardiac cachexia.
Diagnostic criteria of RHFDiagnostic criteria of RHF
Management of RHFManagement of RHFPrevention of RHFPrevention of RHF
The basic aims of prevention are to :The basic aims of prevention are to :
Limit myocardial damage.Limit myocardial damage.
Modulate and reduce neuroendocrine Modulate and reduce neuroendocrine activation.activation.
This includes :This includes :
Treatment of risk factors (smoking/ lipids/ Treatment of risk factors (smoking/ lipids/ HPN…).HPN…).
Revascularization for cases with significant Revascularization for cases with significant reversible ischemia.reversible ischemia.
Life style modificationLife style modification
Diet : small meals, less fat, high fiber diet.Diet : small meals, less fat, high fiber diet.
Limited dietary sodium Limited dietary sodium 2 gm/day. 2 gm/day.
Reduced fluid intake.Reduced fluid intake.
Avoidance of traveling to high altitude, Avoidance of traveling to high altitude,
very hot or humid places. Short air flights very hot or humid places. Short air flights
are preferred to other means of transport.are preferred to other means of transport.
Management of RHFManagement of RHF
Non pharmacological therapy Non pharmacological therapy
1.1. Exercise and rehabilitation :Exercise and rehabilitation :
Regular physical activity is recommended Regular physical activity is recommended according to the patient’s condition.according to the patient’s condition.
Walking or cycling for 10-30 min/day 3-Walking or cycling for 10-30 min/day 3-7d/w.7d/w.
Moderate – intensity resistance training Moderate – intensity resistance training improves strength, endurance, HR improves strength, endurance, HR variability, and forearm blood flow.variability, and forearm blood flow.
2.2. Rest:Rest:
Necessary in severe RHF.Necessary in severe RHF.
Passive mobilization and respiratory Passive mobilization and respiratory
exercise are advised.exercise are advised.
3.3. EducationEducation of the patient and relatives of the patient and relatives
about disease condition, life style about disease condition, life style
modification,drug side effects.modification,drug side effects.
Non pharmacological therapy Non pharmacological therapy
Specific pharmacological therapy Specific pharmacological therapy
Diuretics Diuretics
Loop diuretics, thiazides and potassium Loop diuretics, thiazides and potassium
sparing.sparing.
RALESRALES mortality study : mortality study :
(low dose spironolactone + ACEIs + loop (low dose spironolactone + ACEIs + loop
diuretics) markedly and progressively diuretics) markedly and progressively
improved survival in RHF irrespective of improved survival in RHF irrespective of
etiology.etiology.
Treatment of diuretics resistance :Treatment of diuretics resistance :
Fluid restriction.Fluid restriction.
Change the route (oral to i.v.) and timing Change the route (oral to i.v.) and timing
(single multiple & continuous infusion)(single multiple & continuous infusion)
Combination therapy (Furosemide . HCZ)Combination therapy (Furosemide . HCZ)
Furosemide + HSSFurosemide + HSS
High dose Furosemide (i.v. infusion for 500-High dose Furosemide (i.v. infusion for 500-
1000 mg) plus hypertonic saline solution (150 1000 mg) plus hypertonic saline solution (150
ml 1.4-4.6% NaCl) bid in 30 min for 6-12 days.ml 1.4-4.6% NaCl) bid in 30 min for 6-12 days.
Improved clinical and hemodynamic Improved clinical and hemodynamic
parameters, reduced hospitalization, and parameters, reduced hospitalization, and
maintained the obtained results over time in maintained the obtained results over time in
comparison with the use of high dose comparison with the use of high dose
Furosemide as bolus.Furosemide as bolus.
ACEIsACEIs
Start with small doses with gradual Start with small doses with gradual
increments. increments.
Regular check up of renal function and KRegular check up of renal function and K++..
Significantly improved survival and reduce Significantly improved survival and reduce
hospitalization.hospitalization.
Many trials Many trials (SOLVD, SAVE, PROMISE, (SOLVD, SAVE, PROMISE,
PROVED,…)PROVED,…)
Dry cough, hypotension, Dry cough, hypotension, K K++, renal , renal
insufficiency are side effects.insufficiency are side effects.
ARBS: are the best substitute in the ARBS: are the best substitute in the
presence of side effects presence of side effects (CHARM study). (CHARM study).
Combination therapy remains to be Combination therapy remains to be
defined defined (ON TARGET).(ON TARGET).
ACEIsACEIs
Vasodilators Vasodilators
Isosorbide dinitrate and hydralazine in Isosorbide dinitrate and hydralazine in
combination in combination in V-HeFTV-HeFT trial yield trial yield
significant survival benefit in comparison significant survival benefit in comparison
to placebo and prazocin.to placebo and prazocin.
Digitalis Digitalis
Routine for CHF and AF.Routine for CHF and AF.
In SR : debates regarding its beneficial In SR : debates regarding its beneficial
effects vs toxic effects( DIG trial).effects vs toxic effects( DIG trial).
Smaller doses, in elderly, renal or Smaller doses, in elderly, renal or
hepatic insufficiency.hepatic insufficiency.
