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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
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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
Venezia, 5-6 November 2009
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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Cardiac Resynchronization Therapy
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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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Cardiac Resynchronization Therapy
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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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Cardiac Resynchronization Therapy
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Most candidates for biventricular pacing are alsocandidates for a defibrillator.
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Non pharmachological approaches
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Surgical Strategies
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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
Venezia, 5-6 November 2009
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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Non pharmachological approaches
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Ventricular Assist Device
Venezia, 5-6 November 2009
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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Ventricular Assist Device
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Available ventricular assist device
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Ventricular Assist Device
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INDICATIONS FLOW CHART
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Ventricular Assist Device
Venezia, 5-6 November 2009
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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Ventricular Assist Device
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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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Ventricular Assist Device
Venezia, 5-6 November 2009
Available ventricular assist device
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Ventricular Assist Device
Venezia, 5-6 November 2009
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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Ventricular Assist Device
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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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Ventricular Assist Device
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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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Ventricular Assist Device
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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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Ventricular Assist Device
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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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Ventricular Assist Device
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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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Ventricular Assist Device
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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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Ventricular Assist Device
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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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Ventricular Assist Device
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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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Ventricular Assist Device
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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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