This document provides an overview of mechanical circulatory support devices. It discusses the evolution of such devices and their terminology. Temporary devices discussed include intra-aortic balloon pumps and Impella pumps. Long-term devices discussed include pulsatile flow devices like HeartMate I as well as continuous flow devices like HeartMate II, HeartWare HVAD, and HeartMate 3. Clinical trials are summarized that evaluated these devices as bridges to transplant or destination therapy. Biventricular support devices like the total artificial heart are also covered. The document concludes with recommendations from organizations on the use of these devices.
A ventricular assist device (VAD) is a mechanical pump that helps the ventricles pump blood through the body. VADs are used to treat heart failure and cardiogenic shock. They can partially or completely replace the function of a failing heart. VADs are designed to assist the right ventricle, left ventricle, or both ventricles. Common uses of VADs include bridging patients to transplant, bridging to recovery or decision, and destination therapy for patients who are not eligible for transplant. Complications of VAD therapy include bleeding, infection, thromboembolism, device malfunction, and right heart failure.
Cardiac catheterization is useful for assessing left-to-right shunts through three main techniques: oximetry runs to detect oxygen saturation step-ups, indicator dye dilution to detect early recirculation of dye injected into the proximal chamber, and angiocardiography to directly visualize the anatomic site of the shunt. While oximetry is best to localize the shunt, dye dilution can detect smaller shunts and angiography confirms anatomy. Together these techniques allow diagnosis and quantification of left-to-right intracardiac shunts.
Mechanical circulatory support devices such as left ventricular assist devices (LVADs) are increasingly being used as an alternative to cardiac transplantation for patients with advanced heart failure. LVADs are mechanical pumps that are implanted to support the left ventricle and improve cardiac output. They can be used as a bridge to transplantation, destination therapy for those ineligible for transplant, or potentially as a bridge to recovery in some cases. Common LVAD devices are continuous flow pumps that are more pulsatile than earlier generation pulsatile pumps. LVADs have been shown to improve symptoms, quality of life and survival for advanced heart failure patients.
Assessment of prosthetic valve functionSwapnil Garde
This document discusses the assessment of prosthetic valve function through various imaging modalities. It begins with an introduction to prosthetic valves and outlines topics to be covered, including classification of valve types. Evaluation methods like chest x-ray, fluoroscopy, echocardiography, and CT are described. Parameters assessed on each modality and guidelines for evaluation are provided. Complications of prosthetic valves and 3D imaging advances are also mentioned.
The document defines no-reflow as inadequate myocardial perfusion through a coronary circulation segment without mechanical vessel obstruction. No-reflow occurs in 30% of patients after reperfusion for myocardial infarction and is associated with worse outcomes. It results from microvascular obstruction from distal embolization, ischemic injury, and reperfusion injury. Diagnosis involves assessing TIMI flow, myocardial blush grade, and imaging techniques. Prevention focuses on reducing embolization using thrombectomy or filters while treatment involves vasodilators like adenosine, verapamil, and glycoprotein IIb/IIIa inhibitors.
The document discusses guidelines for assessing diastolic dysfunction according to the ASE/EACVI 2016 guidelines. It defines diastolic dysfunction and describes the stages from grade I to grade IV. For each grade, it discusses the pathophysiology and key echocardiographic findings including mitral inflow patterns, tissue Doppler measurements, pulmonary vein flow, and left atrial size. The guidelines simplify the assessment of diastolic function into four grades based on parameters of left ventricular relaxation, left atrial pressure, mitral E/A ratio, E/e' ratio, pulmonary vein flow, and left atrial size.
The document discusses various techniques for assessing myocardial viability, including stress echocardiography, single photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (MRI). Stress echocardiography evaluates contractile reserve through techniques like dobutamine stress echocardiography. SPECT assesses viability by detecting thallium or technetium uptake, which relies on intact cell membranes. PET detects FDG uptake indicating active glucose metabolism. MRI evaluates viability through detection of late gadolinium enhancement, indicating scar tissue, and can also assess contractile reserve with stress MRI. A combined approach utilizing multiple techniques can provide complementary information on viability.
The document discusses various techniques for cannulation during cardiopulmonary bypass (CPB). Venous cannulation is typically done via the superior vena cava (SVC) and inferior vena cava (IVC) using either a bicaval, single atrial, or cavoatrial approach. Arterial cannulation is usually via the ascending aorta but can also be done through femoral, axillary, or other arteries if needed. Proper positioning and sizing of cannulas is important to maximize blood flow and minimize complications like air embolism, bleeding, or malposition. Factors such as patient anatomy, surgical plan, and vessel disease must be considered to select the optimal cannulation method.
A ventricular assist device (VAD) is a mechanical pump that helps the ventricles pump blood through the body. VADs are used to treat heart failure and cardiogenic shock. They can partially or completely replace the function of a failing heart. VADs are designed to assist the right ventricle, left ventricle, or both ventricles. Common uses of VADs include bridging patients to transplant, bridging to recovery or decision, and destination therapy for patients who are not eligible for transplant. Complications of VAD therapy include bleeding, infection, thromboembolism, device malfunction, and right heart failure.
Cardiac catheterization is useful for assessing left-to-right shunts through three main techniques: oximetry runs to detect oxygen saturation step-ups, indicator dye dilution to detect early recirculation of dye injected into the proximal chamber, and angiocardiography to directly visualize the anatomic site of the shunt. While oximetry is best to localize the shunt, dye dilution can detect smaller shunts and angiography confirms anatomy. Together these techniques allow diagnosis and quantification of left-to-right intracardiac shunts.
Mechanical circulatory support devices such as left ventricular assist devices (LVADs) are increasingly being used as an alternative to cardiac transplantation for patients with advanced heart failure. LVADs are mechanical pumps that are implanted to support the left ventricle and improve cardiac output. They can be used as a bridge to transplantation, destination therapy for those ineligible for transplant, or potentially as a bridge to recovery in some cases. Common LVAD devices are continuous flow pumps that are more pulsatile than earlier generation pulsatile pumps. LVADs have been shown to improve symptoms, quality of life and survival for advanced heart failure patients.
Assessment of prosthetic valve functionSwapnil Garde
This document discusses the assessment of prosthetic valve function through various imaging modalities. It begins with an introduction to prosthetic valves and outlines topics to be covered, including classification of valve types. Evaluation methods like chest x-ray, fluoroscopy, echocardiography, and CT are described. Parameters assessed on each modality and guidelines for evaluation are provided. Complications of prosthetic valves and 3D imaging advances are also mentioned.