Serum digoxin levels and electrolyte Serum digoxin levels and electrolyte
check up.check up.
Dobutamine, Dopamine and Milrinone.Dobutamine, Dopamine and Milrinone.
The routine use in RHF is not The routine use in RHF is not
recommended.recommended.
Best indicated in: acute HF, bridge to Best indicated in: acute HF, bridge to
definitive treat. (revascularization or definitive treat. (revascularization or
transplantation) or palliation in end stage transplantation) or palliation in end stage
RHF.RHF.
Inotropes Inotropes
Combination of B-blockers and Combination of B-blockers and
phosphodiesterase inhibitors (milrinone phosphodiesterase inhibitors (milrinone
and enoximone) seems to be beneficial, and enoximone) seems to be beneficial,
with less side effects.with less side effects.
Inotropes Inotropes
B- BlockersB- BlockersHF is associated with enhanced HF is associated with enhanced adrenergic activity with its direct and adrenergic activity with its direct and indirect toxic myocardial effects.indirect toxic myocardial effects.
B-B is indicated in mild-moderate HF B-B is indicated in mild-moderate HF pretreated with standard therapy.pretreated with standard therapy.
CAPRICORNCAPRICORN study using study using CarvedilolCarvedilol and and MERITMERIT heart failure trial using heart failure trial using Metoprolol,Metoprolol, showed reduction in total mortality by 34% showed reduction in total mortality by 34% and SCD by 41%.and SCD by 41%.
However, symptomatic benefit may be However, symptomatic benefit may be
delayed and initial worsening may delayed and initial worsening may
occur.occur.
It is an important issue in decision It is an important issue in decision
making about starting B.B in severely making about starting B.B in severely
symptomatic cases.symptomatic cases.
B- BlockersB- Blockers
Antithrombotics Antithrombotics
RHF is associated with increased risk of RHF is associated with increased risk of
thromboembolism.thromboembolism.
The annual risk of stroke in controlled CHF The annual risk of stroke in controlled CHF
is 1-2%.is 1-2%.
In stroke prevention in AF (SPAF), it was In stroke prevention in AF (SPAF), it was
10.3% in chronic and 17.7% recent CHF.10.3% in chronic and 17.7% recent CHF.
Anticoagulants definitely reduced risk of Anticoagulants definitely reduced risk of
stroke in the presence of AF, while this stroke in the presence of AF, while this
not yet proved in SR. not yet proved in SR.
Intracardiac thrombi and probably SEC Intracardiac thrombi and probably SEC
are strong indications for long term oral are strong indications for long term oral
anticoagulants.anticoagulants.
Antithrombotics Antithrombotics
AntiarrhythmicsAntiarrhythmics
A.A. For SVT: AF, flutter, SVT.For SVT: AF, flutter, SVT.
1.1. Digoxin to control vent.rate at rest only.Digoxin to control vent.rate at rest only.
2.2. B-blockers: to control vent.rate during B-blockers: to control vent.rate during
exercise.exercise.
3.3. Amiodarone if B-B are contraindicated. Amiodarone if B-B are contraindicated.
4.4. AVN ablation, AF ablation(PV isolation) in AVN ablation, AF ablation(PV isolation) in
refractory cases.refractory cases.
B.B. For vent tachy.: non sust.VT,sust.VT, For vent tachy.: non sust.VT,sust.VT,
SCD.SCD.
1.1. B-blockers.B-blockers.
2.2. Amiodarone.Amiodarone.
3.3. ICD.ICD.
4.4. Radiofrequency ablation (not yet of Radiofrequency ablation (not yet of
proven efficacy)proven efficacy)
AntiarrhythmicsAntiarrhythmics
Statins in CHFStatins in CHF
Among the cholesterol – independed Among the cholesterol – independed
effects of statins is the antihypertrophic effects of statins is the antihypertrophic
on the heart on the heart
Limited studies showed that statins Limited studies showed that statins
improved the quality of life and exercise improved the quality of life and exercise
capacity in patient with nonischemic CM.capacity in patient with nonischemic CM.
Thus statins may be a promising novel Thus statins may be a promising novel
treatment strategy in RHF.treatment strategy in RHF.
Drugs under investigationsDrugs under investigations
1. Vasopeptidase inhibitors (Omapatrilat)1. Vasopeptidase inhibitors (Omapatrilat)
Block not only ACE but also neutral Block not only ACE but also neutral
endopeptidase which leads to enhanced endopeptidase which leads to enhanced
activity of endogenous vasodilators (ANP).activity of endogenous vasodilators (ANP).
Used in HPN and CHF.Used in HPN and CHF.
In a small scale study they improved In a small scale study they improved
morbidity and mortality in RHF.morbidity and mortality in RHF.
May be superior to ACEIs.May be superior to ACEIs.
2.2. Cytokine antagonists (TNF antagonists):Cytokine antagonists (TNF antagonists):
Etanercept or Infliximab.Etanercept or Infliximab.
In a short term pilot study Etanercept in In a short term pilot study Etanercept in
CHF showed improvement in clinical status CHF showed improvement in clinical status
and and EF and EF and LV size. LV size.
