Mechanical circulatory support
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This document discusses mechanical circulatory support devices (MCSDs) and artificial hearts. It begins by explaining heart failure and its stages. It then describes various types of temporary and permanent MCSDs, including their goals, energy sources, blood flow characteristics, and implantation methods. Examples of specific MCSDs are provided like the IABP, ECMO, Impella, TandemHeart, HeartMate XVE, HeartMate II, HeartWare, Jarvik 2000, and total artificial hearts from SynCardia and Carmat. Major complications of MCSDs and artificial hearts discussed are bleeding, infection, and thrombosis.
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RVADs/LVADs and all things mechanical by Dr Jayshree Lavana
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.
Device Impella RP-Sales Project
Erin is a 24-year old woman who needs a heart transplant after experiencing heart failure while running in the park. The Impella RP is a miniature heart pump that is placed via catheter into the femoral vein and pumps blood from the inferior vena cava into the pulmonary artery, unloading the right ventricle. It received FDA approval in January 2015 and can provide right heart support for up to two weeks. The Impella RP is intended for patients experiencing right heart failure after left heart support, heart attack, heart transplant, or heart surgery. It allows the heart to rest and recover its pumping ability with benefits of fast recovery without open heart surgery.
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This document discusses development of percutaneous mitral valve repair techniques and clinical trials. It provides background on chronic mitral regurgitation (MR) and the limitations of medical and surgical treatment. Percutaneous mitral valve repair offers benefits over surgery like reduced morbidity and shorter recovery. The document describes the four main percutaneous repair methods and focuses on the MitraClip edge-to-edge leaflet repair system, including patient selection criteria, procedure steps, and clinical trial results demonstrating safety and effectiveness for treating MR.
VAD
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Ventricular assist devices
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.
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RVADs/LVADs and all things mechanical by Dr Jayshree Lavana
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.
Device Impella RP-Sales Project
Erin is a 24-year old woman who needs a heart transplant after experiencing heart failure while running in the park. The Impella RP is a miniature heart pump that is placed via catheter into the femoral vein and pumps blood from the inferior vena cava into the pulmonary artery, unloading the right ventricle. It received FDA approval in January 2015 and can provide right heart support for up to two weeks. The Impella RP is intended for patients experiencing right heart failure after left heart support, heart attack, heart transplant, or heart surgery. It allows the heart to rest and recover its pumping ability with benefits of fast recovery without open heart surgery.
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VAD
Ventricular assist devices (VADs) are mechanical pumps that are used to partially or completely replace the function of the failing left ventricle (LVAD), right ventricle (RVAD), or both ventricles (BiVAD). Short-term VADs such as the Impella, TandemHeart, and ECMO are used for days to weeks to provide urgent hemodynamic support, while long-term VADs like the HeartMate II and III are implanted surgically to support patients for months to years as either a bridge to transplant or destination therapy. VADs carry risks of complications involving the inflow and outflow cannulas, pumps, batteries, drive lines, and may
FRACTIONAL FLOW RESERVE
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.
Ventricular assist devices
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.
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The document discusses the history and technique of transseptal puncture (TSP). It describes how TSP provides direct access to the left atrium and has become a routine skill for electrophysiologists performing procedures like atrial fibrillation ablation. The technique involves using a Brockenbrough needle and Mullins sheath inserted via the femoral or jugular vein to puncture the interatrial septum, usually at the fossa ovalis. Landmarks, equipment, steps of the procedure, challenges, and complications are reviewed in detail. The summary emphasizes the importance and increasing use of TSP as well as reviews key aspects of the technique and potential complications.
Stent Thrombosis
Stent thrombosis is a rare but serious complication of percutaneous coronary intervention (PCI) with mortality rates between 25-40%. It is classified based on timing (acute, subacute, late, very late) and etiology (primary, secondary). Risk factors include premature discontinuation of dual antiplatelet therapy, smoking, diabetes, chronic kidney disease, acute coronary syndrome, and high platelet reactivity. Strategies to minimize stent thrombosis involve careful patient selection, optimal stent deployment, adherence to potent dual antiplatelet regimens, and treatment involving emergent thrombectomy with escalated antiplatelet therapy.
IABP chetan
1. The document discusses the history, principles, anatomy, physiology, indications, and complications of intra-aortic balloon pumps (IABPs).
2. IABPs were developed in the 1950s and work by inflating during diastole to increase coronary blood flow and deflating during systole to reduce workload on the heart.
3. Proper positioning of the IABP catheter is important for effectiveness with tips typically placed just above the left main bronchus.
4. IABPs reduce myocardial oxygen demand and increase coronary blood flow by lowering systolic pressure and increasing diastolic pressure and flow.
Advanced ventricular assist device ppt
An advanced ventricular assist device (VAD) is a mechanical circulatory device that replaces the pumping action of a failing heart. It uses a continuous flow pump rather than emulating the heart's pulsing action. Key features include being ECG independent, running soundlessly, and producing a weak pulse. Advanced VADs help treat heart failure but also have shortcomings like coagulation, thrombosis, hemolysis, and infection that researchers continue working to address.
