Transcript heart_failure

Heart failure
Doc. MUDr. Lucie Riedlbauchová, PhD
Clinic of Cardiology
University hospital Motol
Source: ESC guidelines on heart failure management 2016
Definition
Clinical syndrome characterized by typical symptoms
(e.g. breathlessness, ankle swelling and fatigue)
that may be accompanied by signs (e.g. elevated jugular
venous pressure, pulmonary crackles and peripheral oedema)
caused by a structural and/or functional cardiac abnormality,
resulting in a reduced cardiac output and/or elevated
intracardiac pressures at rest or during stress.
Prevalence 1-2% in the general population, >10% in individuals > 70years
Incidence 1–3/1 000
Mortality (1999): 10–15 % (1year), 50 % (5 years)
ESC guidelines on heart failure management 2016
ESC guidelines on heart failure management 2016
ESC guidelines on heart failure management 2016
Classification
Chronic HF- patients who have had HF for some time
Stable HF - treated patient with symptoms and signs that have remained
generally unchanged for at least 1 month
Decompensated HF- if chronic stable HF deteriorates, either suddenly or slowly
New-onset (‘de novo’) HF – may present acutely (i.e. consequence of acute
myocardial infarction (AMI)), or in a subacute (gradual) fashion
(i.e. patients with a dilated cardiomyopathy (DCM))
ESC guidelines on heart failure management 2016
ESC guidelines on heart failure
management 2016
Pyramide of heart failure
Persistent severe symptoms of HF
Despite maximal medical treatment
in 5-15% pts.
±OHT
+supports
± CRT
NYHA IV
NYHA II
NYHA I
± ICD
ACEI + ARB
+ BB + spironolacton
+ diuretics + digoxin + other
± CRT
NYHA III
Affects morbidity/ mortality
Affects „only“ symptoms of HF
± ICD
ACEI/ARB + BB + spironolacton
+ diuretics + digoxin
± CRT
± ICD
ACEI/ARB + BB + ASA
+ spironolacton + diuretics
± CRT
± ICD
ACEI/ARB + BB
+ diuretics
± ICD
ACEI/ARB + BB + ASA
Ischemic etiology
ACEI/ARB
Nonischemic etiology
Nonpharmacologic treatment of CHF

Surgical treatment: revascularization/
surgical correction of valves/ ventricular plastics

Cardiac pacing/ CRT (cardiac resynchronization
therapy)
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ICD (implantabile cardioverter – defibrilators)

Elimination methods

Mechanical cardiac supports

Heart transplant
Surgical treatment of chronic heart failure

IHD is present in 60-70% of pts.
with LV dysfunction and in major part
of pts. with HF with preserved EF
(diastolic HF)
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Indication of surgery in CHF:
- surgical correction possible
- potencial profit of surgery >> risk
of surgery
Surgical treatment of CHF
Revascularization
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Coronary angiography indicated
in pts with high risk of IHD
in pts with valvular pathology
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CABG x PCI:
-
character of the coronary disease
potential risks of intervention
degree of LV dysfunction and dilatation
RV dysfunction present/ absent
comorbidities
myocardial viability
(dobutamine ECHO, perfuse SPECT of myocardium, MRI)
Efect of revascularization: symptoms improvement
LV function improvement
? better prognosis?
Surgical treatment of CHF
Mitral valve surgery for regurgitation

Functional MR
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Ischemic MR
– surgical plastic of mitral valve
– CRT (IIb C)
(IIb C)
- severe MR in pt.who was indicated
to CABG and has LVEF>30%
(IC)
– moderate MR in pt. indicated
to CABG where the Mi plastic
is possible

Organic MR
– severe MR in pt. with LVEF>30% (IC)
– severe MR in pt. with LVEF <30%
that is resistant to drugs (IIbC)
Surgical treatment of CHF
Surgical correction of the aortic valve
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-
Aortic stenosis (AoS)
Symptomatic severe AoS with signs of heart failure (IC)
Asymptomatic severe AoS with LVEF<50% (IC)
Severe AoS in pts. with LV dysfunction (IIbC)
Aortic regurgitation (AoR)
-
Symptomatic severe AoR with signs of heart failure (IB)
Asymptomatic severe AoR with LVEF<50% (IC)
Surgical treatment of CHF
Aneurysmectomy
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Indication:
symptomatic aneurysm
Nonpharmacologic treatment of CHF

Surgical treatment: revascularization/
surgical correction of valves/ ventricular plastics

Cardiac pacing/ CRT (cardiac resynchronization
therapy)

ICD (implantabile cardioverter – defibrilators)

