Exam 4 - Heart Failure Flashcards
1
Q
Heart Failure is defined as a complex syndrome that results from:
A
any structural or functional impairment of ventricular filling or blood ejection
s2
2
Q
Five signs of tissue-hypoperfusion that result from HF:
A
fatigue, dyspnea, weakness, edema, and weight gain
s2
3
Q
HF may be caused by structural abnormalities of what 5 cardiac structures?
A
pericardium, myocardium, endocardium, heart valves, or great vessels
s2
4
Q
what EF % classifies HF with reduced EF (aka systolic HF)?
A
EF ≤ 40%
s2
5
Q
what EF % classifies HF with preserved EF (aka diastolic HF)?
A
EF ≥50%
s2
6
Q
A pt with clinical symptoms with an EF between ___ - ___% is labeled as having borderline HF w/ preserved EF
A
40-50%
s2
7
Q
True or false: Diastolic dysfunction is present in both HFrEF and HFpEF.
A
True!
s2
8
Q
Patters of what 2 things are the major distinguishing features between HFrEF and HFpEF?
A
LV dilation and remodeling
s2
9
Q
What serves as the main marker for establishment of HF risk factors, treatment, and outcome?
A
Ejection Fraction!
s2
10
Q
Which of the 2 HFs are women more likely to be affected by?
A
HF w preserved EF
s3
11
Q
Which of the 2 HFs are men more likely to be affected by?
A
HF with reduced EF
s3
12
Q
Which HF is more likely to have modifiable risk factors and a higher prevalence of MI, previous coronary intervention, CABG, and PVD?
A
HF w reduced EF
s3
13
Q
what is the primary determinant of HFpEF?
A
left ventricular diastolic dysfunction
s4
14
Q
what 5 things determine LV’s ability to fill?
A
pulmonary venous blood flow
LA function
mitral valve dynamics
pericardial restraint
active and passive elastic properties of LV
s4
15
Q
What 3 things are majority of measurements of LV Diastolic dysfxn dependent on?
A
HR, loading conditions, and myocardial contractility
s4
16
Q
Higher ________ are required to achieve normal end-diastole volume in pts with HFpEF.
A
LV filling pressures
s4
17
Q
What is the steeper rise of the end-diastolic pressure-volume curve indicative of?
what does it result in regarding LV compliance?
A
delayed LV relaxation and an increase in myocardial stiffness
resulting in reduced LV compliance that restricts filling
s5
18
Q
The reduced LV compliance that eventually restricts filling can precipitate what (regarding the left atrium and pulm system)?
A
LA hypertension, LA systolic & diastolic dysfunction,
pulmonary venous congestion, and exercise intolerance
s5
19
Q
What does the left picture indicate about contractility?
what does the right picture indicate regarding LV compliance?
A
Left: a decrease in myocardial contractility as indicated by a decrease in the slope of the end-systolic pressure-volume relation
Right: a decrease in LV compliance as indicated by an increase in the position of the end-diastolic pressure-volume relation
These diagrams emphasize that heart failure may result from LV systolic or diastolic dysfunction independently
s5
20
Q
List some common causes of Left Ventricular Diastolic Dysfxn
A
21
Q
LV End- diastolic dysfunction or delay in relaxation which is considered a form of “active stiffening” is complicated by
A
Failure of the actin-myosin disassociation, which occurs due to inadequate perfusion or dysfunctional intracellular Ca++ homeostasis
S9
22
Q
The NYHA system focuses primarily on ____ to classify HF?
A
the degree of physical limitation
S18
23
Q
The ACC/AHA focus on ____ to classify HF?
A
on the presence & severity of HF
S18
24
Q
What should be noted with classification of HF?
A
- note that these stages are progressive
- oftenclassified using a combination of both scoring systems
S18
25
Which NYHA Classification has no limitation and no symptoms from ordinary activity?
NYHA Class I
## Footnote
S18
26
What NYHA Classification has mild limitation with activity and comfortable at rest or with mild exertion?
NYHA Class II
## Footnote
S18
27
Which NYHA Classification has significant limitation with any activity and comfortable only at rest?
NYHA Class III
## Footnote
S18
28
Which NYHA Classification has discomfort with any physical activity and symptoms occuring at rest?
NYHA Class IV
## Footnote
S18
29
Which ACC/AHA classification has high risk of developing heart failure but no functional or structural heart deficits?
