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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) 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) Indication of surgery in CHF: - surgical correction possible - potencial profit of surgery >> risk of surgery 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? Surgical treatment of CHF Mitral valve surgery for regurgitation Functional MR 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 - 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 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) 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 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 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 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 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 Terminal heart failure – bridge to OHT - final destination Mechanical supports of the heart Intraaortic baloon contrapulsation Extracorporal systems/ pumps Intracorporal (implantable) devices 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 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 300500 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