Support In Acute Heart Failure Research Articles

Percutaneous Mechanical Circulatory Support in Acute Heart Failure Complicated with Cardiogenic Shock.

Despite advancements in algorithms concerning the management of cardiogenic shock, current guidelines still lack the adequate integration of mechanical circulatory support devices. In recent years, more and more devices have been developed to provide circulatory with or without respiratory support, when conservative treatment with inotropic agents and vasopressors has failed. Mechanical circulatory support can be contemplated for patients with severe, refractory, or acute-coronary-syndrome-related cardiogenic shock. Through this narrative review, we delve into the differences among the types of currently used devices by presenting their notable advantages and inconveniences. We address the technical issues emerging while choosing the best possible device, temporarily as a bridge to another treatment plan or as a destination therapy, in the optimal timing for each type of patient. We also highlight the diverse implantation and removal techniques to avoid major complications such as bleeding and limb ischemia. Ultimately, we hope to shed some light in the gaps of evidence and the importance of conducting further organized studies around the topic of mechanical circulatory support when dealing with such a high mortality rate.

Temporary Mechanical Circulatory Support in Acute Heart Failure.

Cardiogenic shock (CS) is a challenging syndrome, associated with significant morbidity and mortality. Although pharmacological therapies are successful and can successfully control this acute cardiac illness, some patients remain refractory to drugs. Therefore, a more aggressive treatment strategy is needed. Temporary mechanical circulatory support (TCS) can be used to stabilise patients with decompensated heart failure. In the last two decades, the increased use of TCS has led to several kinds of devices becoming available. However, indications for TCS and device selection are part of a complex process. It is necessary to evaluate the severity of CS, any early and prompt haemodynamic resuscitation, prior TCS, specific patient risk factors, technical limitations and adequacy of resources and training, as well as an assessment of whether care would be futile. This article examines options for commonly used TCS devices, including intra-aortic balloon pumps, a pulsatile percutaneous ventricular assist device (the iVAC), veno-arterial extra-corporeal membrane oxygenation and Impella (Abiomed) and TandemHeart (LivaNova) percutaneous ventricular assist device.

Mechanical Circulatory Support for Acute Heart Failure Complicated by Cardiogenic Shock.

Acute heart failure is a potentially life-threatening condition that can lead to cardiogenic shock, which is associated with hypotension and organ failure. Although there have been many studies on the treatment for cardiogenic shock, early mortality remains high at 40–50%. No new medicines for cardiogenic shock have been developed. Recently, there has been a gradual decline in the use of the intra-aortic balloon pump mainly due to a lack of adequate hemodynamic support. Extracorporeal membrane oxygenation and the percutaneous ventricular assist device have become more widely used in recent years. A thorough understanding of the mechanisms of such mechanical support devices and their hemodynamic effects, components of the devices, implantation technique, management, criteria for indications or contraindications of use, and clinical outcomes as well as multidisciplinary decision making may improve the outcomes in patients experiencing cardiogenic shock.

Cardiogenic shock : Current evidence

This CME article addresses the pathophysiology, incidence, current survival outcome and treatment options for patients with cardiogenic shock as a complication of acute myocardial infarction. The shock spiral of left heart failure due to cardiac infarction, subsequent vasoconstriction and paradoxical vasodilation due to the systemic inflammation response syndrome (SIRS) is a vicious circle which must be interrupted. Treatment focuses on the evidence from randomized clinical trials and the current guideline recommendations. With respect to interventional and surgical treatment the question of culprit lesion vs. complete revascularization is still unsolved. For medicinal treatment acetylsalicylic acid (ASA) and heparin are more often supplemented with prasugrel and ticagrelor. In the case of inotropes, dobutamine remains the first-line treatment option and for vasopressors norepinephrine. The calcium sensitizer levosimendan has not provided the hoped for superiority over conventional treatment in randomized trials. The use of intra-aortic balloon pumps (IABP) is no longer recommended as circulatory support in acute heart failure (reduced to classIII). The use of percutaneous implantable mechanical circulatory support devices has not shown asurvival benefit in the few randomized trials carried out so far even when compared with IABP, due to increased bleeding complications.

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

Systolic heart failure: diagnosis and therapy.

