By Dr. Ahmad Y. AlansiAlthawra Modern General HospitalCardiac surgery departmentAnesthesia & ICU unite
Definitions Which heart failure patient should beadmitted in ICU? Monitoring Classification and plan Medical treatment Mechanical support The future Summary
Definition of Advanced HFA subset of patients with chronic HF willcontinue to progress and develop persistentlysevere symptoms despite maximum therapy.Various terminologies have been used todescribe this group of patients who areclassified with ACCF/AHA stage DHF, including “advanced HF,” “end-stageHF,” and “refractory HF.
So the following patients should be admitted toICU : All pateints with NYHA class III-IV. Suspected or diagnoseed ACS . Potential life threatening arrhythmia (VF, VT, highgrade a- v block, persistent symptomatic tachy orbrady). Requiring or at risk of requiring invasive ventilatorysupport . Cardiogenic shock or otherwise requiring chemicalor mechanical circulatory support (dopmamine, dobutamine,….IABP,LVAD….etc) Multisystem Failure .
monitoringinvasiveNoni.e. temperature, respiratory rate,arterial pressure, continuousECG, pulse oximetry, daily I/Ochart and body weight arerequired in all patients
Invasive monitoring:1- Arterial pressure monitoring :continues BP monitoringrepetitive blood gas analysis.2- Central venous catheter :Monitoring right-sided filling pressureDelivering vasoactive medicationRapid volume replacement
3- Pulmonary artery catheterization(PAC)Indicated in patients with left ventriculardysfunction. In patients requiring inotropic orvasoconstrictor drugs.For monitoringCardiac outputEstimation of systemic vascular resistanceMixed venous oxygen saturationLost popularity because of Invasiveness and no different inmortality rate
4- Transoesophageal EchocardiographyRecently gained popularity as a haemodynamicmonitoring tool for ventilated intensive care patients.It provides valuable information about morphologyand haemodynamic state,but interpretation of data requires considerabletraining and experience.So Transthoracic EchoIs more performed and remain the main tool .
Low Output Failure in which there is decreasedcontractility of heart leading to decreasedcardiac output High Output Failure in which demands of bodyare high, which are not met even with increasedcardiac output like in case of severe Anemia ,Thyrotoxicosis and Thiamine deficiency
Which side of heart is affected– Left (more common)– Right (right-sided MI, pulmonary HTN) Which heart function is affected– Systolic (↓ contraction and EF, dilated LV)– Diastolic (↓ relaxation,) Failure of LV filling Contractile function and EF usually normal
The management of heart failure described hereis meant for patients with advanced ordecompensated heart failure. The approachhere is specifically designed for ICU patients: itis based on invasive hemodynamicmeasurements rather than symptoms and usesonly drugs that are given by continuousintravenous infusion
Left-Sided (Systolic) Heart Failure :1- High Blood Pressure2- Normal Blood Pressure3- Low Blood Pressure
Left-Sided (Systolic) Heart Failure :1- High Blood Pressure (e.g. early periodafter cardiopulmonary bypass surgery )Profile: High PCWP/Low CO/High BPTreatment: Vasodilator therapy withnitroprusside or nitroglycerin. If the PCWP remainsabove 20 mm Hg, add diuretic therapy withfurosemide.
Left-Sided (Systolic) Heart Failure :2- Normal Blood Pressure: e.g. ischemicheart disease, acute myocarditis, and the advancedstages of chronic cardiomyopathy.Profile: High PCWP/Low CO/Normal BPTreatment: Inodilator therapy with dobutamine ormilrinone, or vasodilator therapy with nitroglycerin. Ifthe PCWP does not decrease to <20 mm Hg, add diuretictherapy with furosemide.
Left-Sided (Systolic) Heart Failure :3- Low Blood Pressure is the sine quanon of cardiogenic shock. e.g. associatedwith cardiopulmonary bypass surgery, acute myocardialinfarction, viral myocarditis, and pulmonary embolus.Profile: High PCWP/Low CO/Low BPTreatment: Dopamine in vasoconstrictor doses orcombination with Dubtamin.Mechanical assist devices can be used as a temporarymeasure in selected cases.
Diastolic Heart Failure :Incidence of purely diastolic HF in nature is notknown.no general agreement about the optimal treatment buttwo recommendations seems to be valid :1- positive inotropic agents have no role in thetreatment of diastolic heart failure.2- diuretic therapy can be counterproductive,vasodilator agents, such as nitroglycerin and milrinone,Calcium channel blockers like verapamil are effective.
Right Heart FailureThe strategies below pertain only to primary rightheart failure (e.g., following acute myocardialinfarction) and not to right heart failure secondaryto chronic obstructive lung disease:1- If PCWP is below 15 mm Hg, infuse volume until the PCWPor CVP increases by 5 mm Hg or either one reaches 20 mm Hg .2- If the RVEDV is less than 140 mL/m2, infuse volume untilthe RVEDV reaches 140 mL/m2 .3- If PCWP is above 15 mm Hg or the RVEDV is 140 mL/m2 orhigher, infuse dobutamine, beginning at a rate of 5mg/kg/minute .In the presence of AV dissociation or complete heart block,institute sequential A-V pacing and avoid ventricular pacing .