ACC/AHA Class A
## Footnote
S18
30
Which ACC/AHA classification has structural heart deficit but no symptoms?
ACC/AHA Class B
## Footnote
S18
31
Which ACC/AHA classification has heart failure symptoms due to underlying structural heart deficit with medical management?
ACC/AHA Class C
## Footnote
S18
32
Which ACC/AHA classification has advanced disease requiring hospitalization, transplant, or palliative care?
ACC/AHA Class D
## Footnote
S18
33
Which condition has improved survival rate in the past three decades: HFrEF or HFpEF?
HFrEF
## Footnote
S19
34
Which condition benefits with using medications: HFrEF or HFpEF?
HFrEF
## Footnote
S19
35
What are the treatments for HFpEF?
* Mitigation of sx’s
* treat associated conditions
* exercise
* weight loss
## Footnote
S19
36
What are the treatments for HFrEF?
* Beta Blockers
* ACE-Inhibitors
## Footnote
S19
37
What class of medication stimulate β-receptors on the myocardium to activate adenylyl cyclase to increase cAMP?
Catecholamines
## Footnote
Slide 31
38
How does a implantable hemodynamic monitoring improve chronic HF?
it allows remote observation of intracardiac pressures to guide tx and prevent decompensation
## Footnote
Slide 24
39
What are the medical treatments for Chronic HF?
* Diuretics
* B-blockers
* ACE-inhibitors & ARBs
* Lifestyle change
## Footnote
S21-22
40
What are 2 important biomarkers in the diagnosis of HF?
BNP and N-terminal pro-BNP
## Footnote
17
41
How does Loop Diuretics help CHF?
* reduce LV filling pressures
* decrease pulmonary venous congestion
* improve HF sx
## Footnote
S21
42
Which type of pts. are Thiazide diuretics useful and why?
pts with poorly controlled HTN
to prevent the onset of HFpEF
## Footnote
S21
43
How does a Implantable cardioverting-defibrillators (ICDs) helps patients with chronic Heat failure?
Its used to prevent sudden death in pts with advanced heart failure?
## Footnote
Slide 24
44
Which type of CHF are Beta-Blockers strongly recommended for?
**HFrEF**
(HF with reduced EF)
prescribed for other indications (HTN, MI, HR control w/Afib)
## Footnote
S21
45
̴ ____% HF deaths are d/t sudden cardiac dysrhythmias
50%
## Footnote
Slide 24
46
What is the mainstay treatment for HFrEF?
ACE-inhibitors and ARBs
(studies do not show benefit in HFpEF unless used for treatment of HTN)
## Footnote
S22
47
What is the name of the device used by patients in the terminal stages of HF that may benefit from mechanical circulatory support (MCS) by a ventricular assist device (VAD)?
LV assist device
## Footnote
silde 25
48
What are the lifestyle changes that pt. can do to treat CHF?
* Aerobic fitness
* Weight loss
* Salt-restricted, Dietary Approaches to Stop Hypertension (DASH) diet
* Control of HTN and blood glucose
## Footnote
S22
49
HF preserved EF is associated w/ lower BNP and NT-proBNP levels *[than HF reduced EF]* due to what characteristics?
concentric hypertrophy, normal LV chamber size and lower LV end diastolic wall stress
## Footnote
17
50
Causes of LV relaxation
Due to afterload, which is elevated in hypertensive pts. Tachycardia exacerbates the failure of LV relaxation.
## Footnote
S9
51
What is the goal of surgical treatment for CHF?
to prevent ventricular remodeling and retain the natural geometry of the heart
## Footnote
S23
52
What are the benefits of coronary revascularization via CABG or PCI?
* can reverse LV dysfunction following MI
* may prevent permanent EF reductions
* reduce 10-year mortality by 7% (CABG)
## Footnote
S23
53
What is commonly seen w/ HFpEF despite having only a modestly depressed LV systolic fx?
Profound exercise intolerance
## Footnote
S9
54
What is another name for Cardiac resynchronization therapy (CRT) and what is the treatment for?
“biventricular pacing”
tx for HF w/ ventricular conduction delay (prolonged QRS)
## Footnote
S23
55
# Cardiac resynchronization therapy (CRT)
Placement of a ____ cardiac pacemaker (w/RA & RV leads), an additional lead is introduced through the coronary sinus and advanced until it reaches the lateral wall of the ____.