Acute prosthetic valve failure
A 44-year old male presented with chest pain and was found to have acute prosthetic aortic valve failure due to abnormal pannus proliferation trapping the valve orifice. He underwent emergency aortic valve replacement. Pannus formation leading to valve obstruction is a known complication of prosthetic heart valves. Both mechanical and bioprosthetic valves carry risks of structural deterioration or valve obstruction. Transesophageal echocardiography is the gold standard for diagnosing prosthetic valve thrombosis, while treatment options include thrombolysis or surgery depending on the patient's clinical status and risks.
No reflow and slow flow phenomenon during pci
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.
LEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPY
Left ventricular assist devices (LVADs) can provide long-term support for patients with end-stage heart failure who are not candidates for transplant. Continuous-flow LVADs have high 1- and 2-year survival rates of 80% and 70% respectively. While LVADs improve survival and quality of life, patients face risks of complications like bleeding, infection, stroke, and device malfunction. Ongoing management requires careful monitoring and optimization of patient hemodynamics and medical therapies.
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This document provides information about percutaneous transvenous mitral commissurotomy (PTMC), a procedure used to treat mitral stenosis. It discusses the stages and severity of mitral stenosis, indications and contraindications for PTMC, assessment of valve morphology, the PTMC procedure technique, instruments used, balloon size selection, post-procedure evaluation, complications, follow-up care, and long-term prognosis. PTMC is performed to improve the opening of a stenosed mitral valve by splitting the fused commissures using a balloon catheter, and is an important therapeutic option for treating symptomatic mitral stenosis.
Percutaneous circulatory support. iabp, impella and beyond
1) Percutaneous circulatory support devices like IABP, Impella and LVADs can provide hemodynamic support in cardiogenic shock, but their effects on mortality are unclear from randomized trials.
2) While LVADs provide better hemodynamic support than IABP, they also have higher risks of complications like bleeding and limb ischemia. Trials comparing IABP to medical management alone found no significant difference in mortality.
3) Revascularization through PCI or CABG within 36 hours appears to reduce mortality compared to medical stabilization alone for cardiogenic shock patients.
Christopher Hayward's SIN Talk: LVAD
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This document discusses complications that can occur during percutaneous coronary intervention (PCI), specifically contrast-induced nephropathy and coronary perforation. It defines contrast-induced nephropathy as acute kidney injury occurring after administration of radiocontrast media. Coronary perforation is defined as extravasation of contrast or blood from the coronary artery during or after PCI. The document discusses risk factors, prevention, diagnosis and management of these complications.
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This document describes equipment, catheters, and basic intervals used in electrophysiology (EP) studies. It discusses radiographic tables, EP equipment like cardiac stimulators and mapping/ablation catheters. Patient preparation includes fasting, IV access, monitoring equipment. EP catheters come in different sizes and have electrodes for recording electrical activity. Basic intervals measured include P wave to atrial interval, atrial-His bundle interval, His-ventricular interval, and sinus node recovery time. Drive train stimulation with single, double, or triple extra stimuli is used. The document continues with further discussions of EP protocols, arrhythmias, ablation, and pre-excitation pathways.
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Coronary perforation
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Ventricular septal defect after myocardial infarction
This document discusses ventricular septal defects (VSDs) that occur after a myocardial infarction. It provides several key points:
1. Surgical repair is the gold standard treatment for post-infarction VSD, but patients are at high risk for complications and mortality rates remain poor.
2. Transcatheter device closure of VSDs is an emerging alternative to surgery, with studies showing high rates of technical success but also risks of major complications and death within 30 days.
3. Factors associated with increased mortality from both surgical repair and device closure include older age, cardiogenic shock, renal dysfunction, and larger defect size. Overall, post-infarction VSD continues to carry
Chronic total occlusion (CTO)
This document discusses strategies and techniques for managing chronic total occlusions (CTO). CTOs are coronary blockages that are completely blocked for more than 3 months. The document outlines the histopathology of CTOs and factors that predict success or failure of percutaneous coronary intervention (PCI). It also describes various guidewires, microcatheters, and crossing devices that can be used to recanalize CTOs via antegrade or retrograde approaches. Successful PCI of CTOs has been shown to improve angina, reduce the need for bypass surgery, and improve survival.
Management of no reflow
No-reflow occurs when there is a lack of reperfusion to the myocardium after successful coronary recanalization and is defined as inadequate perfusion without angiographic evidence of vessel obstruction. It occurs in 0.6-3.2% of PCI cases and is associated with increased risk of LV dysfunction, remodeling, arrhythmias, heart failure and cardiac rupture. Diagnosis is typically done using myocardial contrast echocardiography or cardiac MRI. Treatment focuses on improving perfusion and includes vasodilators like adenosine, antithrombotics, mechanical strategies like thrombectomy, and preventing no-reflow through measures like pre-conditioning.
Which device to which patient.
This document discusses the different types of mechanical circulatory support devices available for patients with advanced heart failure, including both temporary and durable devices. It provides details on specific patient indications for each type of device. For temporary support, options include intra-aortic balloon pumps (IABP), Impella pumps, TandemHeart, CentriMag, AbioMed BVS 5000, and extracorporeal membrane oxygenation (ECMO). For durable support, left ventricular assist devices (LVADs) discussed are the HeartMate II and HeartWare LVADs, as well as the total artificial heart. The document emphasizes that choice of device depends on each individual patient's clinical situation and goals of therapy.