Diuretics in Hospitalized Patients: RecommendationsClass I1. Patients with HF admitted with evidence of significant fluid overloadshould be promptly treated with intravenous loop diuretics to reducemorbidity (Level of Evidence: B)2. If patients are already receiving loop diuretic therapy, the initialintravenous dose should equal or exceed their chronic oral daily dose andshould be given as either intermittent boluses or continuous infusion.Urine output and signs and symptoms of congestion should be seriallyassessed, and the diuretic dose should be adjusted accordingly to relievesymptoms, reduce volume excess, and avoid hypotension (Level ofEvidence: B)3. The effect of HF treatment should be monitored with carefulmeasurement of fluid intake and output, vital signs, body weight that isdetermined at the same time each day, and clinical signs and symptomsof systemic perfusion and congestion. Daily serum electrolytes, ureanitrogen, and creatinine concentrations should be measured during theuse of intravenous diuretics or active titration of HF medications. (Level ofEvidence: C)
Diuretics in Hospitalized Patients: RecommendationsClass IIa1. When diuresis is inadequate to relieve symptoms, it is reasonableto intensify the diuretic regimen using either:a. higher doses of intravenous loop diuretics (Level of Evidence: B);b. addition of a second (e.g., thiazide) diuretic (Level of Evidence: B).Class IIbLow-dose dopamine infusion may be considered in additionto loop diuretic 1 therapy to improve diuresis and betterpreserve renal function and renal blood flow (Level ofEvidence: B)
Short term therapeutic options( Nondurable)Bridge to recoveryLong term therapeutic optionsBridge to transplantation ( durable)Destination therapy (permanent)Percutaneous devicesIABPImpellaECMO and centrifugeal pump devicesImplantable devices (cardiotomy)LVAD, RVAD, BiVAD, total artificial heart (different models, differentindications)
Class IIaMCS is beneficial in carefully selected* patients with stageD HFrEF in whom definitive management (e.g., cardiactransplantation) or cardiac recovery is anticipated or planned. (Level of Evidence: B)Nondurable MCS, including the use of percutaneous andextracorporeal ventricular assist devices (VADs), isreasonable as a “bridge to recovery” or “bridge to decision”for carefully selected* patients with HFrEF with acute,profound hemodynamic compromise . (Level of Evidence: B)Durable MCS is reasonable to prolong survival for carefullyselected* patients with stage D HFrEF (672-675). (Level ofEvidence: B)
selected* patients are those withLVEF <25% and NYHA class III-IV functionalstatus despite GDMT, when CRT indicated , witheither high predicted 1- to 2-y mortality ordependence on continuous parenteral inotropicsupport.
Intra-Aortic Balloon CounterpulsationIntra-aortic balloon counterpulsation was introducedin 1968 as a method of promoting coronary bloodflow .It is available in various lengths to match body height.Hemodynamic EffectsInflation begins at the onset of diastole, just after the aorticvalve closes that cause Increase in diastolic pressurewhich should also augment coronary bloodflow, because the bulk of coronary flow occurs duringdiastole.Deflation at the onset of ventricular systole, just before theaortic valve opens so Deflation of the balloon reducesthe end-diastolic pressure, This decreases ventricularafterload and promotes ventricular stroke output.
IABP Indication:when cardiac pump failure is life-threatening andeither pump function is expected to improvespontaneously, or a corrective procedure is planned.Cardiogenic shock following CPBAcute MI .Unstable angina,Acute mitral insufficiency,Planned cardiac transplantation.Support PCI & reduce size of Infarction??!!! controversy
Yemeni futureGet to international standards of treatment (new drugs,assist devices programs)TransplantationInternational futureGeneticsStem cell cultures and implantationTruly viable total artificial heart
The approach to advanced or decompensated heart failure in the ICUis best guided by invasive hemodynamic measurements and by thetype of heart failure involved (systolic, diastolic, left-sided, or right-sided failure). The management of acute, decompensated heart failure shouldaugment cardiac output and reduce ventricular filling pressureswhile producing little or no increase in myocardial O2 consumption. Patients with HF admitted with evidence of significant fluid overloadshould be promptly treated with intravenous loop diuretics toreduce morbidity . Diuretic therapy should not play a major role in the management ofacute heart failure, particularly if the failure is due to diastolicdysfunction. Low-dose dopamine infusion may be considered in addition to loopdiuretic 1 therapy to improve diuresis and better preserve renalfunction and renal blood flow . If cardiogenic shock is identified, mechanical cardiac support shouldbe initiated as soon as possible, if indicated.