This stimulates the heart to contract more ____ and efficiently and improve COP
dual chamber
LV
synchronously
## Footnote
S23
56
Prolonged compression of coronary arteries restricts diastolic coronary blood flow, which contributes to ____ ____ and a further reduction in exercise tolerance.
subendocardial ischemia
## Footnote
S9
57
What NYHA class is CRT recommended?
NYHA class III or IV w/ EF < 5% and a QRS duration 120-150 ms
## Footnote
S23
58
59
What are the outcomes of CRT?
* fewer HF sx
* better exercise tolerance
* improved ventricular function
* less hospitalizations
* decreased mortality
## Footnote
S23
60
What are the most common symptoms of HF?
Fatigue, tachypnea, dyspnea, paroxysmal nocturnal dyspnea, orthopnea, S3 gallop, JVD, peripheral edema, exercise intolerance, and reduced tissue perfusion.
## Footnote
S10
61
What are the risks of CRT?
* infection
* misplacement
* device failure
## Footnote
S23
62
What are the most common symptoms of HFpEF?
paroxysmal nocturnal dyspnea, pulmonary edema, dependent edema
## Footnote
s10
63
What is the most common sign of HFrEF?
S3 gallop
## Footnote
S10
64
CRP and GDF15 (growth differentation factor 15 represent what component of HF?
inflammatory component of HF
## Footnote
17
65
When EF is reduced, the presence of HF symptoms establishes the diagnosis of?
HFrEF (following standard guidelines)
## Footnote
S10
66
LVAD is used for
* temporary ventricular assistance while heart is recovering its function
* Pts awaiting cardiac transplant
* Pts are on inotropes or balloon pump (IABP) with potentially reversible medical conditions
* Pts with advanced HF who aren’t transplant candidates
## Footnote
Slide 25
67
Which type of HR is harder to diagnose?
**HFpEF** is often more difficult to diagnose, especially when the pt has little/no symptoms at rest
## Footnote
S11
68
What is disease process is classified as a long-standing HF disease?
Chronic heart failure
## Footnote
Slide 27
69
What does cardiac catheterization define?
Elevated LV systolic and diastolic stiffness using pressure-volume analysis or provocative testing (s/a exercise & rapid IV volume expansion)
## Footnote
S11
70
What other diagnostic measure can offer further information about severity of HFpEF?
Direct measurement of RV filling.
## Footnote
S11
71
True or false: Acute heart failure: Slow onset, often presenting w/life-threatening conditions
False: Acute heart failure: rapid onset, often presenting w/life-threatening conditions
*Pts may require hospitalization, tx is aimed at decreasing volume & stabilizing hemodynamics*
## Footnote
Slide 27
72
What diagnostic finding provides strong evidence of HFpEF and is a predictor of mortality?
Mean pulmonary capillary wedge pressure >15mmHg at rest or 25mmHg during exercise
## Footnote
S11
73
The term Acute heart failure applies to what patient population?
* present with worsening preexisting HF
* present for the first time with HF
## Footnote
Slide 27
74
What would you expect to see on CXR of someone w/ HF?
pulmonary dz, cardiomegaly, pulmonary venous congestion, and interstitial or alveolar pulmonary edema.
## Footnote
S13
75
What is an early radiographic sign of LV failure and pulmonary venous HTN?
distention of the pulmonary veins in the upper lobes of the lungs
## Footnote
S13
76
What are the sx of ADHF?
* **fluid retention
* weight gain
* dyspnea**
*as the result of decompensation due to inadequate compensation*
## Footnote
Slide 27
77
You read in the chart that the pt has perivascular edema, so you look at pt's CXR and you see...
hilar or perihilar haze with ill-defined margins
## Footnote
S13
78
What are the characteristics of De novo AHF?
* increase in intracardiac filling
* pressures or acute myocardial dysfunction
* decreased peripheral perfusion
* pulmonary edema
## Footnote
Slide 28
79
Pt presents with interlobular edema. What would you expect to see on CXR?
Kerley lines, which produce a honeycomb pattern
## Footnote
S13
80
What is the leading caused of de novo HF?
* Cardiac ischemia cause by a coronary occlusion
81
How can a SRNA stabilize a patient with cardiac ischemia caused by a coronary occlusion ?