CRT
Cardiac resynchronization therapy (CRT) involves implanting electrodes in the left and right ventricles of the heart to coordinate their contractions and improve heart function in patients with heart failure. CRT works by delivering electrical pulses that resynchronize the timing of the ventricles' contractions. Studies show CRT can improve symptoms, exercise capacity, quality of life and reduce mortality and hospitalizations in heart failure patients. CRT devices include a pacemaker or defibrillator and leads placed in the heart to deliver electrical pulses. Doctors program the devices to optimize timing between the ventricles. CRT is effective for treating ventricular dyssynchrony seen in conditions like left bundle branch block.
Code Management: VT & VF
This document defines ventricular tachycardia and ventricular fibrillation, and outlines the ACLS algorithms for cardiac arrest caused by VT/VF. VT is defined as too rapid myocardial contraction preventing adequate cardiac output, while VF is rapid, uncoordinated myocardial cell contraction preventing coordinated contraction. Causes include ischemia, structural heart issues, electrolyte disturbances, and others. Immediate CPR and defibrillation improve odds of return of spontaneous circulation (ROSC). If ROSC is achieved, post-cardiac arrest care is needed to manage ischemia/reperfusion injury risks like low blood pressure and cardiac dysfunction.
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The document discusses the history and technique of transseptal puncture (TSP). It describes how TSP provides direct access to the left atrium and has become a routine skill for electrophysiologists performing procedures like atrial fibrillation ablation. The technique involves using a Brockenbrough needle and Mullins sheath inserted via the femoral or jugular vein to puncture the interatrial septum, usually at the fossa ovalis. Landmarks, equipment, steps of the procedure, challenges, and complications are reviewed in detail. The summary emphasizes the importance and increasing use of TSP as well as reviews key aspects of the technique and potential complications.
Stent Thrombosis
Stent thrombosis is a rare but serious complication of percutaneous coronary intervention (PCI) with mortality rates between 25-40%. It is classified based on timing (acute, subacute, late, very late) and etiology (primary, secondary). Risk factors include premature discontinuation of dual antiplatelet therapy, smoking, diabetes, chronic kidney disease, acute coronary syndrome, and high platelet reactivity. Strategies to minimize stent thrombosis involve careful patient selection, optimal stent deployment, adherence to potent dual antiplatelet regimens, and treatment involving emergent thrombectomy with escalated antiplatelet therapy.
IABP chetan
1. The document discusses the history, principles, anatomy, physiology, indications, and complications of intra-aortic balloon pumps (IABPs).
2. IABPs were developed in the 1950s and work by inflating during diastole to increase coronary blood flow and deflating during systole to reduce workload on the heart.
3. Proper positioning of the IABP catheter is important for effectiveness with tips typically placed just above the left main bronchus.
4. IABPs reduce myocardial oxygen demand and increase coronary blood flow by lowering systolic pressure and increasing diastolic pressure and flow.
Advanced ventricular assist device ppt
An advanced ventricular assist device (VAD) is a mechanical circulatory device that replaces the pumping action of a failing heart. It uses a continuous flow pump rather than emulating the heart's pulsing action. Key features include being ECG independent, running soundlessly, and producing a weak pulse. Advanced VADs help treat heart failure but also have shortcomings like coagulation, thrombosis, hemolysis, and infection that researchers continue working to address.
Acute prosthetic valve failure
A 44-year old male presented with chest pain and was found to have acute prosthetic aortic valve failure due to abnormal pannus proliferation trapping the valve orifice. He underwent emergency aortic valve replacement. Pannus formation leading to valve obstruction is a known complication of prosthetic heart valves. Both mechanical and bioprosthetic valves carry risks of structural deterioration or valve obstruction. Transesophageal echocardiography is the gold standard for diagnosing prosthetic valve thrombosis, while treatment options include thrombolysis or surgery depending on the patient's clinical status and risks.
No reflow and slow flow phenomenon during pci
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.
LEFT VENTRICULAR ASSIST DEVICE- DESTINATION THERAPY
Left ventricular assist devices (LVADs) can provide long-term support for patients with end-stage heart failure who are not candidates for transplant. Continuous-flow LVADs have high 1- and 2-year survival rates of 80% and 70% respectively. While LVADs improve survival and quality of life, patients face risks of complications like bleeding, infection, stroke, and device malfunction. Ongoing management requires careful monitoring and optimization of patient hemodynamics and medical therapies.
PTMC/PBMC
This document provides information about percutaneous transvenous mitral commissurotomy (PTMC), a procedure used to treat mitral stenosis. It discusses the stages and severity of mitral stenosis, indications and contraindications for PTMC, assessment of valve morphology, the PTMC procedure technique, instruments used, balloon size selection, post-procedure evaluation, complications, follow-up care, and long-term prognosis. PTMC is performed to improve the opening of a stenosed mitral valve by splitting the fused commissures using a balloon catheter, and is an important therapeutic option for treating symptomatic mitral stenosis.
Percutaneous circulatory support. iabp, impella and beyond
1) Percutaneous circulatory support devices like IABP, Impella and LVADs can provide hemodynamic support in cardiogenic shock, but their effects on mortality are unclear from randomized trials.