The document defines no-reflow as inadequate myocardial perfusion through a coronary circulation segment without mechanical vessel obstruction. No-reflow occurs in 30% of patients after reperfusion for myocardial infarction and is associated with worse outcomes. It results from microvascular obstruction from distal embolization, ischemic injury, and reperfusion injury. Diagnosis involves assessing TIMI flow, myocardial blush grade, and imaging techniques. Prevention focuses on reducing embolization using thrombectomy or filters while treatment involves vasodilators like adenosine, verapamil, and glycoprotein IIb/IIIa inhibitors.
The document discusses guidelines for assessing diastolic dysfunction according to the ASE/EACVI 2016 guidelines. It defines diastolic dysfunction and describes the stages from grade I to grade IV. For each grade, it discusses the pathophysiology and key echocardiographic findings including mitral inflow patterns, tissue Doppler measurements, pulmonary vein flow, and left atrial size. The guidelines simplify the assessment of diastolic function into four grades based on parameters of left ventricular relaxation, left atrial pressure, mitral E/A ratio, E/e' ratio, pulmonary vein flow, and left atrial size.
The document discusses various techniques for assessing myocardial viability, including stress echocardiography, single photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (MRI). Stress echocardiography evaluates contractile reserve through techniques like dobutamine stress echocardiography. SPECT assesses viability by detecting thallium or technetium uptake, which relies on intact cell membranes. PET detects FDG uptake indicating active glucose metabolism. MRI evaluates viability through detection of late gadolinium enhancement, indicating scar tissue, and can also assess contractile reserve with stress MRI. A combined approach utilizing multiple techniques can provide complementary information on viability.
The document discusses various techniques for cannulation during cardiopulmonary bypass (CPB). Venous cannulation is typically done via the superior vena cava (SVC) and inferior vena cava (IVC) using either a bicaval, single atrial, or cavoatrial approach. Arterial cannulation is usually via the ascending aorta but can also be done through femoral, axillary, or other arteries if needed. Proper positioning and sizing of cannulas is important to maximize blood flow and minimize complications like air embolism, bleeding, or malposition. Factors such as patient anatomy, surgical plan, and vessel disease must be considered to select the optimal cannulation method.
Ventricular assist devices (VADs) are mechanical pumps that help the failing heart pump blood. They can be used as a bridge to transplantation, destination therapy for those not eligible for transplant, or as a bridge to recovery or decision. VADs range from short-term percutaneous devices to long-term implantable devices. Long-term devices include pulsatile flow, axial continuous flow, and total artificial hearts. Selection depends on duration of support needed, whether right or left ventricular support is required, and the patient's prognosis and treatment goals. Implantation requires open-heart surgery and postoperative management focuses on prevention of complications like bleeding, infection, and thromboembolism.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Cardiopulmonary bypass in pediatric patients with congenital heart disease requires special considerations due to physiological differences from adults. These include smaller blood volumes, higher oxygen demands, and the presence of intracardiac and extracardiac shunting. The bypass plan must account for the specific anatomy and physiology of each patient's heart defect to ensure adequate perfusion and protection during surgery. Flow rates, temperature management, venting strategies, and cardioplegia administration may need to be modified from standard adult protocols. Close monitoring is important to detect any issues with oxygen delivery or end-organ perfusion during bypass.
Contrast echocardiography uses microbubble ultrasound contrast agents to improve image quality. These microbubbles remain in the intravascular space and allow for assessment of cardiac structure, function, and perfusion. Second generation contrast agents use an inert gas encapsulated by albumin or phospholipid shells. They interact with ultrasound by reflecting at fundamental frequencies and resonating to produce harmonic frequencies. Continuous infusion provides steady contrast levels needed for perfusion assessment. Contrast echocardiography is a non-invasive technique that improves evaluation of the heart.
This document discusses ischemic preconditioning and postconditioning. It defines ischemic preconditioning as brief episodes of myocardial ischemia that increase the heart's ability to tolerate subsequent prolonged ischemia. Brief periods of ischemia prior to a longer period of ischemia can reduce infarct size and arrhythmias. Ischemic postconditioning involves brief reperfusion/re-occlusion cycles at the end of prolonged ischemia and can also reduce infarct size. The mechanisms of protection involve triggers, transducers, and end effectors at the myocyte level. Clinical studies provide evidence that ischemic preconditioning and postconditioning improve outcomes for patients experiencing myocardial ischemia.
This document discusses the no-reflow phenomenon, which occurs when restoration of coronary artery patency after procedures like primary percutaneous coronary intervention (PCI) does not translate to improved tissue perfusion. No-reflow occurs in 30% of patients after reperfusion for acute myocardial infarction and is associated with worse outcomes. It is caused by microvascular obstruction from distal embolization, ischemic injury, reperfusion injury, and individual patient susceptibility. Methods to diagnose no-reflow include angiography, coronary Doppler, cardiac MRI, and myocardial contrast echocardiography. Prevention strategies target reducing ischemic time, microvascular spasm, and distal embolization through early reperfusion, pharmacological agents, and ischemic conditioning techniques.
A transesophageal echocardiogram, or TEE, is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. It has several advantages and some disadvantages compared with a transthoracic echocardiogram.
No reflow and slow flow phenomenon during pcirahul arora
This document discusses strategies and prevention of slow flow and no-reflow phenomenon during percutaneous coronary intervention (PCI). It defines no-reflow as inadequate myocardial perfusion through a coronary artery without mechanical obstruction. No-reflow occurs in 8-11% of primary PCIs and is associated with worse clinical outcomes. The pathophysiology involves distal embolization, ischemic injury, reperfusion injury, and individual patient susceptibility. Preventing no-reflow requires reducing thrombus burden, ischemia time, reperfusion injury through anti-inflammatory drugs, and addressing risk factors like diabetes.
This document discusses fractional flow reserve (FFR), which is a technique used to functionally assess the significance of coronary artery stenosis. FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow if there was no stenosis. It is calculated as the ratio of mean distal coronary pressure (Pd) to mean aortic pressure (Pa) during maximal hyperemia induced by pharmacological agents. An FFR value below 0.75 is associated with inducible ischemia, while a value above 0.80 indicates an insignificant stenosis in most cases. FFR has advantages over angiography alone in evaluating stenosis as it accounts for vessel characteristics like length and takes collateral flow into consideration.
The document discusses various clinical trials related to cardiovascular diseases. It summarizes the ACCORD BP study which found that targeting a SBP of <120 mm Hg compared to <140 mm Hg in patients with type 2 diabetes did not reduce cardiovascular events. It also summarizes the HOPE trial which found that ramipril reduced cardiovascular deaths, myocardial infarction, and stroke in high-risk patients without low ejection fraction or heart failure. Finally, it summarizes the EUROPA trial which found that perindopril reduced the primary endpoint of cardiovascular mortality, non-fatal MI, and cardiac arrest in patients with stable coronary artery disease.
