1. Heart failure Doc. MUDr. Lucie Riedlbauchová, PhD Clinic of Cardiology
University hospital Motol
Source: ESC guidelines on heart failure management 2016

2. 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

3. ESC guidelines on heart failure management 2016

4. Classification Chronic HF- patients who have had HF for some time
ESC guidelines on heart failure management 2016
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))

5. ESC guidelines on heart failure management 2016

6. ESC guidelines on heart failure
management 2016

7. Pyramide of heart failure
Persistent severe symptoms of HF
Despite maximal medical treatment in 5-15% pts.
Affects morbidity/ mortality
Affects „only“ symptoms of HF
ACEI/ARB + BB + spironolacton
+ diuretics + digoxin
ACEI + ARB
+ BB + spironolacton
+ diuretics + digoxin + other
± CRT
± ICD
±OHT
+supports
NYHA IV
NYHA III
NYHA II
± CRT
± ICD
± CRT
± ICD
ACEI/ARB + BB + ASA
+ spironolacton + diuretics
ACEI/ARB + BB
+ diuretics
NYHA I
± ICD
ACEI/ARB + BB + ASA
ACEI/ARB
Ischemic etiology
Nonischemic etiology

8. 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

9. 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)
Indication of surgery in CHF:
- surgical correction possible
- potencial profit of surgery >> risk
of surgery

10. Surgical treatment of CHF Revascularization
Coronary angiography indicated
in pts with high risk of IHD
in pts with valvular pathology
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?

11. Surgical treatment of CHF Mitral valve surgery for regurgitation
Functional MR – surgical plastic of mitral valve (IIb C)
– CRT (IIb C)
Ischemic MR 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)

12. Surgical treatment of CHF Surgical correction of the aortic valve
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)

13. Surgical treatment of CHF Aneurysmectomy
Indication:
symptomatic aneurysm

14. 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

15. Cardiac pacing in chronic heart failure (CHF)
Indications for permanent pacemaker implant
are the same as in pts. with bradycardias
without heart failure
Specific features of cardiac pacing in CHF:
- to maintain normal chronotropic response
- to maintain coordinated contraction
of both atriums and ventricles

16. 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

17. Pacing from the RV apex change in the activation sequence QRS 83ms

18. Ventricular activation physiologically x LBBB
QRS 83ms
LV precedes
RV for 4ms RB
QRS 186ms
RV precedes
LV for 70ms

19. Dyssynchrony CRT - cardiac resynchronization therapy Atrioventricular
Interventricular
Intraventricular
Dyssynchrony P Q T
R1 R2
Atrial
Systole
RV Contraction
RV Relax
Ventricular
Contraction
Atrial
Systole
Pre-Ejection
Period
PEP
Ventr
Relax
LV Contraction LV
Filling Time
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.

20. Mechanism of CRT
Mechanical activation
Electrical activation RV LV

21. Biventricular pacing Where to implant the LV pacing lead
LAO 45°
RAO 30°
Epicardially – endovasally via CS tree
- minithoracotomy
Endocardially – transseptal punction – risk of tromboembolie,
Limited experience, different activation sequence
(from endocardium to epicardium)

22. Biventricular pacing Where to implant the LV pacing lead
Angiography of CS (RAO 30°)
Final position of the leads (RAO 30°)

23. Dyssynchrony Atrioventricular Interventricular Intraventricular R1 R2P Q T
R1 R2
RV Relax
RV Contraction
Atrial
Systole
Filling Time
LV Contraction LV
Ventricular
Contraction
Pre-Ejection
Period
PEP
Ventr
Relax
CRT ON
LV Relax
RV Relax
Atriale
Systole
RV Contraction
LV Contraction
Ventr
Relax
Ventricular
Contraction
Atrial
Systole
Pre-Ejection Period
Filling Time
Grines CL, Circulation 1989

24. Effects of CRT restoration of the activation sequence Acute effect
Long-term effect
restoration of the activation sequence
shortening of the total time of ventricular activation
LV filling time prolongation
mitral regurgitation
wall stress
contractility
myocardial oxygen consumption
NYHA class (ø 0,5-0,8 of class)
Quality of life improvement
exercise tolerance
(6-min walk test +20%, VO2max %)
LVEF (ø up to 6%)
reverse remodeling
(ø LVEDD reduction 15%)
hospitalizations for HF ( %)
mortality
(studies PATH-CH, MUSTIC, MIRACLE, COMPANION, CARE-HF and other)