2) While LVADs provide better hemodynamic support than IABP, they also have higher risks of complications like bleeding and limb ischemia. Trials comparing IABP to medical management alone found no significant difference in mortality.
3) Revascularization through PCI or CABG within 36 hours appears to reduce mortality compared to medical stabilization alone for cardiogenic shock patients.
Christopher Hayward's SIN Talk: LVAD
Cardiologist Chris Hayward talks about LVAD (Left ventricular assist devices) for the Sydney Intensive Network. The audio is found on www.intensivecarenetwork.com
PCI complications
This document discusses complications that can occur during percutaneous coronary intervention (PCI), specifically contrast-induced nephropathy and coronary perforation. It defines contrast-induced nephropathy as acute kidney injury occurring after administration of radiocontrast media. Coronary perforation is defined as extravasation of contrast or blood from the coronary artery during or after PCI. The document discusses risk factors, prevention, diagnosis and management of these complications.
Implication of 3D Mapping in EP
This document discusses the implications of 3D mapping in electrophysiology procedures. It provides an overview of common arrhythmias treated with catheter ablation such as WPW syndrome, AVNRT, atrial flutter, and atrial fibrillation. It describes the typical sequence of an EP study and ablation procedure. It also discusses classification of tachycardias as focal or macroreentrant, and different reentry patterns. The document highlights the development of 3D mapping technologies including contact and non-contact mapping systems, and their ability to create 3D geometry and electroanatomic maps with integration of CT/MRI images. It reviews studies validating the reduction of fluoroscopy time with 3D mapping approaches.
Electrophysiology study basics
This document describes equipment, catheters, and basic intervals used in electrophysiology (EP) studies. It discusses radiographic tables, EP equipment like cardiac stimulators and mapping/ablation catheters. Patient preparation includes fasting, IV access, monitoring equipment. EP catheters come in different sizes and have electrodes for recording electrical activity. Basic intervals measured include P wave to atrial interval, atrial-His bundle interval, His-ventricular interval, and sinus node recovery time. Drive train stimulation with single, double, or triple extra stimuli is used. The document continues with further discussions of EP protocols, arrhythmias, ablation, and pre-excitation pathways.
Principles Of Intra Aortic Balloon Pump Counterpulsation
The document discusses the principles of intra-aortic balloon pump counterpulsation. It provides a brief history of IABP development and use. It describes the hemodynamic effects of IABP including reducing systolic pressure and increasing diastolic pressure in the aorta and left ventricle. It lists common indications and contraindications for IABP use as well as potential complications. It also outlines the technique for IABP insertion and operation.
BMV,PTMC,BALLOON MITRAL VALVOTOMY, BAL, VIRBHAN BALAI, DR VIRBHAN
This document discusses balloon mitral valvuloplasty (BMV) and balloon aortic valvuloplasty (BAV). It describes the indications for BMV as symptomatic or asymptomatic severe mitral stenosis. The Inoue technique for BMV is explained in detail, including transseptal puncture and sequential balloon inflation. Complications of BMV include severe mitral regurgitation, mortality, and cardiac perforation. BAV was used historically but was abandoned due to high restenosis rates and no improvement in patient survival.
Coronary perforation
This document discusses the treatment of coronary perforations that can occur during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). It describes 5 types of coronary perforations and provides guidance on how to treat each type. For minor perforations (Type I), careful observation is sufficient. For more significant perforations (Types II-III), prolonged balloon inflation at the perforation site is recommended, along with reversing anticoagulation if needed. For life-threatening bleeding (Type IV), measures may include pericardiocentesis, prolonged balloon inflation, and deployment of a covered stent. Surgery is needed for some unresponsive perforations (Type II-III).
Ventricular septal defect after myocardial infarction
This document discusses ventricular septal defects (VSDs) that occur after a myocardial infarction. It provides several key points:
1. Surgical repair is the gold standard treatment for post-infarction VSD, but patients are at high risk for complications and mortality rates remain poor.
2. Transcatheter device closure of VSDs is an emerging alternative to surgery, with studies showing high rates of technical success but also risks of major complications and death within 30 days.
3. Factors associated with increased mortality from both surgical repair and device closure include older age, cardiogenic shock, renal dysfunction, and larger defect size. Overall, post-infarction VSD continues to carry
Chronic total occlusion (CTO)
This document discusses strategies and techniques for managing chronic total occlusions (CTO). CTOs are coronary blockages that are completely blocked for more than 3 months. The document outlines the histopathology of CTOs and factors that predict success or failure of percutaneous coronary intervention (PCI). It also describes various guidewires, microcatheters, and crossing devices that can be used to recanalize CTOs via antegrade or retrograde approaches. Successful PCI of CTOs has been shown to improve angina, reduce the need for bypass surgery, and improve survival.
Management of no reflow
No-reflow occurs when there is a lack of reperfusion to the myocardium after successful coronary recanalization and is defined as inadequate perfusion without angiographic evidence of vessel obstruction. It occurs in 0.6-3.2% of PCI cases and is associated with increased risk of LV dysfunction, remodeling, arrhythmias, heart failure and cardiac rupture. Diagnosis is typically done using myocardial contrast echocardiography or cardiac MRI. Treatment focuses on improving perfusion and includes vasodilators like adenosine, antithrombotics, mechanical strategies like thrombectomy, and preventing no-reflow through measures like pre-conditioning.