Elimination methods

Mechanical cardiac supports

Heart transplant
Cardiac pacing in chronic heart failure (CHF)
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Indications for permanent pacemaker implant
are the same as in pts. with bradycardias
without heart failure
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Specific features of cardiac pacing in CHF:
- to maintain normal chronotropic response
- to maintain coordinated contraction
of both atriums and ventricles
Optimalization of AV delay
Modification of AV delay
+ restoration of diastolic filling
pattern (early philling phase
separated from atrial contraction)
Prolongation of the LV diastolic
filling time
Pacing from the RV apex
 change in the activation sequence
QRS 83ms
QRS 142ms
Ventricular activation physiologically x LBBB
LV precedes
RV for 4ms
RV precedes
LV for 70ms
RB
QRS 83ms
QRS 186ms
Atrioventricular
Dyssynchrony
Interventricular
Intraventricular
R1 R2
R1 R2
P
Q
Atrial
Systole
T
P
RV Contraction
RV Relax Atrial
LV Contraction
LV Systole
Q
T
PEP
Ventricular
Contraction
P
Ventr
Relax
Atrial
Systole
Filling Time Pre-Ejection
Period
Grines CL, Circulation 1989
CRT ON
CRT - cardiac resynchronization therapy
Pacing techniques positively affecting haemodynamic status of HF pts.
due to restoration of impaired synchrony of ventricular contraction.
Mechanism of CRT

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Electrical activation
RV
LV
Mechanical activation
Biventricular pacing
Where to implant the LV pacing lead
RAO 30°
LAO 45°
Epicardially – endovasally via CS tree
- minithoracotomy
Endocardially – transseptal punction – risk of tromboembolie,
Limited experience, different activation sequence
(from endocardium to epicardium)
Biventricular pacing
Where to implant the LV pacing lead
Angiography of CS (RAO 30°)
Final position of the leads (RAO 30°)
Atrioventricular
Dyssynchrony
Interventricular
Intraventricular
R1 R2
R1 R2
P
Q
Atrial
Systole
T
P
RV Contraction
RV Relax Atrial
LV Contraction
LV Systole
Q
P
T
PEP
Ventricular
Contraction
Ventr
Relax
Atrial
Systole
Filling Time Pre-Ejection
Period
CRT ON
Atriale
Systole
RV Contraction
LV Contraction
RV Relax Atrial
LV Relax Systole
Ventricular
Contraction
Filling Time Pre-Ejection Period
Grines CL, Circulation 1989
Ventr
Relax
Atrial
Systole
Effects of CRT
Acute effect
Long-term effect
restoration of the activation sequence
NYHA class (ø 0,5-0,8 of class)
Quality of life improvement
exercise tolerance
shortening of the total time of ventricular
activation
(6-min walk test +20%, VO2max +10-15%)
LV filling time prolongation
LVEF (ø up to 6%)
reverse remodeling
mitral regurgitation
wall stress
contractility
myocardial oxygen consumption
(ø LVEDD reduction 15%)


hospitalizations for HF (- 30-50%)
mortality
(studies PATH-CH, MUSTIC, MIRACLE, COMPANION, CARE-HF and other)
When is CRT indicated
ESC guidelines 2013
Sinus/ atrial fibrillation
LVEF ≤ 35%
NYHA II-IV
Optimal medical treatment
Nonpharmacologic treatment of CHF

Surgical treatment: revascularization/
surgical correction of valves/ ventricular plastics

Cardiac pacing/ CRT (cardiac resynchronization
therapy)

ICD (implantabile cardioverter – defibrilators)

Elimination methods

Mechanical cardiac supports

Heart transplant
Causes of death in CHF

Mortality – 10-15% (1 year), 50% (5 years)
NYHA II
NYHA II 5-15%
annual mortality
NYHA III
NYHA IV
NYHA III 20-50%
annual mortality
annual mortality
NYHA IV30-70%
12%
15%
24%
11%
26%
33%
64%
1n=103
2 3
Sudden death
56%
59%
n=103
1 2 3
n=27
Terminal feart failure
Other causes
MERIT-HF Study Group, LANCET 1999
Epidemiology of sudden death
Definition of sudden death:
- death from natural reasons that occurs in 1 hour since the onset of symptoms
- if the pt.is found dead already, the death is considered to be sudden if it occurs
in a pt.who was healthy and without problems in the preceding 24hrs.
(Abildstrom, SZ, In Malik, M: Risk of arrhythmia and sudden death. London 2001)
Sudden death in USA: cca 300 000/ year
Definition of sudden cardiac death (SCD):
- natural and unexpected death from cardiac reasons that manifests
as sudden loss of consciousness in 1 hour since the beginning
of acute symptoms. The cardiac disease may, but needn´t to be known earlier.
SCD in USA: cca 30 000/ year
Incidence of SCD: cca 0,36 – 1,28 / 1000 inhabitants per year
risk factors of SCD: age, man gender, black race, smoking, emotional stress,
intensive physical activity, heart failure, syncope, LV dysfunction,
inducibility of VT and nonsupresibility of VT by antiarrhythmics during EP in IHD
Other
Epidemiology of
sudden cardiac
death
Other
Sarcoidosis
Corrected CHD
LV aneurysm
without IHD
Idiopathic VT from RV
Idiopathic VT from LV
HCM
3%
Normal
structural
finding
DCM
10%
15%
31% IHD-post MI
3%
4%
IHD
81%
Europe / USA
4%
5%
10%
17% DCM / HCM
11%
11%
ARVC
Japan (Aizawa Y, et al. Internal Medicine 2004)
Causes of sudden cardiac death
Causes of SCD: ARRHYTHMIAS = cca 50% of SCD (ICD studies):
VT degenerating into VF with possible asystoly later – cca 60%
Primary VF – cca 10%
Electromechanical dissociation and asystoly – cca 30%
Presence of asystole increases with time after the onset of symptoms