* stabilizing hemodynamics
* restoring myocardial perfusion
* improving myocardial contractility
## Footnote
Slide 28
82
Pt presents with alveolar edema, what would you expect to see on CXR?
homogeneous densities in the lung fields, typically in a butterfly pattern
## Footnote
S13
83
Radiographic evidence of pulmonary edema may lag behind the clinical evidence of pulmonary edema by up to ____hours
12 hours
## Footnote
S13
84
Myocardial hypertrophy, dynamic LV outflow obstruction, mitral regurg, diastolic dysfunction, myocardial ischemia and dysrhythmias are all related to what condition?
hypertrophic cardiomyopathy
## Footnote
45
85
Nonischemic cause of de novo HF include
* drug-induced (toxic)
* peripartum cardiomyopathies
## Footnote
Slide 28
86
Hypertrophied myocardium has a ____ relaxation time and ___ compliance
prolonged relaxation and decreased compliance!
## Footnote
45
87
Which criteria is more specific in diagnosis of HFpEF and incorporates several echocardiographic indexes based on 2-dimensional measurements?
European Sociaty of Cardiology (ESC)
## Footnote
S15
88
De novo HF may lead to _____ _________ dysfunction.
long-term cardiac dysfunction
*management of the underlying cause may allow for complete restoration *
## Footnote
Slide 28
88
Nesiritide works by inhibiting the ________ and promoting arterial, venous, and coronary vaso-____________, decreasing LVEDP and improving ___________.
Nesiritide works by inhibiting the **RAAS **and promoting arterial, venous, and coronary **vasodilation**, decreasing LVEDP and improving **dyspnea**
## Footnote
33 - AHF
89
ESC guidelines rely entirely on ____ echocardiogram; and are limited because they do not incorporate ____testing.
resting
provocative
## Footnote
S15
89
Nesiritide induces diuresis and ____________, relaxes cardiac muscle, and lacks any ____________ effects
Nesiritide induces diuresis and **natriuresis**, relaxes cardiac muscle, and lacks any **dysrhythmic** effects
*Natriuresis is when the body excretes more sodium and causes a diuretic response*
## Footnote
33 - AHF
90
European Society of Cardiology criterias
## Footnote
S15
90
What class of medication is proven to correct elevated filling pressures and reduce afterload.
Vasodilators
## Footnote
Slide 30
90
T/F
Nesiritide has shown advantage over traditional vasodilators such as NTG & SNP
False
Nesiritide has **not** shown advantage over traditional vasodilators such as NTG & SNP
## Footnote
33 - AHF
91
The hemodynamic profile that is included in acute HF?
* low cardiac output
* high ventricular filling pressures
* HTN or HoTN
## Footnote
Slide 29
91
# hypertrophic cardiomyopathy
Surgery is reserved for pt w/ large outflow tract gradients & severe symtoms despite medical tx. What are 3 surgical strategies?
What treatment if *still* symptomatic?
-septal myomectomy
-cardiac cath w/ injection to induce ischemia to septal perforator arteries
-echo guided percutaneous septal ablation
*If still symptomatic, MVR can be done to counteract systolic anterior motion of mitral leaflet*
## Footnote
48
92
What underlying pathologies are common in HF pts with EKG abnormalities?
LVH, previous MI, arrhythmias and conduction abnormalities
## Footnote
S16
92
Which medication is effective in rapidly decreasing afterload?
Which medicatioin is used as an adjunct to diurectic therapy?
* SNP
* NTG
## Footnote
Slide 30
93
# T or F?
Myocardial ischemia is present in Hypertrophic cardiomyoapthy whether or not they have CAD
True
## Footnote
45
93
# hypertrophic cardiomyopathy
What is the primary tx for pt at risk for death r/t dysrhytmias?
ICD placement!
## Footnote
48
94
Dysthytmias are the most sudden cause of death in young pts w/ hypertrophic cardiomyopathy. What causes dysrthymias?
disorganized cellular architecture, scarring, and an expanded interstitial matrix
## Footnote
45
95
What are the 6 most common inotropic drugs used in AHF? (chart)
## Footnote
32 - AHF
95
What characterizes dilated cardiomyoapthy
what is the initial symptom?
LV [or biventricular] dilation, biatrial dilation, decreased ventricular wall thickness, and systolic dysfunction
initial symptom--> HF (CP may occur as well)
## Footnote
46
96
What is the first line of treatment for AHF should be given immediately in pts with fluid overload to mitigate?