This document discusses various topics related to cardioplegia, including alternative arresting agents and additives, crystalloid versus blood cardioplegia, and potential new technologies. It provides details on adenosine receptors, minute work and oxygen demand, alternative arresting agents such as beta blockers and adenocaine, agents affecting calcium transport, and ways to avoid substrate depletion. It compares crystalloid and blood cardioplegia, outlining advantages and disadvantages of each. Finally, it discusses novel strategies for cardioprotection such as ischemic preconditioning, post-conditioning, and remote ischemic preconditioning.
The document summarizes key aspects of cardiac catheterization and hemodynamic data collection. It describes the normal cardiac cycle, pressure measurement systems, normal pressure waveforms, methods to measure cardiac output like thermodilution and Fick, how to evaluate valvular stenosis and regurgitation, determine vascular resistance and shunts. Specific details are provided on assessing aortic stenosis, mitral stenosis, right-sided valves and quantifying regurgitant fractions. Oxygen saturation analysis and Fick principles are outlined for shunt determinations.
The document summarizes key aspects of coronary blood flow regulation and determinants of myocardial oxygen consumption. It discusses how:
1) Myocardial contraction and oxygen delivery are closely linked, and the balance between oxygen supply and demand is critical for normal heart function.
2) The major determinants of myocardial oxygen consumption are heart rate, systolic pressure, and left ventricular contractility. Increases in these factors require proportional increases in coronary flow and oxygen delivery.
3) Coronary vascular resistance has three main components - epicardial conduit resistance, microcirculatory resistance, and extravascular compressive resistance which varies through the cardiac cycle. Maintaining the balance of these factors is important for adequate oxygen supply
Deep hypothermic circulatory arrest in pediatric cardiac surManu Jacob
Deep hypothermic circulatory arrest (DHCA) involves stopping blood circulation during deep hypothermia to provide a bloodless surgical field for complex pediatric cardiac surgery. It requires cooling the patient to 15-22°C using cardiopulmonary bypass before arresting circulation. The duration of DHCA is limited to 30-60 minutes for brain protection. Neurological outcomes can be improved through careful management of factors like temperature, hematocrit levels, acid-base balance, and neuroprotective drugs during DHCA and cardiac bypass. Monitoring tools like EEG, TCD and SjVO2 help guide cerebral protection during these procedures.
Basic haemodynamic assessment with echo (iHeartScan)SCGH ED CME
The document outlines the basic steps for assessing haemodynamic states using echocardiography:
1. Estimate left ventricular preload by measuring end diastolic volume or dimension, characterizing it as hypovolaemic, normal, or dilated.
2. Estimate systolic function by measuring ejection fraction, fractional shortening, or visual assessment.
3. Estimate left atrial pressure by examining interatrial septal motion and size, characterizing pressure as normal or high.
4. Make a final assessment of the primary dysfunction as normal, hypovolaemic, primary diastolic failure, primary systolic failure, systolic and diastolic failure, vasodilation
This document provides guidance on performing a comprehensive transesophageal echocardiography (TEE) examination including standard imaging plane levels and views. It describes how to obtain standard mid-esophageal (ME) views such as the five-chamber, four-chamber, and two-chamber views as well as transgastric (TG) views including the basal short-axis, midpapillary short-axis, and apical short-axis views. Each view is defined by the structures seen and clinical applications. Probe manipulation techniques including adjustments to transducer angle and position are outlined to transition between views for a systematic TEE exam.
This document provides an overview of standard transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) views. It describes the imaging windows, planes, and positions for obtaining basic and modified TTE views such as parasternal, apical, and subcostal views. It also outlines TEE imaging levels and how to manipulate the probe to obtain standard midesophageal and transgastric views, including 4-chamber, 2-chamber, aortic valve, and left ventricular views. The document aims to guide practitioners in performing comprehensive TTE and TEE exams through appropriate patient positioning and transducer manipulation.
Basics of Electrophysiologic study, part 1 (2020)salah_atta
An electrophysiologic study involves inserting electrode catheters into the heart to record electrical activity and induce arrhythmias. The document discusses:
1. The procedure involves placing catheters in the heart to record electrograms from the atria, His bundle, ventricles and coronary sinus.
2. The aims are diagnostic to evaluate arrhythmias and bradycardias, and therapeutic for ablation of arrhythmias.
3. Key measurements taken include intervals between P waves, His bundle activation and QRS complex to identify conduction abnormalities.
4. Tracings are analyzed to determine the rhythm, sequence of activation, effects of pacing, and identify arrhythmia mechanisms like accessory pathways
This document provides guidance on managing patients who do not respond to cardiac resynchronization therapy (CRT). It discusses that while CRT has been shown to reduce heart failure hospitalizations and mortality, 30-35% of patients do not adequately respond. The document then reviews factors that determine CRT response, including electrical and mechanical dyssynchrony. It also discusses different criteria used to define response and notes lack of agreement. Potential reasons for non-response are explored, including lead placement and individual patient factors. The document concludes by recommending approaches for evaluating and managing CRT non-responders.
The document discusses the evolution of treatments for acute ischemic stroke (AIS), including intravenous thrombolysis and mechanical thrombectomy. It summarizes key randomized trials that established the benefits of mechanical thrombectomy. The first-generation trials using early thrombectomy devices did not show benefit, but recent trials using stent retrievers demonstrated significantly improved recanalization rates and superior outcomes for mechanical thrombectomy combined with intravenous thrombolysis compared to intravenous thrombolysis alone in eligible patients presenting within 6 hours of stroke onset. The document concludes that mechanical thrombectomy is now a standard treatment for AIS but remains underutilized.
Ventricular assist devices (VADs) are mechanical pumps that help the failing heart pump blood. They can be used as a bridge to transplantation, destination therapy for those not eligible for transplant, or as a bridge to recovery or decision. VADs range from short-term percutaneous devices to long-term implantable devices. Long-term devices include pulsatile flow, axial continuous flow, and total artificial hearts. Selection depends on duration of support needed, whether right or left ventricular support is required, and the patient's prognosis and treatment goals. Implantation requires open-heart surgery and postoperative management focuses on prevention of complications like bleeding, infection, and thromboembolism.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Cardiopulmonary bypass in pediatric patients with congenital heart disease requires special considerations due to physiological differences from adults. These include smaller blood volumes, higher oxygen demands, and the presence of intracardiac and extracardiac shunting. The bypass plan must account for the specific anatomy and physiology of each patient's heart defect to ensure adequate perfusion and protection during surgery. Flow rates, temperature management, venting strategies, and cardioplegia administration may need to be modified from standard adult protocols. Close monitoring is important to detect any issues with oxygen delivery or end-organ perfusion during bypass.