Which device to which patient.
This document discusses the different types of mechanical circulatory support devices available for patients with advanced heart failure, including both temporary and durable devices. It provides details on specific patient indications for each type of device. For temporary support, options include intra-aortic balloon pumps (IABP), Impella pumps, TandemHeart, CentriMag, AbioMed BVS 5000, and extracorporeal membrane oxygenation (ECMO). For durable support, left ventricular assist devices (LVADs) discussed are the HeartMate II and HeartWare LVADs, as well as the total artificial heart. The document emphasizes that choice of device depends on each individual patient's clinical situation and goals of therapy.
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Cardiac resynchronization therapy (CRT) involves implanting electrodes in the left and right ventricles of the heart to coordinate their contractions and improve heart function in patients with heart failure. CRT works by delivering electrical pulses that resynchronize the timing of the ventricles' contractions. Studies show CRT can improve symptoms, exercise capacity, quality of life and reduce mortality and hospitalizations in heart failure patients. CRT devices include a pacemaker or defibrillator and leads placed in the heart to deliver electrical pulses. Doctors program the devices to optimize timing between the ventricles. CRT is effective for treating ventricular dyssynchrony seen in conditions like left bundle branch block.
Code Management: VT & VF
This document defines ventricular tachycardia and ventricular fibrillation, and outlines the ACLS algorithms for cardiac arrest caused by VT/VF. VT is defined as too rapid myocardial contraction preventing adequate cardiac output, while VF is rapid, uncoordinated myocardial cell contraction preventing coordinated contraction. Causes include ischemia, structural heart issues, electrolyte disturbances, and others. Immediate CPR and defibrillation improve odds of return of spontaneous circulation (ROSC). If ROSC is achieved, post-cardiac arrest care is needed to manage ischemia/reperfusion injury risks like low blood pressure and cardiac dysfunction.
MCS.pptx mechanical circulatory su pport
This document discusses mechanical circulatory support devices for heart failure. It notes that heart failure affects millions of people annually and has a high mortality rate. For patients with end-stage heart failure, cardiac transplantation has been the gold standard treatment, but donor organs are limited. Mechanical circulatory support devices like left ventricular assist devices can improve quality of life and survival for patients waiting for a transplant or who are ineligible for transplant. The document discusses various types of mechanical circulatory support devices and their indications, components, and physiology. It also covers patient assessment, contraindications, and short-term versus long-term support options.
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Mechanical Circulatory Support.pptx
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.
Pharmacotherapy of Arrhythmias
This document discusses normal cardiac electrophysiology and the mechanisms of arrhythmias. It begins by describing the normal sinus rhythm and the role of ion channels and gap junctions. It then explains the cardiac action potential and factors that determine the resting membrane potential. Different types of abnormal impulse formation are described, including abnormal automaticity, triggered activity, and reentry. The document outlines evaluation and management of arrhythmias and discusses specific arrhythmias like atrial fibrillation, SVT, and VT. In summary, it provides an overview of cardiac electrophysiology, mechanisms of arrhythmias, evaluation, and treatment approaches.
Mechanical circulatory support devices
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.
Device therapy for heart failure monitoring and management
The document discusses device therapy for heart failure management and monitoring. It notes that heart failure results in high mortality and morbidity and places a significant financial burden on healthcare systems. Implantable devices like implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) play an important role in managing advanced heart failure by treating arrhythmias, improving morbidity and mortality, and increasing quality of life. Several landmark randomized controlled trials provided evidence of the benefits of CRT in reducing mortality and improving outcomes for heart failure patients.
Device therapy for heart failure monitoring and management
1) Device therapy such as ICDs and CRT play an important role in managing advanced heart failure by treating life-threatening arrhythmias and improving morbidity and survival.
2) Clinical trials such as MUSTIC, MIRACLE, and CARE-HF demonstrated that CRT improves symptoms, exercise capacity, quality of life and reduces mortality in patients with heart failure and ventricular dyssynchrony.
3) The COMPANION trial showed that CRT with or without an ICD provided greater benefits than medical therapy alone in reducing the risk of all-cause mortality and hospitalizations.
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This document provides information on post-cardiac surgery monitoring and follow up. It discusses admission to the ICU, initial assessment, monitoring techniques, complications that can occur like bleeding and hemodynamic issues, and management strategies for those complications. The early focus is on stabilizing vital signs, addressing hypothermia, identifying potential issues like low cardiac output, and treating medical causes of bleeding through correcting coagulation abnormalities.
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EMGuideWire's Radiology Reading Room: Mechanical Circulatory Support Devices
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Mechanical Circulatory Support Devices and is brought to you by Jenna Pallansch, MD, Morgan Penzler, MD, Gabriella Rivera Camacho, MD, Blaire Langa, NP, Claire Lawson, NP, Ashley Moore-Gibbs, DNP, Laszlo Littmann, MD, and Richard Musialowski, MD.
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1) Coronary artery bypass grafting (CABG) is performed to improve quality of life and reduce mortality for patients with coronary artery disease.