Drugs under investigationsDrugs under investigations
3. Endothelin antagonists:3. Endothelin antagonists:
Serum endothelin-1 is elevated in RHF.Serum endothelin-1 is elevated in RHF.
It has a potent vasoconstrictive action with It has a potent vasoconstrictive action with
adverse effects in the structure and function adverse effects in the structure and function
of the heart and peripheral vessels.of the heart and peripheral vessels.
Bosentan in a small dose is an endothelin Bosentan in a small dose is an endothelin
receptor antagonist, with promising initial receptor antagonist, with promising initial
results in a large-scale ongoing study.results in a large-scale ongoing study.
Drugs under investigationsDrugs under investigations
Future prospects Future prospects
New methods to promote angiogenesis New methods to promote angiogenesis
(gene therapy), stem cell implantation and (gene therapy), stem cell implantation and
autogenous myocyte cultures.autogenous myocyte cultures.
Given intracoronary or intrapericardial Given intracoronary or intrapericardial
hoping to increase vascularity and hence hoping to increase vascularity and hence
viability and function of the myocardium.viability and function of the myocardium.
Ultrafilteration Ultrafilteration
Is employed in resistant cases with Is employed in resistant cases with fluid retention. fluid retention.
To remove excess water and sodium, To remove excess water and sodium, thus escape from the cardiorenal thus escape from the cardiorenal vicious circle.vicious circle.
Intermittent hemofilteration and Intermittent hemofilteration and hemodialysis.hemodialysis.
More effectively using extracorporeal More effectively using extracorporeal or slow isolated ultrafilteration.or slow isolated ultrafilteration.
Pacemakers is RHFPacemakers is RHF
Resynchronization therapyResynchronization therapy Based on the presence of intravent. Based on the presence of intravent. conduction disturbance resulting in conduction disturbance resulting in discoordinated vent.conduction in 30% of CHF.discoordinated vent.conduction in 30% of CHF.
Resynchronization using biventricular or Resynchronization using biventricular or multisites pacing, enhances vent. contraction multisites pacing, enhances vent. contraction and reduces MR.and reduces MR.
Although complex procedure, marked Although complex procedure, marked improvement in symptoms and exercise improvement in symptoms and exercise tolerance is achieved tolerance is achieved (MUSTIC study).(MUSTIC study).
LV assist Devices LV assist Devices
Used as a Used as a temporary bridge to temporary bridge to
cardiac transplantation or recovery cardiac transplantation or recovery
of the heart post-cardiac surgeryof the heart post-cardiac surgery or or
from a major cardiac insult.from a major cardiac insult.
Biomechanical assistance of LV and / or Biomechanical assistance of LV and / or
RV can be achieved with a variety of devices RV can be achieved with a variety of devices
ranging from enhanced external counter ranging from enhanced external counter
pulsation pulsation (EECP),(EECP), IABC IABC
to to Vent. Assist systemsVent. Assist systems and and to totally to totally
implantable artificialimplantable artificial heart. heart.
LV assist Devices LV assist Devices
Surgery for RHFSurgery for RHF
1.1. Revascularization in IHD with viable Revascularization in IHD with viable
myocardium: CABG or transmural laser myocardium: CABG or transmural laser
revascularization (TLR).revascularization (TLR).
2.2. Mitral reconstruction (MVR or replacement) Mitral reconstruction (MVR or replacement)
in severe MR, with excellent short and in severe MR, with excellent short and
intermediate term outcome.intermediate term outcome.
3.3. Aneurysmectomy.Aneurysmectomy.
4.4. Cardiomyoplasty via stimulated skeletal Cardiomyoplasty via stimulated skeletal
muscle wraps and recently via muscle wraps and recently via
nonstimulated synthetic wraps.nonstimulated synthetic wraps.
5.5. Partial left ventriculectomy (Batista) in Partial left ventriculectomy (Batista) in
trial to restore normal cardiac trial to restore normal cardiac
dimensional physiology.dimensional physiology.
Surgery for RHFSurgery for RHF
5. Cardiac transplantation :5. Cardiac transplantation :
Indications :Indications :NYHA IV, VONYHA IV, VO22 max < 10 ml /kg/min max < 10 ml /kg/min
Recurrent uncontrolled VT..Recurrent uncontrolled VT..
Severe ischemia not amenable to Severe ischemia not amenable to revascularization.revascularization.
EF < 20%.EF < 20%.
Contraindications :Contraindications :Age > 65 years old.Age > 65 years old.
Active infections, malignancy, DM, renal or hepatic Active infections, malignancy, DM, renal or hepatic failure.failure.
Fixed severe PH.Fixed severe PH.
Surgery for RHFSurgery for RHF
Although cardiac transplantation is the Although cardiac transplantation is the
most effective therapy for end-stage RHF, most effective therapy for end-stage RHF,
yet it is limited by yet it is limited by donor organ supplydonor organ supply and and
need for immunosuppression.need for immunosuppression.
Xenotransplantation:Xenotransplantation: especially porcine or especially porcine or
non human primate hearts may represent non human primate hearts may represent
a solution to the organ shortage.a solution to the organ shortage.
Surgery for RHFSurgery for RHF