Contrast echocardiography uses microbubble ultrasound contrast agents to improve image quality. These microbubbles remain in the intravascular space and allow for assessment of cardiac structure, function, and perfusion. Second generation contrast agents use an inert gas encapsulated by albumin or phospholipid shells. They interact with ultrasound by reflecting at fundamental frequencies and resonating to produce harmonic frequencies. Continuous infusion provides steady contrast levels needed for perfusion assessment. Contrast echocardiography is a non-invasive technique that improves evaluation of the heart.
This document discusses ischemic preconditioning and postconditioning. It defines ischemic preconditioning as brief episodes of myocardial ischemia that increase the heart's ability to tolerate subsequent prolonged ischemia. Brief periods of ischemia prior to a longer period of ischemia can reduce infarct size and arrhythmias. Ischemic postconditioning involves brief reperfusion/re-occlusion cycles at the end of prolonged ischemia and can also reduce infarct size. The mechanisms of protection involve triggers, transducers, and end effectors at the myocyte level. Clinical studies provide evidence that ischemic preconditioning and postconditioning improve outcomes for patients experiencing myocardial ischemia.
This document discusses the no-reflow phenomenon, which occurs when restoration of coronary artery patency after procedures like primary percutaneous coronary intervention (PCI) does not translate to improved tissue perfusion. No-reflow occurs in 30% of patients after reperfusion for acute myocardial infarction and is associated with worse outcomes. It is caused by microvascular obstruction from distal embolization, ischemic injury, reperfusion injury, and individual patient susceptibility. Methods to diagnose no-reflow include angiography, coronary Doppler, cardiac MRI, and myocardial contrast echocardiography. Prevention strategies target reducing ischemic time, microvascular spasm, and distal embolization through early reperfusion, pharmacological agents, and ischemic conditioning techniques.
A transesophageal echocardiogram, or TEE, is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. It has several advantages and some disadvantages compared with a transthoracic echocardiogram.
No reflow and slow flow phenomenon during pcirahul arora
This document discusses strategies and prevention of slow flow and no-reflow phenomenon during percutaneous coronary intervention (PCI). It defines no-reflow as inadequate myocardial perfusion through a coronary artery without mechanical obstruction. No-reflow occurs in 8-11% of primary PCIs and is associated with worse clinical outcomes. The pathophysiology involves distal embolization, ischemic injury, reperfusion injury, and individual patient susceptibility. Preventing no-reflow requires reducing thrombus burden, ischemia time, reperfusion injury through anti-inflammatory drugs, and addressing risk factors like diabetes.
This document discusses fractional flow reserve (FFR), which is a technique used to functionally assess the significance of coronary artery stenosis. FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow if there was no stenosis. It is calculated as the ratio of mean distal coronary pressure (Pd) to mean aortic pressure (Pa) during maximal hyperemia induced by pharmacological agents. An FFR value below 0.75 is associated with inducible ischemia, while a value above 0.80 indicates an insignificant stenosis in most cases. FFR has advantages over angiography alone in evaluating stenosis as it accounts for vessel characteristics like length and takes collateral flow into consideration.
The document discusses various clinical trials related to cardiovascular diseases. It summarizes the ACCORD BP study which found that targeting a SBP of <120 mm Hg compared to <140 mm Hg in patients with type 2 diabetes did not reduce cardiovascular events. It also summarizes the HOPE trial which found that ramipril reduced cardiovascular deaths, myocardial infarction, and stroke in high-risk patients without low ejection fraction or heart failure. Finally, it summarizes the EUROPA trial which found that perindopril reduced the primary endpoint of cardiovascular mortality, non-fatal MI, and cardiac arrest in patients with stable coronary artery disease.
This document discusses various topics related to cardioplegia, including alternative arresting agents and additives, crystalloid versus blood cardioplegia, and potential new technologies. It provides details on adenosine receptors, minute work and oxygen demand, alternative arresting agents such as beta blockers and adenocaine, agents affecting calcium transport, and ways to avoid substrate depletion. It compares crystalloid and blood cardioplegia, outlining advantages and disadvantages of each. Finally, it discusses novel strategies for cardioprotection such as ischemic preconditioning, post-conditioning, and remote ischemic preconditioning.
The document summarizes key aspects of cardiac catheterization and hemodynamic data collection. It describes the normal cardiac cycle, pressure measurement systems, normal pressure waveforms, methods to measure cardiac output like thermodilution and Fick, how to evaluate valvular stenosis and regurgitation, determine vascular resistance and shunts. Specific details are provided on assessing aortic stenosis, mitral stenosis, right-sided valves and quantifying regurgitant fractions. Oxygen saturation analysis and Fick principles are outlined for shunt determinations.
The document summarizes key aspects of coronary blood flow regulation and determinants of myocardial oxygen consumption. It discusses how:
1) Myocardial contraction and oxygen delivery are closely linked, and the balance between oxygen supply and demand is critical for normal heart function.
2) The major determinants of myocardial oxygen consumption are heart rate, systolic pressure, and left ventricular contractility. Increases in these factors require proportional increases in coronary flow and oxygen delivery.
3) Coronary vascular resistance has three main components - epicardial conduit resistance, microcirculatory resistance, and extravascular compressive resistance which varies through the cardiac cycle. Maintaining the balance of these factors is important for adequate oxygen supply
Deep hypothermic circulatory arrest in pediatric cardiac surManu Jacob
Deep hypothermic circulatory arrest (DHCA) involves stopping blood circulation during deep hypothermia to provide a bloodless surgical field for complex pediatric cardiac surgery. It requires cooling the patient to 15-22°C using cardiopulmonary bypass before arresting circulation. The duration of DHCA is limited to 30-60 minutes for brain protection. Neurological outcomes can be improved through careful management of factors like temperature, hematocrit levels, acid-base balance, and neuroprotective drugs during DHCA and cardiac bypass. Monitoring tools like EEG, TCD and SjVO2 help guide cerebral protection during these procedures.
Basic haemodynamic assessment with echo (iHeartScan)SCGH ED CME
The document outlines the basic steps for assessing haemodynamic states using echocardiography:
1. Estimate left ventricular preload by measuring end diastolic volume or dimension, characterizing it as hypovolaemic, normal, or dilated.
2. Estimate systolic function by measuring ejection fraction, fractional shortening, or visual assessment.
3. Estimate left atrial pressure by examining interatrial septal motion and size, characterizing pressure as normal or high.
4. Make a final assessment of the primary dysfunction as normal, hypovolaemic, primary diastolic failure, primary systolic failure, systolic and diastolic failure, vasodilation
This document provides guidance on performing a comprehensive transesophageal echocardiography (TEE) examination including standard imaging plane levels and views. It describes how to obtain standard mid-esophageal (ME) views such as the five-chamber, four-chamber, and two-chamber views as well as transgastric (TG) views including the basal short-axis, midpapillary short-axis, and apical short-axis views. Each view is defined by the structures seen and clinical applications. Probe manipulation techniques including adjustments to transducer angle and position are outlined to transition between views for a systematic TEE exam.