25. When is CRT indicated ESC guidelines 2013
Sinus/ atrial fibrillation
LVEF ≤ 35%
NYHA II-IV
Optimal medical treatment

26. 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

27. Causes of death in CHF Mortality – 10-15% (1 year), 50% (5 years)
NYHA II
annual mortality 5-15%
NYHA III
annual mortality 20-50%
NYHA IV
annual mortality 30-70%
64%
59%
24%
12%
15%
26%
11%
56%
33%
n=103
n=27
Sudden death
Terminal feart failure
Other causes
MERIT-HF Study Group, LANCET 1999

28. 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 / 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 / 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

29. Epidemiology of sudden cardiac death
Europe / USA
Normal
structural
finding
Other
HCM 3%
DCM
10%
IHD
81%
Epidemiology of sudden cardiac death
IHD-post MI
DCM / HCM
Idiopathic VT from LV
Idiopathic VT from RV
LV aneurysm
without IHD
11%
ARVC
Corrected CHD
Sarcoidosis
Other
Japan (Aizawa Y, et al. Internal Medicine 2004)
17%
10% 5% 4% 3%
15%
31%

30. 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

31. 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

32. Goals of ICD therapy Secondary endpoint: 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

33. ICD (implantabile cardioverter-defibrilator)

34. Functions of ICD - back-up pacing in the ventricle after DC shock
Defibrillation
– sensing of VF charging shock 15-34J
- successful termination in 98%
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)

35. ATP with VT termination
DC shock

36. 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

37. Common contraindications of ICD
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

38. 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

39. Methods of elimination (RRT- renal replacement therapy)
Indication to start RRT in acute care: A-E-I-O-U
A – acidosis: noncompensated metabolic acidosis (pH < 7.1)
E – electrolyte abnormalities: K+>6,5mmol/l or increasing quickly
Na <115mmol/l, Na >160mmol/l
I – intoxication: intoxication with dialysable toxins (lithium, vankomycin…)
O – overload of fluids: pulmonary oedema refractory to diuretics, anasarka,
heart failure resistent to diuretics
U – uremia and renal failure: 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

40. 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

41. 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

42. 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
Terminal heart failure – bridge to OHT
- final destination

43. Mechanical supports of the heart
Intraaortic baloon contrapulsation
Extracorporal systems/ pumps
Intracorporal (implantable) devices
Arteficial heart (total arteficial heart)

44. Intraaortic baloon contrapulsation (IABK)
+ easy and quick introduction
- No active support of the heart
Synchronized inflation/ deflation of the ballon
Synchronization with ECG
arterial pressure
Contraindication:
Severe AoR
Aortic dissection
Severe stenosis on the pelvic arteries
MODS
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.

45. Mechanical supports of the heart
Indications
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
Hemodynamic parameters:
CI <2l/min
MAP < 65mmHg
PCWP ≥ 18mmHg
PAPd > 20mmHg
CVP > 20mmHg
Contraindications
Absolute CI:
Kr > 440 umol/l, or clearance Kr <0,5ml/s
Total bili > umol/l
Severe infection – sepsis
Primary koagulopathy
Tumor
Cerebrovascular disease
Diseases of the aorta
Relative CI
Affection of pulmonary parenchym
Mechanical valve
CI of anticoagulation therapy
Disease of the periferal vessels
EtOH or drug abusement

46. Mechanical supports of the heart - extracorporal/ paracorporal
Thoratec

47. Mechanical supports of the heart - implantable
MicroMed De Bakey VAD
Mid-term / long-term support

48. Mechanical supports of the heart - total arteficial heart
Heart Mate II LVAD

49. Mechanical supports of the heart - percutaneous heart supports
Impella
Tandem Heart pVAD

50. 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

51. 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

52. Orthotopic heart transplant (OHT)
Bicaval technique

53. Thank you for attention

54. IHD Intermitentní hemodialýza
CVVH
Continuous Venous Venous Hemofiltration filters middle sized particles and  can take off up to 1 liter per hour
Need replacement fluids
SCUF Slow continuous ultrafiltration, ideal for removing fluid overload, can remove cc/hr
No replacement fluids needed
CVVHD
Continuous Venous Venous Hemodialysis
Small particle filtration and fluid removal
Need dialysate
CVVHDF
Continuous Venous Venous Hemodiafiltration
Combination of both of the above modes, filters small and medium particles
Need fluid replacement and dialysate