The present review highlights recent findings on perioperative systolic heart failure. It briefly summarizes the pathophysiology of heart failure and provides the reader with new insight in diagnosis and treatment of systolic heart failure. In addition, we review new therapeutic strategies with pharmacologic agents and mechanical assist devices to treat systolic heart failure. Left ventricular systolic heart failure is a high-risk disease for patients undergoing cardiac and noncardiac surgery and poses a high burden on the anesthesiologist in charge. Perioperative echocardiography is well established for urgent diagnosis in the operating room and is superior to biomarker-based diagnosis. Although cardiovascular disease associated mortality decreases, systolic heart failure related mortality remains at a high of 50% after 5 years. As a consequence, left ventricular assist device implantation rates grow rapidly and include approximately 30-40% patients with desperate clinical situation and destination therapy. Extracorporeal life support for acute heart failure needs further investigation to document possible indications and side-effects. Recent advances in the field of cardiovascular anesthesiology comprise advanced use of perioperative echocardiography, mechanical circulatory assist devices, and customized pharmacologic management.

Aortic Cannula Disruption Following Long-Term LVAD Support

The Levitronix CentriMag is approved in Europe for 30 days as uni- or biventricular support in acute heart failure as a bridge to recovery, bridge to heart transplantation or to a long-term left ventricular assist device (LVAD). We report the case of a patient who was supported with the same Levitronix CentriMag pump for 119 days without changing any components of the circuit or the pump head because of an anatomical condition which precluded the feasibility of pump exchange and who did not experience any mechanical failure of the impeller but eventually died due to the rupture of the cannulae. This is the first report of failure of paracorporeal short-term LVAD due to disruption of one cannula with a properly functioning pump.

Cavo-pulmonary anastomosis associated with left ventricular in comparison with biventricular circulatory support in acute heart failure

Right ventricular (RV) failure during left ventricular assist device (LVAD) support can result in severe hemodynamic compromise with high mortality. This study investigated the acute effects of cavo-pulmonary anastomosis on LVAD performance and RV myocardial compromise in comparison with biventricular circulatory support, in a model of biventricular failure. LVAD support was performed by centrifugal pump in 21 pigs with severe biventricular failure obtained by FV induction. Animals were randomized to be submitted to cavo-pulmonary anastomosis, to biventricular circulatory support or to control group. They were maintained under circulatory support and hemodynamic monitoring for 3h. Venous lactate and cytokines serum levels were also obtained. Endocardium samples were analyzed by electronic microscopy. FV maintenance was responsible for acute LVAD impairment after 180 min in the control group. cavo-pulmonary anastomosis resulted in non-significant improvement of LVAD pump flow in relation to control group (+55±14 ml/kg/min, P=0.072), while animals under biventricular support maintained higher LVAD flow (+93±17 ml/kg/min, P=0.012). Mean arterial pressure remained constant only in biventricular group (P<0.001), which also presented decrease of right atrial and ventricular pressures. Similar increases in lactate and cytokines levels were observed in the three groups. Ultra-structural analysis documented low levels of myocardial swelling in the biventricular group (P=0.017). The concomitant use of cavo-pulmonary anastomosis during LVAD support in a pig model of severe biventricular failure resulted in non-significant improvement of hemodynamic performance and it did not effectively replace the use of biventricular support.

Current and Future Perspectives in Cardiogenic Shock, Reperfusion Strategies and Hemodynamic Inotropic Support for Acute Heart Failure

Current and Future Perspectives in Cardiogenic Shock, Reperfusion Strategies and Hemodynamic Inotropic Support for Acute Heart Failure

Effects of Intra-Aortic Balloon Pump Versus Centrifugal Pump on Myocardial Energetics and Systemic Circulation in a Porcine Model of Rapidly Worsening Acute Heart Failure