This document provides an overview of standard transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) views. It describes the imaging windows, planes, and positions for obtaining basic and modified TTE views such as parasternal, apical, and subcostal views. It also outlines TEE imaging levels and how to manipulate the probe to obtain standard midesophageal and transgastric views, including 4-chamber, 2-chamber, aortic valve, and left ventricular views. The document aims to guide practitioners in performing comprehensive TTE and TEE exams through appropriate patient positioning and transducer manipulation.
Basics of Electrophysiologic study, part 1 (2020)salah_atta
An electrophysiologic study involves inserting electrode catheters into the heart to record electrical activity and induce arrhythmias. The document discusses:
1. The procedure involves placing catheters in the heart to record electrograms from the atria, His bundle, ventricles and coronary sinus.
2. The aims are diagnostic to evaluate arrhythmias and bradycardias, and therapeutic for ablation of arrhythmias.
3. Key measurements taken include intervals between P waves, His bundle activation and QRS complex to identify conduction abnormalities.
4. Tracings are analyzed to determine the rhythm, sequence of activation, effects of pacing, and identify arrhythmia mechanisms like accessory pathways
This document provides guidance on managing patients who do not respond to cardiac resynchronization therapy (CRT). It discusses that while CRT has been shown to reduce heart failure hospitalizations and mortality, 30-35% of patients do not adequately respond. The document then reviews factors that determine CRT response, including electrical and mechanical dyssynchrony. It also discusses different criteria used to define response and notes lack of agreement. Potential reasons for non-response are explored, including lead placement and individual patient factors. The document concludes by recommending approaches for evaluating and managing CRT non-responders.
The document discusses the evolution of treatments for acute ischemic stroke (AIS), including intravenous thrombolysis and mechanical thrombectomy. It summarizes key randomized trials that established the benefits of mechanical thrombectomy. The first-generation trials using early thrombectomy devices did not show benefit, but recent trials using stent retrievers demonstrated significantly improved recanalization rates and superior outcomes for mechanical thrombectomy combined with intravenous thrombolysis compared to intravenous thrombolysis alone in eligible patients presenting within 6 hours of stroke onset. The document concludes that mechanical thrombectomy is now a standard treatment for AIS but remains underutilized.
This study evaluated a novel transcatheter interatrial shunt device for treating heart failure with preserved ejection fraction (HFPEF). 64 patients underwent successful implantation of the device. At 6 months follow up, 71% of patients had a reduction in pulmonary capillary wedge pressure at rest or during exercise compared to baseline. The procedure was well tolerated with no safety issues. The results suggest the device may help reduce left atrial pressure and improve functional status for patients with HFPEF, though the study had limitations as an open-label single-arm trial with short follow up.
This document provides an overview of nuclear cardiology techniques used in the assessment of coronary artery disease (CAD). It discusses the history and development of nuclear medicine imaging including planar imaging and SPECT/PET. Key aspects summarized are:
1. SPECT imaging involves injection of radiotracers like thallium-201 or technetium-99m which distribute to the myocardium proportional to blood flow. Gamma photons are detected and reconstructed to provide 3D images of radiotracer distribution.
2. PET imaging uses positron-emitting radiotracers like rubidium-82 or ammonia-13 for perfusion and fluorodeoxyglucose for metabolism. It provides higher resolution functional imaging
This document summarizes a seminar on invasive and non-invasive hemodynamic monitoring in the intensive care unit (ICU). It discusses various monitoring techniques including clinical parameters, blood pressure, echocardiography, esophageal Doppler monitoring, gastric tonometry, central venous pressure, and pulmonary artery catheters. For each method, it covers principles of measurement, indications, limitations, evidence, and clinical applications in critically ill patients. The document emphasizes that hemodynamic monitoring should improve outcomes when coupled with effective treatments, and intensive care physicians should be trained in goal-directed echocardiography.
This document discusses the evolution of treatments for acute ischemic stroke caused by large vessel occlusion over the past three decades. It describes the development of intravenous thrombolysis using alteplase, including early safety trials, phase 3 efficacy trials, and limitations. It also discusses the emergence of endovascular therapies such as mechanical thrombectomy and the importance of neuroimaging such as CT and CT perfusion in selecting appropriate patients. The role of collateral circulation and a "tissue window" approach are also highlighted.
This document summarizes a presentation on cardiac resynchronization therapy (CRT). It discusses how CRT works to restore synchronized heart contraction in patients with heart failure and ventricular dyssynchrony. It reviews several important clinical trials that demonstrated the benefits of CRT in reducing mortality and hospitalization. The document also discusses current guidelines for CRT, factors that can reduce the effectiveness of CRT, and ongoing areas of research around using CRT in populations with narrow QRS or mild heart failure symptoms.
Recent evidence for mechanical thrombolysisDr Vipul Gupta
The document discusses recent evidence for mechanical thrombectomy in acute ischemic stroke. It summarizes several recent randomized controlled trials that compared mechanical thrombectomy using stent retrievers to standard medical therapy alone. The trials showed that mechanical thrombectomy significantly improved rates of reperfusion and functional independence, with absolute increases in good clinical outcomes ranging from 13.5% to 31.4%. Mechanical thrombectomy also reduced mortality in some trials. Based on these results, international guidelines now recommend endovascular therapy with stent retrievers for appropriately selected patients within 6 hours of stroke onset.
1) Cardiogenic shock is defined as hypotension, hypoperfusion, and elevated filling pressures caused by depressed left ventricular function following myocardial injury. Mortality from cardiogenic shock remains high at 50-70%.
2) Risk factors for cardiogenic shock include age over 65, female gender, large myocardial infarction, anterior infarction location, prior infarction history, diabetes, and hypertension. Post-mortem studies show extensive myocardial damage in patients who die from cardiogenic shock.
3) Early revascularization through percutaneous coronary intervention or coronary artery bypass grafting may improve survival outcomes for cardiogenic shock, especially in patients under age 75, according to the landmark SHOCK trial. Adjunctive therapies including intra
Survival in patients with advanced heart failure (AHF) has improved over the last 2 decades. An increasing number of patients however, are dying with progressive heart failure over the same duration. Optimal utilization of medical therapies and devices like implantable defibrillators and biventricular pacemakers are the likely reasons patients are surviving longer albeit with progressive HF.
Evolution in mechanical circulatory support (MCS) devices has occurred over the same period, such that they can now be rapidly instituted providing support for pump failure, often percutaneously, with timely restitution of physiologic and metabolic derangements with fewer complications.