2) Anesthesia for CABG involves monitoring the patient throughout various stages including pre-bypass, maintenance on bypass, and weaning from bypass.
3) Key aspects include induction, myocardial protection through hypothermia and cardioplegia, and monitoring the patient closely during and after coming off bypass.
Diagnostic tests in cardiology
Diagnostic tests are used in cardiology to confirm data from a patient's history and physical assessment. Common tests include blood studies to detect cardiac biomarkers released during injury, imaging studies like echocardiograms and CT scans to visualize the heart structures, and stress tests to evaluate the heart's response to physical or pharmacological stress. Electrocardiograms are also routinely performed to analyze the heart's electrical activity. More invasive procedures like cardiac catheterization can further evaluate conditions and guide treatment. The results of diagnostic tests along with the clinical picture are important for cardiologists to diagnose and manage cardiovascular conditions.
ECMO.pptx
This document discusses extracorporeal membrane oxygenation (ECMO), including its indications, types (veno-arterial and veno-venous), management strategies, and the experience with ECMO at Heart Hospital. ECMO can be used as a bridge to recovery, decision-making, surgery, long-term devices like LVADs, or transplant. It involves draining blood from the body, removing carbon dioxide and adding oxygen through an external oxygenator before returning the blood. Management involves anticoagulation and monitoring various patient parameters. Complications can include bleeding, infection, and organ dysfunction. Criteria and protocols are discussed for weaning patients off ECMO support.
CABG
This document provides an overview of coronary artery bypass graft (CABG) surgery. [1] It defines CABG as a procedure that grafts arteries to bypass blockages in the coronary arteries and improve blood flow to the heart. [2] It discusses the pre-operative, intra-operative, and post-operative nursing management of patients undergoing CABG, including assessment, interventions to ensure patient safety and comfort, and monitoring for complications during recovery. [3] The objectives are for students to understand the CABG procedure, indications, nursing care involved, and potential complications.
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CABG
This document discusses the history and guidelines for coronary artery bypass grafting (CABG). It provides:
1) Key events and innovations in the development of CABG, including the first successful procedures in the USSR, US, and Bulgaria.
2) Indications for CABG based on the number and location of diseased vessels and patient characteristics, as outlined in European and US guidelines.
3) Considerations for conduit choice, preoperative evaluation, and risk stratification prior to CABG.
4) An overview of how CABG differs from percutaneous coronary intervention (PCI) in treating both present and future coronary lesions due to the placement of bypass grafts in the mid coronary arteries.
Acute aortic syndrome
Acute aortic syndrome (AAS) refers to life-threatening pathologies of the thoracic aorta including aortic dissection, penetrating aortic ulcer, intramural hematoma, and leaking aortic aneurysm. Management of AAS involves surgery for ascending aorta pathologies and medical management or potential intervention for descending aorta issues depending on complications. Investigation options include TEE, CTA, MRI, and aortography but have limitations. Surgical and endovascular options aim to prevent complications like rupture but have significant mortality and morbidity risks.
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Surgery has a long history, with the earliest known surgeries dating back over 7,000 years to trepanation procedures in Ukraine. Significant developments include ancient Egyptian brain surgery, Sushruta's pioneering of plastic surgery techniques in India in 600 BC, and advances made by Greek physicians like Hippocrates and Galen. In medieval times, surgery declined but was practiced by barbers and monks. Key historical figures helped establish modern surgical principles like controlling bleeding (Pare), understanding anatomy (Vesalius), anesthesia (Morton), antisepsis (Lister), and advances in multiple surgical specialties in the late 19th/early 20th centuries. Major 20th century developments include antibiotics, trans
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This document provides an overview of transplant surgery principles and history. It discusses how in ancient times, limb replacement was performed. In the 1950s, the first successful kidney transplant occurred between identical twins without immunosuppression. In the following decades, drugs like azathioprine and cyclosporine were discovered that allowed transplantation of other organs by preventing rejection. The document also describes the types of graft rejection, principles of immunosuppression therapy, complications of infection and malignancy, and definitions relevant to transplantation.
Surgical oncology ( malignancies )
Malignant tumors can be classified based on their cell of origin and include carcinomas, sarcomas, and germ cell tumors. They are characterized by uncontrolled growth, invasion of surrounding tissues, and spread through lymphatics or bloodstream. Diagnosis is confirmed through biopsy and histopathological examination showing features of malignancy. While some genetic and environmental factors are known to increase cancer risk, the exact causes remain unclear. Staging systems help determine prognosis and appropriate treatment.
Surgical oncology 1 ( Benign tumors)
This document provides information on benign tumors, including their definition, differences between benign and malignant tumors, and descriptions of specific benign tumor types. Some key points:
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- Common benign tumor types described include lipomas, fibromas, papillomas, neurofibromas, and pigmented nevi. Specific features and classifications of lipomas and neurofibromas are outlined.
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Tricuspid valve disease
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Cardiopulmonary bypass
1. Cardiopulmonary bypass (CPB) was first successfully used by John Gibbon in 1953 and has since revolutionized cardiac surgery by allowing temporary replacement of heart and lung function.
2. CPB involves cannulating major vessels to establish bypass between the cardiopulmonary bypass machine and the patient, allowing the heart to be isolated from circulation.