Diuretics
## Footnote
Slide 29
96
What is class of medication emerged as potential adjunct therapy, to reduce the arterial constriction, hyponatremia, and the volume overload associated with AHF?
Vasopressin receptor antagonists
## Footnote
Slide 30
97
In asymptomatic patients, what is the only sign of Hypertrophic cardiomyopathy?
unexplained left ventricular hypertrophy
## Footnote
46
98
What Exogenous recombinant BNP binds to A and B-type natriuretic receptors?
Exogenous BNP: **Nesiritide**, a recombinant BNP that binds to A- and B-type natriuretic receptors
## Footnote
33 - AHF
99
What are some diagnostic abnormalities in patients w/ hypertrophic cardiomyopathy?
hint: ekg and echo
EKG abnormalities (75-90% pt) show high QRS voltage, ST segment and T wave abnormalities, abnormal Q, and atrial enlargment
Echo: myocardial wall thickness >15mm; and EF >80%
*terminal states: EF severely depressed*
## Footnote
46
99
What is an example of Vasopressin receptor antagonists?
Tolvapatan
## Footnote
Slide 30
100
True of false: An AHF patient with hypotension or cardiogenic shock may first require hemodynamic support prior to diuretic therapy.
True
## Footnote
29
100
# dilated cardiomyoapthy
Ventricular dilation may lead to what 2 valve abnormalities?
mitral and tricuspic regurgitation
## Footnote
49
101
Which diagnostic testing has low predictive value for diagnosis or risk- prediction of heart failure?
EKG alone
## Footnote
S16
102
What are the diruetic given as a bolus followup by a continous infusion
Furosemide
Bumetanide
Torsemide
*given as bolus or continuous infusions*
## Footnote
Slide 29
102
103
# hypertrophic cardiomyopathy
Cardiac catherization allows direct measurement of ______ ____?
left ventricular end diastolic pressure
## Footnote
46
103
Common complications in dilated cardiomyopathy? (4)
dysrhythmias, conduction abnormalities, emboli and sudden death
## Footnote
49
104
Medical treatment for hypertrophic cardiomyopathy (4)
-BB, CCB
-if develop HF--> diuretics
-disopyramide (add on if still symptomatic)
-amiodarone if develops dysrhythmias! (most effective)
| disopyramide has negative inotropic effect- improves LV outflow obsructi
## Footnote
47
104
When medical management fails and organ dysfunction occurs, urgent _________ ___________ __________ (MCS) is indicated.
When medical management fails and organ dysfunction occurs, urgent **mechanical circulatory support** (MCS) is indicated
## Footnote
34 - AHF
105
Reducing in_________ _________ leads to decreased________ ________ and ________ _______ _________ __________ (______), reducing pulmonary congestion.
intravascular volume
central venous
pulmonary capillary wedge pressures (PCWP)
## Footnote
Slide 29
105
Common echo and EKF findings in dilated cardiomyopathy are?
- echo: dilation of all 4 chambers, especially the LV. Global hypokinesis
- EKG: ST and T wave abnormalities w/ LBBB
- comon dyrhythmias: PVC and AFIB
## Footnote
50
106
What complication that develops in hypertrophic cardiomyopathy is associated w/ increased risk of thromboembolism, HF and death?
What is the treatment
a-fib--> amiodarone!
Need long term anticoagulation if chronic
## Footnote
47
106
The Society of Thoracic Surgeons (STS) developed a MCS decision-making tool based on pt clinical profiles. What is that tool or Profile System called?
Inter-agency Registry of Mechanically Assisted Circulatory Support
INTERMACS Profile System
## Footnote
34 - AHF
107
Treatment for dilated cardiomyopathy
Tx is similiar to chronic HF. AC initiated as well.
Prophylactic ICD--> decreases sudden death by 50%
Ultimately--> cardiac transplant :( (DCM is the main indication for transplant)
## Footnote
50
108
What are some examples of catecholamines being use for Acute HF treatment?
epinephrine
norepinephrine
dopamine
dobutamine
## Footnote
Slide 31
109
What is a class of medication indirectly increase cAMP by inhibiting its degradation to help treat acute HF?
What is an example of this medication ?