MCS devices can be classified as Short term and Long term. Short term devices such as Intraaortic balloon pumps (IABP), Impella ®, TandemHeart® or Venoarterial extracorporeal membrane oxygenation (VA – ECMO) using a Cardiohelp® device, are usually employed as ‘Bridge to Recovery’(BTR) or Bridge to Decision’(BTD), usually in acute settings. Long term devices such as implantable left ventricular assist devices (LVADs) e.g. Heartmate II® & 3®, Heart ware HVAD® are implanted as ‘Bridge to transplant’ (BTT) or ‘Destination therapy’ (DT) usually in patients ‘sliding’ on inotropes when they are transplant eligible (BTT) or ineligible (DT) respectively.
Ventricular assist devices have traditionally been developed for left ventricular support in case of severe left heart or biventricular dysfunction. Historically, right ventricular (RV) dysfunction following LVAD implantation or as a component of biventricular dysfunction was managed with either medical therapy, temporary VADs (i.e. ECMO configuration with continuous flow centrifugal pumps like CentriMag®, Rotaflow ®) or occasionally with LVADs placed on the right side. Recently the Impella RP® and ProtekDuo®, percutaneously placed pumps with inflow in the inferior vena cava & right atrium respectively and outflow in pulmonary artery, have become available as less invasive options, for short term RV support.
The Syncardia® is the only approved total artificial heart system currently in use; however various biventricular, total heart systems (e.g. BiVACOR®) in development show promise.
Mechanical circulatory devices provide attractive, viable, physiologically plausible ventricular support options that can be used effectively in carefully selected patients.
Recent evidence for mechanical thrombolysisDr Vipul Gupta
1. The document summarizes key findings from recent endovascular thrombectomy trials for acute ischemic stroke. It found that stent retrievers significantly improved rates of revascularization and functional independence compared to standard medical care.
2. Time to treatment is critical, with most trials requiring treatment initiation within 6 hours of symptom onset. Advanced imaging helped select patients most likely to benefit.
3. The trials established endovascular thrombectomy using stent retrievers as the standard of care for appropriately selected stroke patients with large vessel occlusions. This represents a major advance in acute stroke treatment.
This document discusses the current management of cardiogenic shock. It defines cardiogenic shock and describes its causes, predictors of mortality, and pathophysiology. Treatment involves hemodynamic support, volume management, inotropic drugs, and early revascularization, which significantly reduces mortality. Mechanical circulatory support devices like IABP, Tandem Heart, Impella, and ECMO can further improve hemodynamics and outcomes when used as adjuncts to optimal medical therapy. Timing of revascularization is critical, with survival benefits seen for up to 48 hours after myocardial infarction onset. Special considerations are discussed for managing shock in the elderly, from mechanical causes, and with specific device therapies.
Interventional management of out hospital cardiac arrestAhmedElBorae1
1) Out-of-hospital cardiac arrest remains a major cause of death, though improvements in pre-hospital care have increased ROSC rates to 50%.
2) Significant coronary artery disease is present in 70% of cases. Coronary angiography finds acute culprit lesions in up to 90% of STEMI patients and 58% of non-STEMI patients.
3) Observational studies show the feasibility and safety of immediate invasive coronary strategies after cardiac arrest, with overall survival rates of 76% and neurological recovery in 52% of "comatose" survivors. However, randomized trials are still needed to confirm benefits.
This document discusses the treatment of pulmonary embolism (PE), specifically addressing the debate around treating massive versus submassive PE with thrombolysis. It presents three case studies of patients treated with thrombolysis for suspected PE. It then defines massive and submassive PE and reviews the potential pros and cons of systemic thrombolysis for submassive PE. Guidelines from studies and trials are presented on administering thrombolytics, anticoagulation treatment, and risk-adjusted management strategies for acute PE. The document concludes that the decision to treat with thrombolysis is difficult and should involve input from seniors/consultants, stakeholders, and a multidisciplinary discussion weighing the risks and benefits of thrombolysis for each
Which mechanical circulatory support should we use as first line optiondrucsamal
1) Temporary mechanical circulatory support options like intra-aortic balloon pumps, Impella pumps, TandemHeart pumps, and extracorporeal membrane oxygenation (ECMO) can be used as first-line support for acute cardiogenic shock.
2) These temporary options are placed percutaneously in the catheterization lab and can provide partial to full cardiac output support.
3) Larger ventricular assist devices require open heart surgery and are better suited for longer term chronic support if the patient does not recover with temporary support. The optimal support strategy depends on the individual patient's clinical status and prognosis.
an updated account on management of TIA, Ischemic and hemorrhagic stroke in Sri Lanka. This is based on American Stroke Association and NICE guidelines.
Similar to Mechanical circulatory support devices (20)
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2) Key balloons described are the Inoue balloon, Accura balloon, JOMIVA balloon, and the double balloon and multi-track techniques.
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- Tips for proper use of VCDs and potential complications.
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Mechanisms & management of atrial fibrillationRohitWalse2
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1) The document discusses management of left main coronary artery (LMCA) disease, including definitions, data on medical management versus revascularization, and techniques for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).
2) Registry and randomized controlled trial data show that PCI and CABG have similar outcomes for LMCA disease, with PCI having higher rates of repeat revascularization.
3) Intravascular ultrasound and fractional flow reserve can help assess intermediate LMCA stenosis and optimize stent placement and outcomes. Achieving adequate stent expansion is important for bifurcation lesions.
This document provides an overview of electrophysiological evaluation of Wolff-Parkinson-White (WPW) syndrome. It discusses the history of WPW, types of bypass tract locations, goals of the electrophysiology study including identifying accessory pathways and inducing arrhythmias. The study involves baseline measurements, pacing maneuvers like incremental atrial pacing and extrastimulus testing to identify properties of the accessory pathway. Programmed stimulation is used to induce tachycardias and entrainment mapping helps to determine the tachycardia mechanism. Radiofrequency ablation aims to eliminate conduction over the accessory pathway which is confirmed with post-ablation testing.
This document summarizes the results of several randomized controlled trials comparing different stenting strategies for coronary bifurcation lesions. It finds that:
1) Trials generally show no significant differences in outcomes between simple/provisional stenting versus complex/two-stenting strategies for non-left main bifurcations.
2) For left main bifurcations, the DK Crush trial found reduced events with a planned two-stent strategy, while the EBC Main trial found no significant difference between provisional versus dual stenting.
3) Overall, the evidence suggests provisional stenting is usually sufficient for non-left main bifurcations, while planned two-stenting may provide a benefit for left main lesions
- Implantable cardioverter defibrillators (ICDs) are recommended for patients with hypertrophic cardiomyopathy (HCM) who have survived sudden cardiac arrest, have spontaneous sustained ventricular tachycardia, or meet certain high-risk criteria.
- Risk stratification should be performed at initial evaluation and periodically to determine ICD need based on factors like family history of sudden cardiac death and abnormal blood pressure response.
