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Heart failure Doc. MUDr. Lucie Riedlbauchová, PhD Clinic of Cardiology

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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 R2
P 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


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