PDE-inhibitors
milrinone
## Footnote
Slide 31
110
Stress cardiomyopathy aka apical ballooning syndrome is a temporary primary cardiomyopathy characterized by what abnormalities?
LV apical hypokinesis and ischemic EKG changes (coronary arteries are still patent)
-Temporary dysruption of contractility in LV apex (and rest of heart has normal contractility)
## Footnote
51
111
___________ _______________ Pump: functions by cyclic ____________balloon inflation after ________ valve closure, followed by deflation during __________
**Intraaortic Balloon** Pump (IABP): functions by cyclic helium balloon inflation after **aortic** valve closure, followed by deflation during **systole**
## Footnote
35 - AHF
113
Common symptoms in stress cardiomyopathy? What is the most common cause?
chest pain, dyspnea.
Stress is most common cause
women > men
## Footnote
51
114
115
IABP improves LV coronary perfusion by ____________ LVEDP
____________and x-ray are the primary modes for placement evaluation
IABP improve LV coronary perfusion by **reducing **LVEDP
TEE and x-ray are the primary modes for placement evaluation
## Footnote
35 - AHF
116
IABP degree of support varies because of the set ____________, the ________ of the balloon, and the ____________ of supported beats
IABP degree of support varies b/o the set **volume**, the **size** of the balloon, and the **ratio** of supported beats
## Footnote
35 - AHF
117
Full IABP support would be 1:1 (one inflation for every heartbeat)
In tachycardic pts, a setting of __:__
(________ inflation per every________ heartbeats) is ideal
Full support would be 1:1 (one inflation for every heartbeat)
In tachycardic pts, a setting of **1:2** (**one** inflation per every **two** heartbeats) is ideal
## Footnote
35 - AHF
118
IABP provides only ____________ improvements in cardiac output
(_____-_____ L/min) and render pts immobile, limiting its long-term use
Overall, IABP provides only **modest** improvements in cardiac output (**0.5–1 L/min**) and render pts immobile, limiting its long-term use
## Footnote
35 - AHF
119
What is a Ventricular Assist Device (VAD) that can be placed percutaneously to reduce LV strain and myocardial work in the setting of acute heart failure?
Impella
## Footnote
36 - AHF
120
How long can an Impella be left in a patient for?
Can be utilized for up to 14 days
## Footnote
36 - AHF
121
An Impella serves a transition to ____________ or a bridge to ____________ procedures.
What are the four procedures mentioned on this slide?
Serves as a transition to**recovery**
Bridge to **cardiac** procedures **(CABG, PCI, VAD, transplant)**
## Footnote
36 - AHF
122
The Impella consists of a miniature ____________ blood pump inserted through the ____________ artery, advanced through the aortic valve and is situated in the ______
The Impella consists of a miniature **rotary** blood pump inserted through the **femoral **artery, advanced through the aortic valve and is situated in the **LV **
## Footnote
36 - AHF
123
The Impella pump draws blood continuously from the LV through the ________port and ejects it into the ascending aorta through its ____________ port
The Impella pump draws blood continuously from the LV through the **distal** port and ejects it into the ascending aorta through its **proximal** port
## Footnote
36- AHF
124
____________ VAD: support devices that can provide extracorporeal membrane oxygenation (ECMO)
Consists of a small pump & controller, which is helpful for transport, but generates ________, causing more ________ and lower flows.
**Peripheral** VAD: support devices that can provide extracorporeal membrane oxygenation (ECMO)
Consists of a small pump & controller, which is helpful for transport, but generates **heat**, causing more **hemolysis** and lower flows
## Footnote
38 - AHF
125
Peripheral VAD: If these devices have an ____________, they are considered ECMO, and used to support the right or left side of the heart
If these devices have an **oxygenator**, they are considered ECMO, as opposed to having no oxygenator, but used to support the right or left side of the heart
## Footnote
38 - AHF
126
What VAD/ECMO device is necessary for cardiorespiratory support or as an alternative to Peripheral VAD/ECMO?
Why would we use this device over Peripheral VAD/ECMO?
**Central ECMO** may be necessary for cardiorespiratory support or as an alternative to peripheral ECMO
We would use Central ECMO *if adequate flow rates are not achievable* with Peripheral VAD.
## Footnote
36 - AHF
127
Where are Central VAD/ECMO devices placed (2 spots)?
How are these spots surgically accessed?