- For left ventricular outflow tract obstruction, beta blockers and calcium channel blockers are first-line medical therapies while septal myectomy or alcohol septal ablation are invasive options that provide long-term reduction in outflow gradient.
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In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
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Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
1. - DR. ROHIT WALSE
SENIOR RESIDENT
DM CARDIOLOGY
SCTIMST
MECHANICAL CIRCULATORY
SUPPORT DEVICES
2. SCOPE OF DISCUSSION
• INTRODUCTION
• EVOLUTION
• DEVICE TERMINOLOGY
• TEMPORARY DEVICES
• LONG TERM DEVICES
• RECOMMENDATIONS
3. INTRODUCTION
• Definition- Mechanical Circulatory Support
(MCS) Devices are mechanical pumps
designed to assist or replace the function of
either the left or the right ventricle or both
ventricles of the heart.
8. CHARACTERISTICS OF MCS DEVICES
• Location of the pumping chamber
• Specific ventricle/s supported
• Pumping mechanism
• Indicated duration of support-temporary/long
term
9. TERMINOLOGY
• PUMP LOCATION
Extracorporeal- Outside the body
Paracorporeal- Outside but adjacent to body
Intracorporeal- Implanted within the body
Orthotopic- In the normal position of heart
14. IABP- Intra Aortic Balloon Counter
Pulsation
PUMP MECHANISM COUNTERPULSATION
ENERGY SOURCE PNEUMATIC
METHOD OF PLACEMENT PERCUTANEOUS OR OPERATIVE
VENTRICLE SUPPORTED LV
DEGREE OF SUPPORT PARTIAL
15. MECHANISM
• Inflation at aortic valve
closure:
• Increases aortic diastolic blood
pressure
• Increases diastolic coronary
perfusion
• Net neutral effect on cerebral
perfusion
• Increases C.O./“runoff” to
subdiaphragmatic organs
• Deflation prior to systole:
• Reduces impedance to LV ejection
(afterload)
• Reduces myocardial oxygen
consumption
16. A = One complete cardiac
cycle
B = Unassisted aortic end
diastolic pressure
C = Unassisted systolic
pressure
D = Diastolic Augmentation
E = Reduced aortic end
17. INDICATIONS OF IABP
• Cardiogenic shock complicating AMI
• Prior to high risk PCI
• Prior to high risk CABG
• Severe acute MR
• Ventricular septal rupture
• Rescue after failed PCI going to CABG
• Bridge to VAD in patients awaiting transplant
20. Study Population Inclusion Endpoints Results
TACTICS 2005 57 AMI patients
with CS status
post-fibrinolytic
therapy
All-cause mortality at 6
months
1. 43% of the
fibrinolysis-only
group had died
versus 34%
of the fibrinolysis–
IABP group
(P=0.23)
2. Patients with
Killip class >II, 6-
month mortality
was 80% Vs 39%
(P=0.05).
• Agreed with the Class I C recommendation that IABP be
considered for “cardiogenic shock not quickly reversed with
pharmacological therapy as a stabilizing measure for
angiography and prompt revascularization”(AHA 1999)
21. Study Population Inclusion Endpoints Results
Prondzinsky et al
2010
45 AMI patients
with CS S/P
primary PCI
1. Change in APACHE
II scores over 4
days
2. Inflammatory
markers, brain
natriuretic
peptide levels,
hemodynamic
values, and in-
hospital mortality
1. BNP levels
were lower in
patients
receiving IABP
therapy
2. In-hospital
mortality was
similar (38.6%
versus 28.6%;
P=ns).
22. Study Population Inclusion Endpoints Results
IABP-SHOCK II 2012 600 AMI patients
with CS of <12
hours duration
30-day mortality 39.7% in the
IABP group
versus 41.3% in
the optimal
medical therapy
group; P=0.69)
23. ACC/AHA 2013 [ESC 2012-IIb]
• IIa- IABP can be useful for patients with
cardiogenic shock after STEMI who do not
quickly stabilise with pharmacoinvasive
therapy.
24. ESC-2014 Guidelines
IABP insertion should be considered in patients
with hemodynamic instability/cardiogenic shock
due to mechanical complications
IIa C
Routine use of IABP in patients with cardiogenic
shock is not recommended III A
25.
26. • Mortality in the IABP and the control group
(66.3% versus 67.0%; P=0.98).
• There were also no differences in recurrent
myocardial infarction, stroke, repeat
revascularization, or rehospitalization for
cardiac reasons (all P>0.05).
2018
27. IABP as BTT
• N= 32 IABP therapy (BTT) Vs 135 Electively
transplanted patients
• 80% - Survived to transplant without
additional MCS
• Mortality at 1 year -9.4% versus 11.1%;
(P=0.80)
28. • N = 88 patients with end-stage heart failure
• Axillary– subclavian IABP therapy.
• Survival to recovery, transplantation, or
durable mechanical support- 93.2%
• Access site complications - 9.1%
29. IMPELLA
PUMP MECHANISM CONTINUOUS FLOW ROTARY PUMP
ENERGY SOURCE ELECTRIC
METHOD OF PLACEMENT PERCUTANEOUS OR OPERATIVE
VENTRICLE SUPPORTED LV / RV
DEGREE OF SUPPORT PARTIAL
31. Advantages
• Does not require EKG or arterial waveform
triggering
• Facilitates stability even in the setting of
tachyarrhythmias or electromechanical
disassociation
32. Disadvantages
• Risk of device migration
• Device malfunction because of thrombosis
• Hemolysis
• Bleeding requiring transfusion
• Arrhythmias
• Limb ischemia
• Tamponade, aortic or mitral valve injury, and
stroke.
33. • ISAR-SHOCK trial
• 26 AMI patients with CS
• Impella LP 2.5 or IABP therapy
• 10 Endpoint: Change in C.I. after 30 minutes of
support
• Impella LP 2.5: 0.49±0.46 vs IABP therapy:
0.11±0.31 L/min/m2; P=0.02
• 20 Endpoint: 30-day mortality- 46% in both
groups
34. • IMPRESS TRIAL
• N = 48 AMI patients with CS
• Impella CP Vs IABP therapy
• Device placement - either prior to PCI, during PCI,
or immediately after PCI.
• 30 day mortality- Similar (50% -Impella CP or
46% -IABP therapy, P=0.92)
• Six-month mortality - 50% in both groups
35. • Case series
• N= 40
• March 2009 to December 2015
• Survival to transplant, LVAD, recovery- 75%
• Conclusion: Effective as a bridge to
transplantation, a bridge to bridge and a
bridge to recovery
36. TANDEM HEART
PUMP MECHANISM CONTINUOUS FLOW ROTARY PUMP
ENERGY SOURCE ELECTRIC
METHOD OF PLACEMENT PERCUTANEOUS
VENTRICLE SUPPORTED LV
DEGREE OF SUPPORT PARTIAL (2-4L/MIN)
37.