3. Myocardial protection techniques like cardioplegic arrest and hypothermia are used during CPB to protect the heart from ischemic damage while it is stopped.
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Chd essentials
This document discusses congenital heart disease (CHD), which are abnormalities in heart structure present from birth. CHDs arise during gestation and are the most common birth defect. While many CHDs cause increased blood flow to the lungs, some cause obstruction of blood flow. CHDs are classified as cyanotic if they involve deoxygenated blood in the arteries, or acyanotic. Common acyanotic defects include patent ductus arteriosus, atrial septal defect, and ventricular septal defect. Tetralogy of Fallot is a common cyanotic defect involving a right-to-left shunt.
CAD & CABG
1. Coronary artery disease is caused by atherosclerosis developing in three stages, culminating in plaque rupture and thrombosis.
2. Risk factors for atherosclerosis and CAD include smoking, hyperlipidemia, hypertension, diabetes, male gender, increasing age, and family history.
3. Acute coronary syndromes include unstable angina, NSTEMI, and STEMI, differentiated by cardiac enzymes and ECG changes. High-risk patients with ongoing symptoms should receive urgent angiography and revascularization.
Aortic stenosis and aortic valve replasement
This document discusses aortic stenosis and aortic valve replacement. It begins by describing the causes of aortic stenosis as either congenital or acquired. For treatment, it discusses the guidelines for aortic valve replacement and compares mechanical versus biological prosthetic valves. The key surgical approaches are also summarized, including conventional surgery, Ross procedure, homografts, and newer transcatheter aortic valve implantation procedures. Overall, the document provides an overview of aortic stenosis and the current options for surgical and non-surgical management.
Mitral valve disease
The document discusses mitral regurgitation (MR), including its natural history, pathophysiology, classification, causes, symptoms, signs, quantification via echocardiography, and indications for mitral valve surgery. It notes that asymptomatic patients with MR can have a long latent period before symptoms develop. Severe MR is classified based on criteria such as jet area, regurgitant volume, and effective regurgitant orifice area. Etiologies include myxomatous degeneration, rheumatic fever, and ischemic cardiomyopathy. Evaluation involves assessing left atrial and ventricular size and function along with MR severity. Surgery is indicated for severe, symptomatic MR or asymptomatic patients with good ventricular function and a high likelihood of
Aneurysms & dissections
This document discusses aneurysms and dissections of the thoracic aorta. It begins by describing the anatomical layers of the thoracic aorta and then defines different types of aneurysms including true aneurysms, false aneurysms, fusiform aneurysms, saccular aneurysms, and dissecting aneurysms. It discusses causes, symptoms, natural history, risk factors, and investigations for thoracic aortic aneurysms. It also describes specific conditions like Marfan syndrome, Ehlers-Danlos syndrome, and Loeys-Dietz syndrome that are associated with aortic aneurysms. The principles and indications for surgery to treat thoracic aortic aneurysms are outlined.
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This document provides information on congenital heart disease. It discusses various types of acyanotic heart defects including atrial septal defects (ASD), ventricular septal defects (VSD), patent ductus arteriosus (PDA), and coarctation of the aorta (CoA). For each condition, it describes the pathophysiology, clinical presentation, diagnostic evaluation, and treatment options including surgical repair. Common anatomical variations are defined for different subtypes of each condition.
Varicose disease varicosity
This document discusses varicose veins and their treatment. It begins by describing the anatomy and physiology of the venous system, including the roles of superficial, perforator, and deep veins as well as venous valves and the venous pump. It then discusses varicose veins specifically, including risk factors, classifications, and complications. Clinical features of varicose veins are outlined. The pathophysiology of varicose veins involves valve incompetence and chronic venous hypertension. Investigative tests for varicose veins are described. Surgical and non-surgical treatment options are presented.
Covid 19 & cardiac surgery
Cardiac surgery departments and providers face significant challenges in treating patients during the COVID-19 pandemic. Patients undergoing cardiac surgery are often older with pre-existing health conditions, putting them at high risk for severe COVID-19 infections before and after procedures. While emergency cardiac surgeries and interventions should continue following strict safety protocols, elective procedures may need to be postponed to avoid risks to patients and conserve critical care resources that may be needed to treat COVID-19 patients. Cardiac surgery teams also need to take precautions to avoid exposure given the risk of working with intubated COVID-19 patients. The long term impacts of the pandemic on cardiac surgery capabilities and the healthcare system remain uncertain.
Mechanical complications of cad
This document discusses several mechanical complications that can arise from coronary artery disease, including left ventricular aneurysm, ventricular septal defect, left ventricular free wall rupture, and ischemic mitral regurgitation. It provides details on the causes, presentations, diagnoses, and surgical treatments for each complication. Surgical techniques like linear repair, patch repair, and infarct exclusion are described for repairing left ventricular aneurysms and ventricular septal defects. The importance of addressing these complications through early surgical intervention is emphasized.
