Advanced HF Flashcards
Advanced HF definition
Progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy
NYHA class 3/4
Increasing inability to meet the metabolic demands of end organs/muscle
Symptoms/signs of advanced HF
Severe symptoms of HF with dyspnea/fatigue at rest or with minimal exertion
Recurrent fluid retention (edema, pulmonary congestion)
Weight loss without other cause (cardiac cachexia)
Hypotension
Frequent ICD shocks
Worsening renal function
Hyponatremia
High BNP
Cardiogenic shock
Marked and persistent hypotension (SBP < 80 for > 30 mins)
Marked reduction in CO clearance
Elevated pulmonary capillary wedge pressure (>18)
Elevated systemic vascular resistance
LMNOP treatment for acute HF
L: Lasix (IV diuretics) M: monitoring N: nitrates O: oxygen P: positive pressure/positioning
Role of Inotropes
Increase CO
Some vasodilatory properties
Side effects of inotropes
Hypotension
Arrhythmias
Have not been shown to improve long-term mortality
3 MOAs of different inotropes
Beta receptor agonist (dobutamine)
DA receptor agonist (dopamine)
Increase intracellular Ca (milrinone)
Intra-aortic balloon pump
Long helium filled balloon inserted via femoral artery
Connected to an external console
Inflates early in diastole (creates positive pressure to improve coronary perfusion)
Deflates at end diastole/systole (creates negative pressure to reduce afterload and improve systolic function)
Not used very much anymore
VAD
Ventricular assist device
Supplements the native CO
Heart is the back up pump
Continuous flow pumps (no pulse)
3 indications for VAD
Bridge to transplant
Bridge to eligibility for transplant
Bridge to recovery
Complications of mechanical support
Thromboembolism Bleeding Infection RV failure Hemolysis Renal failure
Indications for heart transplant
Stage D HF Refractory cardiogenic shock Peak VO2 <10 ml/kg/min NYHA 3/4 Refractory arrhythmias Refractory angina Complex congenital heart disease
Heart transplant donor criteria
Age < 55 No hx of chest trauma or cardiac disease No prolonged hypotension or hypoxemia Appropriate hemodynamics (MAP > 60, CVP 8-12) Inotropic support < 10 Normal ECG, echo and angiography Negative serology
Complications of heart transplant
Rejection Infection HTN Renal disease Hyperlipidemia DM Cardiac allograft vasculopathy Malignancy
Contraindications of heart transplant
Age > 65-70 Active/recent malignancy DM with end organ damage Severe lung disease BMI < 20 or > 35-40 Irreversible pHTN PVD Addictions, psychosocial, psychiatric SUD