Primary arrhythmias

Monomorphic VT (mVT)
Polymorphic VT
Ventricular fibrilation (VF)
AV blocade without ectopic activity
SA blocade without ectopic activity
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Causes of sudden cardiac death
Causes of secondary arrhythmias and/or
elektrical activity without mechanical response:







AMI
Tromboembolism
– stroke
- embolie into the coronary arteries
- pulmonary embolism
Rupture of aneurysm of the abdominal aorta
Hyperpotassemia / hypopotassemia
Hypoglykemia
Drugs
– TdP with QT prolongation
- ventricular flutter after Na channel blocking
- antiarrhythmics
Sleep apnea syndrome
Goals of ICD therapy

Primary endpoint: prevention of SCD
Secondary endpoint: therapy
of sustained monomorphíc VTs (smVT)
that are not directly life-threatening
and/or that are hemodynamically well
tolerated
ICD
(implantabile cardioverter-defibrilator)
Functions of ICD

Defibrillation
– sensing of VF
charging
- successful termination in 98%

shock 15-34J
Anti-tachycardic pacing (ATP)
= termination of smVT of the reentrant mechanism
- successrate cca 90%, when unsuccessful shock delivery
(increase in successful VT termination to 98%)
(studie PAIN-FREE)

Cardioversion = aplication of a shock with energy < 10J
 Anti-bradycardic pacing
- back-up pacing in the ventricle after DC shock
- DDD pacing in pts.with concomittant indication to pacing
 Memory storing EGM during therapy delivery
 ICD + CRT (cardiac resynchronization therapy)
ATP with VT termination
DC shock
Indication to ICD

Indication based on the clinical manifestation
Cardiac arrest
VT documented on ECG without cardiac arrest
Syncope
Profylakctic indication
Contraindications of ICD implant
Primary x secondary preventive indication
Secondary prevention of SCD („post event“)
– risc of recurrence of VT/VF 30-50% in 2 years
Primary prevention of SCD („pre-event“) – risc stratification
Indicationbased on the underlying heart disease
Common contraindications of ICD
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VT/VF in pts. with disease of a worse prognosis
<6 months
Severe psychiatric disease that may be worsen
by the ICD implant or that prevent regular visits
Terminal heart failure resistant to pharmacologic
treatment in pts. who are not OHT candidates
Severe neurologic symptomatology after cardiac
arrest
Nonpharmacologic treatment of CHF

Surgical treatment: revascularization/
surgical correction of valves/ ventricular plastics

Cardiac pacing/ CRT (cardiac resynchronization
therapy)

ICD (implantabile cardioverter – defibrilators)

Elimination methods

Mechanical cardiac supports

Heart transplant
Methods of elimination
(RRT- renal replacement therapy)
Indication to start RRT in acute care: A-E-I-O-U
A – acidosis:
E – electrolyte abnormalities:
I – intoxication:
O – overload of fluids:
U – uremia and renal failure:
noncompensated metabolic acidosis (pH < 7.1)
K+>6,5mmol/l or increasing quickly
Na <115mmol/l, Na >160mmol/l
intoxication with dialysable toxins (lithium, vankomycin…)
pulmonary oedema refractory to diuretics, anasarka,
heart failure resistent to diuretics
oligurie (< 200 mL/12 hours)
urea >30 mmol/l or kreatinin >300 umol/l
uremic complications (encephalopathy/myopathy/
neuropathy/pericarditis)
febrilie > 40° C
Indication: severe renal failure and need to remove abundant fluid
Methods of elimination
(RRT- renal replacement therapy)
Diffusion (dialysis) = exchange of small particles based on the concentration gradient
Ultrafiltration = passage of water and dissolved particles (small or intermediate size)
through the membrane based on the pressure gradient
Main indications of UF:
1.resistence on diuretics with hyponatremia
2.oligurie with renal function impairment
3.acute decompensation with signs of anasarca
Nonpharmacologic treatment of CHF