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1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
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2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Mechanical circulatory support
- 1. MECHANICAL CIRCULATORY SUPPORT DEVICES & ARTIFICIAL HEARTS Department of Cardiac and Vascular Surgery Medical University Plovdiv Hristo Rahman
- 2. HEART FAILURE • HF as a complication: • Terminal stage of any heart disease • HF affects: • - Ventricular filling ( diastolic dysfunction ); • - Myocardial contraction ( systolic dysfunction ). • The heart is unable to adequately provide blood circulation needed for the normal functioning of the metabolic processes within peripheral tissues, other organs and systems • Secondary Multi-System Organ Failure (MSOF) develops as a result of terminal HF
- 4. STAGE DEFINITION А At high risk for HF but without structural heart disease or symptoms of HF and structural heart disease not present ( pts. with: hypertension and diabetes; cardiotoxic cancer chemotherapy, etc. ) B Structural heart disease appears including changes in chamber size or shape, valvular lesions, LVH, but NO symptoms of HF ( pts. with: prior MI; asymptomatic valvular heart disease, etc.) C Structural heart disease with prior or current symptoms of HF ( pts. with: chronic systolic or diastolic LV dysfunction ) D Refractory HF requiring specialised interventions Patients are symptomatic at rest despite max. medical therapy. Need of MCSD and/or Heart Transplant
- 5. HF stage D ( ACCF & AHA ) ETIOLOGY • ISCHAEMIC CARDIOMYOPATHY • DILATED CARDIOMYOPATHY • 1) viral-induced • 2) toxic • 3) drug-induced • 4) alcohol-induced • SARCOIDOSIS • PERIPARTUM CARDIOMYOPATHY
- 6. MECHANICAL CIRCULATORY SUPPORT ( MCS ) • DEFINITION • - Means of generating kinetic energy, needed to maintain blood circulation by artificial devices • AIMS • - 1) To support: ( IABP, ECMO, Impella Recover, TandemHeart ) • - 2) To partially or fully replace: ( HeartMate XVE, Thoratec VAD, Jarvik 2000, SynCardia TAH ) • Pump function of compromised LV/RV or LV+RV
- 7. MECHANICAL CIRCULATORY SUPPORT DEVICES ( MCSDs ) • TEMPORARY MCSDs: • - 1) short period of time ( days ) • ( IABP, ECMO, Impella Recover, TandemHeart, ABIOMED BVS 5000 ) • - 2) long period of time ( weeks, months, years ) • ( HeartMate XVE, Thoratec VAD, CardioWest TAH ) • PERMANENT MCSDs ( Destination therapy ) • ( HeartMate II, AbioCor TAH, Jarvik 2000, INCOR LVAD )
- 8. MECHANICAL CIRCULATORY SUPPORT DEVICES ( MCSDs ) • Mechanical pump mechanism location • 1) outside of body ( extra-/paracorporeal ) • ( Thoratec PVAD ) • 2) within body ( intracorporeal ) • ( INCOR LVAD, HeartMate II, Jarvik 2000 )
- 9. MECHANICAL CIRCULATORY SUPPORT DEVICES ( MCSDs ) • GOALS: • SUPPORT OF COMPROMISED MYOCARDIAL PUMP FUNCTION UNTIL: • 1) event of full myocardial recovery • Bridge-to-Recovery • 2) event of adequate decision for further management • Bridge-to-Decision • 3) event of continuing support with another type of MCSD • Bridge-to-Bridge • 4) event of heart transplant surgery • Bridge-to-Transplantation • 5) for the rest of life • Destination therapy
- 10. MECHANICAL CIRCULATORY SUPPORT DEVICES ( MCSDs ) • Source of energy • 1) Electric ( HeartMate XVE ) • 2) Pneumatic ( Thoratec VAD ) • Position of energy source ( battery ) • 1) Intracorporeal ( AbioCor TAH ) • 2) Paracorporeal ( HeartMate II, SynCardia TAH ) ( transcutaneously conducted electric energy )
- 11. MECHANICAL CIRCULATORY SUPPORT DEVICES ( MCSDs ) • Characteristics of the generated blood flow • 1) Pulsatile • ( HeartMate XVE, Thoratec VAD, CardioWest TAH ) • 2) Laminar • ( Impella Recover, HeartMate II, Jarvik 2000, INCOR LVAD )
- 12. MECHANICAL CIRCULATORY SUPPORT DEVICES ( MCSDs ) • Implantation methods • 1) Percutaneous • ( IABP, ECMO, Impella Recover, TandemHeart ) • 2) Surgical • ( HeartMate II, Thoratec VAD, INCOR, AbioCor TAH ) • 3) Percutaneous and/or Surgical • ( IABP, ECMO, Impella Recover )
- 13. IABP
- 14. ECMO
- 15. Impella Recover
- 16. TandemHeart
- 17. ABIOMED BVS 5000
- 18. Thoratec VAD
- 19. HeartMate XVE
- 20. HeartMate II
- 21. HeartMate III
- 22. HeartMate III • No CPB • 2 mini-thoracotomies • * minimally invasive • E. Potapov, DHZB, 2016
- 23. HeartWare
- 24. HeartMate II vs. HeartMate III
- 25. Jarvik 2000
- 27. SynCardia TAH
- 28. Carmat TAH
- 29. AbioCor TAH
- 30. AbioCor TAH
- 31. MAJOR COMPLICATIONS OF MCSDs & TAHs • BLEEDING • INFECTION • THROMBOSIS