The present experimental study compared the effectiveness of counterpulsation provided by the intra-aortic balloon pump (IABP) versus that of a nonpulsatile, radial-flow centrifugal pump (CFP) in rapidly worsening acute heart failure (HF). Eighteen pigs were included in the study. After the induction of acute moderate HF, circulatory support was randomly provided with either the IABP or CFP. No significant change in cardiac output (CO) and mean aortic pressure (MAP) was observed with either pump. The IABP caused a significantly greater decrease than the CFP in 1) double product (13.138 +/- 2.476 mm Hg/min vs. 14.217 +/- 2.673 mm Hg/min, p = 0.023), 2) left ventricular systolic pressure (LVSP, 100 +/- 8 mm Hg vs. 106 +/- 10 mm Hg, p = 0.046), and 3) end-diastolic aortic pressure (EDAP, 70 +/- 6 mm Hg vs. 86 +/- 6 mm Hg, p = 0.000). The effects of both pumps on total tension time index and LAD flow were similar. After the induction of severe HF, the IABP had its main effects on afterload and decreased LVSP from 88 +/- 6 mm Hg to 78 +/- 9 mm Hg, (p = 0.008), and EDAP from 57 +/- 9 mm Hg to 49 +/- 14 mm Hg, (p = 0.044), whereas the CFP exerted its effects mainly on preload, lowering LV end-diastolic pressure from 19 +/- 5 mm Hg to 11 +/- 4 mm Hg, (p = 0.002). CO and MAP were similarly increased by both assist systems. The IABP (by lowering afterload) and CFP (by lowering preload) both offered significant mechanical support in acute HF. However, afterload reduction offered principally by the IABP seems preferable for the recovery of the acutely failing heart.

Efficacy and Mechanisms of Biventricular and Left/Right Direct Cardiac Compression in Acute Heart Failure Sheep

Direct cardiac compression (DCC) with implanted heart patches has previously demonstrated efficacy of biventricular (BiV) support in acute heart failure (HF) sheep. We hypothesized that this was primarily due to a left ventricular (LV) effect. This study compared BiV, LV, and right ventricular (RV) assists in terms of hemodynamic and energetic response. Ten sheep underwent instrumentation and device implantation at least 1 week prior to study. HF (50% reduction in cardiac output) was maintained with intravenous esmolol infusion. BiV, LV, and RV assists were activated randomly with intervening stable HF periods. BiV assist was more effective than either LV or RV assist in restoring hemodynamic parameters; however, there was no difference in efficacy of LV and RV support. RV assist preserved left coronary flow patterns and chamber geometry compared to other assist conditions, but increased LV preload. These results suggest that LV and RV support each make a significant contribution to the efficacy of BiV assist, albeit through different mechanisms.

Circulatory support for OPCAB procedures.

During off-pump coronary artery bypass grafting (OPCAB) which allows complete revascularization through a median sternotomy, revascularization of the lateral and posterior walls requires the verticalization of the heart, which may cause haemodynamic disturbance. This concern has stimulated the development of circulatory support with mini-pumps. Initially, these pumps were designed for the right side of the heart, which was found to be the main contributor to haemodynamic instability under experimental conditions. The three types of mini-pumps that have been developed so far - two for the right side of the heart and one for both sides - are reviewed as well as a new concept of integrated cardiopulmonary bypass (CPB) circuit with reduced surface and priming volume. However, with increasing experience and improved methods of exposition, OPCAB has become a procedure that can be performed without support in the majority of the cases. Nevertheless, the concept of miniaturization and the possibility to insert these devices through a peripheral access has opened the way to new indications, mainly short-term circulatory support for acute heart failure. This development is welcome in a field where available devices are invasive and plagued with a heavy morbidity.

Mechanical circulatory support for acute heart failure

Circulatory support devices are frequently required in postcardiotomy shock, postmyocardial infarction shock, and acute myocarditis. A panel of cardiac surgeons addressed the use of these devices in 4 patients. Cardiogenic shock after mitral valve replacement was considered best served by a left ventricular assist device (VAD) with apical rather than atrial cannulation. A left VAD should be placed first and a right VAD only if needed. Acute myocardial infarction shock was considered best treated with a left VAD with left ventricular cannulation to avoid thrombosis. If cardiac transplantation is an option, a long-term device must be considered. Young patients with acute fulminant myocarditis should be implanted with VADs in anticipation of recovery, and transplantation should be delayed. Patients with severe heart failure after coronary bypass grafting were considered best served by an extracorporal membrane oxygenation (ECMO) system or a VAD. Current postcardiotomy survival rates of postcardiotomy patients of 20% to 40% are worthwhile, but can be improved. Temporary devices such as ECMO can be changed to more long-term devices when necessary.