Central cannulas are placed in the **right atrium and aorta**
Accessed:
Invasive and require **sternotomy** or **thoracotomy** for placement
## Footnote
36 - AHF
128
What are the three benefits of Central VAD/ECMO?
Benefits:
1. complete ventricular decompression
2. avoidance of limb impairment
3. avoidance of SVC syndrome
## Footnote
36 - AHF
129
T/F
Pts on ECMO likely have increased lung perfusion as blood bypasses the lungs before returning to the aorta
FALSE
Pts on ECMO likely have **reduced** lung perfusion as blood bypasses the lungs before returning to the aorta
## Footnote
39 - AHF
130
Due to ECMO ____________anesthetics may be significantly limited by functional shunting around the lungs
For this reason what other anesthetic techniques are considered?
**Inhaled anesthetics **may be significantly limited by functional shunting around the lungs
*higher amount of inhaled anesthetics may be required*
**TIVA** should be considered for pts on ECMO
## Footnote
39 - AHF
131
The CRNA should recognize that the ECMO membrane is ____________, causing many agents, including fentanyl, to become ____________within the circuit.
CRNA must recognize that the ECMO membrane is **lipophilic**, causing many agents, including fentanyl, to become **sequestered** within the circuit
## Footnote
39 - AHF
132
* Peripheral VAD = __________ membrane oxygenation (ECMO)
* Consists of a small pump & controller = helpful for _______,
* but generates ____ >> ______ and lower flows
* If oxygenator = ECMO,
* no oxygenator = used to ______ R or L heart
## Footnote
AHF Surgical Treatment
* extracorpeal
* transport
* heat ... hemolysis
* support
133
# Cetnral VAD/ECMO
* cannulas placed in ___ atrium + aorta
* invasive _____ / ______ to place
* benefits = complete _____ decompresion ,, avoid ____ impairment ,, avoid ____ syndrome
## Footnote
AHF Surgical Treatment
* Right
* sternotomy / thoracotomy
* ventriuclar ,, limb ,, SVC
134
# ECMO
* Pts on ECMO have reduced ____ perfusion bc blood bypasses before returning to aorta
* Inhaled Anes = ____ bc of shunting
* _____ should be considered for ECMO pts
* ECMO membrane = ____ + may cause agents like ____ to become sequestered within circuit
## Footnote
AHF Surgical Tx
* lung
* limited
* TIVA
* lipophilic ,, fentanyl
135
# Biventricular Assist Device
* Used to _____ support of ventricles with 2 independent circuits
* This allows for ______ of either L or R sided support
* separate circuits achieved by _____ placement
* R + L sides can be centrally ______ individually
## Footnote
AHF Surgical Tx
* decouple
* weaning
* percutaneous
* cannulated
136
* HF pts have increased risk of :: ___ failure, ______, pna, + require longer periods of ______ _________
* Comprehensive preop exam to determine if ______ or require treatment
* 3 reasons to POSTPONE surgery ??
## Footnote
AHF Preoperative Mgmt
* Renal failure ,, sepsis ,, mechanical ventilation
* compensated
* decompensation ,, change in status ,, De Novo AHF
137
* ____ held on day of surgery
* continue ____ bc it's managment is essential
* ______ put pt at risk for intraop Hotn
* perform a _______ if worsening dyspnea
* 4 labs necessary ??
* ____ lab is not routine
* ICDs and Pacemakers should be ______ prior to surgery
## Footnote
AHF Preoperative Mgmt
* Diuretics
* Beta blockers
* ACE-I
* TTE -- echo
* CBC , lytes , LFTs , coagulation
* BNP
* interrogated
138
* Group of myocardial disease with ___________ or _____ dysfx
* These exhibit as ventricular __________ or ________
* Cardiomyopathy is either confined to __________ (**primary**) or part of _____ disorders (**secondary**)
## Footnote
Cardiomyopathies
* mechanical or electrical
* hypertrophy or dilation
* heart or systemic
139
* affects all ___
* most common ______ CV disease
* characterized by _____ + absence of other diseases that could cause it
* presents with hypertrophy of the ___________________ and ________________
* Histologic features are hypertrophied ____ cells and ________ myocardial scarring
## Footnote
Hypertrophic Cardiomyopathy
* ages
* genetic
* L Ventricle Hypertrophy
* intraventricular septum and antero-lateral free wall
* myocardial ,, patchy