Surgical treatment: revascularization/
surgical correction of valves/ ventricular plastics

Cardiac pacing/ CRT (cardiac resynchronization
therapy)

ICD (implantabile cardioverter – defibrilators)

Elimination methods

Mechanical cardiac supports

Heart transplant
Mechanical supports of the heart
Indication:

Acute myocardial infarction with shock
- failure of PCI
- mechanical complication of MI
(rupturë of septum, acute MiR)

Planned coronary intervention
in pt. with high risk

Cardiogenic shock after cardiac surgery

Acute fulminant myocarditis
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Terminal heart failure – bridge to OHT
- final destination
Mechanical supports of the heart
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Intraaortic baloon contrapulsation
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Extracorporal systems/ pumps
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Intracorporal (implantable) devices
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Arteficial heart (total arteficial heart)
Intraaortic baloon contrapulsation
(IABK)
Synchronized inflation/ deflation of the ballon
Synchronization with ECG
arterial pressure
Indication:
• Severe coronary disease with HF that doesn´t react
on standard therapy
• Mechanical complications of MI
• Bridge to recovery after MI with cardiogenic shock
• Low cardiac output syndrome after cardiac surgery
• Myocarditis with severe HF
• Bridge to OHT in ischemic pts.
Contraindication:
• Severe AoR
• Aortic dissection
• Severe stenosis on the pelvic arteries
• MODS
+ easy and quick introduction
- No active support of the heart
Mechanical supports of the heart
Indications
Contraindications
HF refractory to therapy with organ
hypoperfusion even on high doses
of vasopressors (at least 2 drugs):
Dopamin ≥ 10ug/kg/min
Dobutamin ≥ 10ug/kg/min
Adrenalin ≥ 0,02ug/kg/min
Isoprenalin ≥ 0,05ug/kg/min
Milrionon ≥ 0,75ug/kg/min
PGE1
Absolute CI:
Kr > 440 umol/l, or clearance Kr <0,5ml/s
Total bili > 50-85umol/l
Severe infection – sepsis
Primary koagulopathy
Tumor
Cerebrovascular disease
Diseases of the aorta
Hemodynamic parameters:
CI <2l/min
MAP < 65mmHg
PCWP ≥ 18mmHg
PAPd > 20mmHg
CVP > 20mmHg
Relative CI
Affection of pulmonary parenchym
Mechanical valve
CI of anticoagulation therapy
Disease of the periferal vessels
EtOH or drug abusement
Mechanical supports of the heart
- extracorporal/ paracorporal
Thoratec
Mechanical supports of the heart
- implantable
MicroMed De Bakey VAD
Mid-term / long-term support
Mechanical supports of the heart
- total arteficial heart
Heart Mate II LVAD
Mechanical supports of the heart
- percutaneous heart supports
Impella
Tandem Heart pVAD
Nonpharmacologic treatment of CHF

Surgical treatment: revascularization/
surgical correction of valves/ ventricular plastics

Cardiac pacing/ CRT (cardiac resynchronization
therapy)

ICD (implantabile cardioverter – defibrilators)

Elimination methods

Mechanical cardiac supports

Heart transplant
Orthotopic heart transplant (OHT)
Indication:
 advanced HF (NYHA III-IV) that is refractory to medical
treatment and that is not possible to treat in another way
 advanced LV dysfunction
 signs of a poor prognosis – probability of survival
on the medical treatment <50% (spiroergometry)
Absolute contraindications
• active infection
• malignity
• another disease that worsen survival
• advanced dysfunction of the parenchymatous organs
• high vascular pulmonary resistence (PAR > 4W.j.)
Relative contraindications
• age > 65years
• diabetes with organ complications
• active peptic ulcus
Orthotopic heart transplant (OHT)
Bicaval technique
Thank you for attention
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IHD Intermitentní hemodialýza
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CVVH
Continuous Venous Venous Hemofiltration filters middle sized particles and can take
off up to 1 liter per hour
Need replacement fluids
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SCUF
Slow continuous ultrafiltration, ideal for removing fluid overload, can remove 300500 cc/hr
No replacement fluids needed
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CVVHD
Continuous Venous Venous Hemodialysis
Small particle filtration and fluid removal
Need dialysate
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CVVHDF
Continuous Venous Venous Hemodiafiltration
Combination of both of the above modes, filters small and medium particles
Need fluid replacement and dialysate