38. • N=41
• AMI patients with CS
• Hemodynamic support with either IABP therapy
Vs the TandemHeart.
• The primary end point- Improvements in cardiac
index[CI], pulmonary artery pressure, and PCWP
were seen in patients receiving the TandemHeart
• Secondary end points- 30-day mortality was
similar (43% versus 45%; P=0.86)
39. • N= 33
• Presenting within 24 hours of developing CGS
• IABP (n = 14) Vs TandemHeart pVAD (n = 19)
• Mean duration of support - 2.5 days
• TandemHeart pVAD- significantly greater increase in
cardiac index and mean arterial blood pressure and
significantly greater decreases in PCWP.
• Overall 30-day survival and severe adverse events were
not significantly different between the 2 groups
40. • 80 ischemic and 37 patients nonischemic CMP
• Tandemheart support for 5.8 +/- 4.75 days
Outcome Ischemic DCM Non ischemic
DCM
P value
30 day
mortality
40.2% 32% Ns
6 months
mortality
45.3% 35% Ns
41. ECMO
• blood is aspirated via a 18- to 21-Fr venous inflow
cannula in the femoral or internal jugular vein,
directed into a membrane oxygenator, and
returned to the arterial system via a 15- to 22-Fr
outflow cannula in the femoral or axillary artery,
PUMP MECHANISM CONTINUOUS FLOW ROTARY PUMP
ENERGY SOURCE VARIABLE
METHOD OF PLACEMENT PERCUTANEOUS OR OPERATIVE
VENTRICLE SUPPORTED LV & RV
DEGREE OF SUPPORT FULL (4-6 L/MIN)
44. • 975 patients with in-hospital cardiac arrest
events who underwent CPR for longer than 10
min
• 113 Conventional CPR group vs 59
extracorporeal CPR group
• ROSC- 24 [52%] CPR VS 42 [91%]-ECPR
45. • N- 295
• 1992-2007
• Multiinstitutional data from the
extracorporeal Life Support
Organization(ELSO) registry
• Survival - 27% of adults with cardiac arrest
facing imminent mortality
46. ECMO IN ADVANCED HF
• Patients with CS because of
• acute myocarditis,
• primary graft dysfunction,
• rejection
• As a bridge to bridge or bridge to transplant
47. • N= 81
• V-A ECMO for
• CS secondary to DCM, myocarditis,
postcardiotomy, posttransplantation.
• Median follow up- (11 months)
• In-hospital mortality- 58%
• Long term survival- 34.5%
• The majority of patients (57%) experienced >1
major ECMO-related complication.
48. • N= 517
• V-A ECMO after cardiac surgery
• Mean duration - 3.28±2.85 days.
• Successful weaning -63.3%
• 24.8%- Discharged.
Outcome Survival
6 months 17.6%
1 yr 16.5%
5 yrs 13.7%
74. BIVENTRICULAR SUPPORT
• Severebiventricular failure or predominant
right ventricular failure with significant left
ventricular disease, or those with complex
congenital heart disease.
• Total artificial heart (TAH) -
SynCardia temporary Total artificial
Heart
75. TAH
PUMP MECHANISM PULSATILE, VOLUME DISPLACEMENT
ENERGY SOURCE PNEUMATIC
METHOD OF PLACEMENT OPERATIVE
VENTRICLE SUPPORTED BV
IMPLANTABLE PUMP ORTHOTOPIC PLACEMENT
INDICATION BTT, DT
• 160g two artificial ventricles
• 70 mL SV - 9.5 L / minute
• Patients must have a BSA >1.7 m2
• A distance of ≥10 cm from the 10th anterior
vertebral body to the inner table of the sternum
on CT
77. • N= 116
• 70 cc Syncardia
• Survival to transplant- 79% (TAH) Vs 46%
(Control) [P<0.001]
• One-year survival rate- 70% (TAH) Vs 31%
controls (P<0.001)
• One-year and five-year survival rates after
transplantation -86% and 64%
N Engl J Med 2004; 351:859-867
78. • FDA Approval as BTT- 2004
• FDA Approval for 50 cc Syncardia- March 10,
2020
National Heart, Lung, and Blood Institute, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, and others,
provide important prognostic information for patients with advanced heart failure (HF) receiving mechanical support
18 hospitals without primary angioplasty capabilities in the U.S., Australia, and Europe between November 1996
2018
The mean duration of IABP therapy was 21±16 days
Eighty percent of patients had their IABPs surgically implanted in the right subclavian artery. The median duration of IABP support was 21 days (maximum 135 days).
Cardiac index- no difference at 4 hrs & 24 hrs. Feasibility and safety of a percutaneously delivered LVAD; effective and superior hemodynamic support.
92% H/O cardiac arrest requiring resuscitation.
More bleeding events (8 versus 2)- Impella CP than in the IABP group.
Case series- JACC
Oxygenated blood is withdrawn from the LA via a 21-Fr inflow cannula placed via transseptal puncture and then reinjected into the lower abdominal aorta or iliac arteries via a 15- to 17-Fr outflow cannula
Nineteen patients (90%) required blood transfusions (median 8.0 U, interquartile range, 3.8–16.5 U; IABP n=8; P=0.002), and 13 patients (62%) had signs of disseminated intravascular coagulation
blood is aspirated via a 18- to 21-Fr venous inflow cannula in the femoral or internal jugular vein, directed into a membrane oxygenator, and returned to the arterial system via a 15- to 22-Fr outflow cannula in the femoral or axillary artery,
(leg ischemia, femoral hemorrhage because of arterial laceration, cannula insertion-site infection, pulmonary edema, and circuit-related hemolysis)
Inotropic score, in μg/kg/min, was calculated as follows: dopamine + dobutamine + 100 × epinephrine + 100 × norepinephrine + 15 × milrinone
CAUSE OF ARREST- CARDIAC+ NON CARDIAC
Peripheral ECMO was switched to central ECMO in 3 patients (6%) because of leg ischemia or inadequate support.
major bleeding (32%), femoral vein thrombosis (10%), arterial ischemia (19%), vena cava thrombosis (7.4%), surgical wound infection (17%), pulmonary edema (12%), and stroke (8.6%)
29%- percutaneous cannuation; no mortality difference in central vs peripheral cannulation
Excellent hemodynamic support and improved survival
Titanium microspheres and a fibrillar textured inner surface that promoted the formation of a "pseudointima" that resists thrombogenesis.
350g, 10 L/min
150 g, 50cc, 10 L/min
2-year survival free from disabling stroke (with “disabling” defined as a modified Rankin scale score of ≥4 assessed 24 weeks after the stroke), with the patient alive with the originally implanted device, having undergone elective transplantation, or with the device explanted because of left ventricular recovery