This document discusses advanced treatments for refractory heart failure, including devices and surgery. Cardiac resynchronization therapy (CRT), implantable cardioverter defibrillators (ICD), and combination devices are recommended implantable options. Percutaneous and surgical interventions include coronary revascularization, stem cell therapy, mitral valve procedures, LV assist devices, cardiac reshaping surgeries, and heart transplantation. Other treatments mentioned are ultrafiltration to remove fluid overload and CPAP for patients with heart failure and sleep apnea.
RECENT ADVANCES IN THE MANAGEMENT OF REFRACTORY HEART FAILUREApollo Hospitals
Heart failure is a pathophysiological state in which structural or functional cardiac disorder impairs the ability of the heart to function as a pump to support the physiological circulation. The medical therapy remains the
mainstay of treatment in these patients. The medical therapy can improve the quality of life and the longevity in
these patients, but this becomes insufficient in refractory heart failure. The heart failure is considered refractory when patients continued to be symptomatic despite optimal dose of medications, characterized by advanced structural heart disease. These patients will need frequent hospitalizations and the overall prognosis is very poor.
RECENT ADVANCES IN THE MANAGEMENT OF REFRACTORY HEART FAILUREApollo Hospitals
Heart failure is a pathophysiological state in which structural or functional cardiac disorder impairs the ability of the heart to function as a pump to support the physiological circulation. The medical therapy remains the
mainstay of treatment in these patients. The medical therapy can improve the quality of life and the longevity in
these patients, but this becomes insufficient in refractory heart failure. The heart failure is considered refractory when patients continued to be symptomatic despite optimal dose of medications, characterized by advanced structural heart disease. These patients will need frequent hospitalizations and the overall prognosis is very poor.
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
amyloid .cardiac amyloidosis. Pathogenetic steps in the development of amyloid diseases.AL amyloidosis. ATTR amyloidosis.ATTRwt amyloidosis.
Potential for misdiagnosis of amyloidosis
Vymada Tablet (ARNI: Angiotensin Receptor Neprilysin Inhibitor) is an anti-hypertensive drug used in combination with Sacubitril & Valsartan to reduce the risk of cardiovascular events in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction.
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
amyloid .cardiac amyloidosis. Pathogenetic steps in the development of amyloid diseases.AL amyloidosis. ATTR amyloidosis.ATTRwt amyloidosis.
Potential for misdiagnosis of amyloidosis
Vymada Tablet (ARNI: Angiotensin Receptor Neprilysin Inhibitor) is an anti-hypertensive drug used in combination with Sacubitril & Valsartan to reduce the risk of cardiovascular events in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction.
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
Toxicology is a very important topic and if u try reading each
poisons Separately , u will definitely forget them.
So best way to remember them more is to practice
MCQs and then read topics by correlating.
That’s what I think….
It may or may not apply for u…..
But atleast try once like this and then choose your own way .
Cardiologist Chris Hayward talks about LVAD (Left ventricular assist devices) for the Sydney Intensive Network. The audio is found on www.intensivecarenetwork.com
2009 Focused Update:
ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults
J. Am. Coll. Cardiol. April 14, 2009; 53;1343-1382
Circulation. April 14, 2009;119;1977-2016
Advanced Heart Failure Therapies: Cardiac Transplantation and Mechanical Circ...Allina Health
By Michael A. Samara, MD. A discussion about the growing population of patients with heart failure, advances in heart failure therapies, and the role of ECMO and LVAD implants in improving outcomes. "ECMO is an older therapy that is undergoing a renaissance. We've learned that poorer outcomes were a consequence of resorting to ECMO too late after multiple system failure. Now we're starting ECMO in the cath lab, even during active CPR."
A heart transplant, or a cardiac transplant, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease. As of 2008 the most common procedure is to take a working heart from a recently deceased organ donor (cadaveric allograft) and implant it into the patient. The patient's own heart is either removed (orthotopic procedure) or, less commonly, left in place to support the donor heart (heterotopic procedure). Post-operation survival periods average 15 years. Heart transplantation is not considered to be a cure for heart disease, but a life-saving treatment intended to improve the quality of life for recipients
Slide 1: Title Slide
Extrachromosomal Inheritance
Slide 2: Introduction to Extrachromosomal Inheritance
Definition: Extrachromosomal inheritance refers to the transmission of genetic material that is not found within the nucleus.
Key Components: Involves genes located in mitochondria, chloroplasts, and plasmids.
Slide 3: Mitochondrial Inheritance
Mitochondria: Organelles responsible for energy production.
Mitochondrial DNA (mtDNA): Circular DNA molecule found in mitochondria.
Inheritance Pattern: Maternally inherited, meaning it is passed from mothers to all their offspring.
Diseases: Examples include Leber’s hereditary optic neuropathy (LHON) and mitochondrial myopathy.
Slide 4: Chloroplast Inheritance
Chloroplasts: Organelles responsible for photosynthesis in plants.
Chloroplast DNA (cpDNA): Circular DNA molecule found in chloroplasts.
Inheritance Pattern: Often maternally inherited in most plants, but can vary in some species.
Examples: Variegation in plants, where leaf color patterns are determined by chloroplast DNA.
Slide 5: Plasmid Inheritance
Plasmids: Small, circular DNA molecules found in bacteria and some eukaryotes.
Features: Can carry antibiotic resistance genes and can be transferred between cells through processes like conjugation.
Significance: Important in biotechnology for gene cloning and genetic engineering.
Slide 6: Mechanisms of Extrachromosomal Inheritance
Non-Mendelian Patterns: Do not follow Mendel’s laws of inheritance.
Cytoplasmic Segregation: During cell division, organelles like mitochondria and chloroplasts are randomly distributed to daughter cells.
Heteroplasmy: Presence of more than one type of organellar genome within a cell, leading to variation in expression.
Slide 7: Examples of Extrachromosomal Inheritance
Four O’clock Plant (Mirabilis jalapa): Shows variegated leaves due to different cpDNA in leaf cells.
Petite Mutants in Yeast: Result from mutations in mitochondrial DNA affecting respiration.
Slide 8: Importance of Extrachromosomal Inheritance
Evolution: Provides insight into the evolution of eukaryotic cells.
Medicine: Understanding mitochondrial inheritance helps in diagnosing and treating mitochondrial diseases.
Agriculture: Chloroplast inheritance can be used in plant breeding and genetic modification.
Slide 9: Recent Research and Advances
Gene Editing: Techniques like CRISPR-Cas9 are being used to edit mitochondrial and chloroplast DNA.
Therapies: Development of mitochondrial replacement therapy (MRT) for preventing mitochondrial diseases.
Slide 10: Conclusion
Summary: Extrachromosomal inheritance involves the transmission of genetic material outside the nucleus and plays a crucial role in genetics, medicine, and biotechnology.
Future Directions: Continued research and technological advancements hold promise for new treatments and applications.
Slide 11: Questions and Discussion
Invite Audience: Open the floor for any questions or further discussion on the topic.
THE IMPORTANCE OF MARTIAN ATMOSPHERE SAMPLE RETURN.Sérgio Sacani
The return of a sample of near-surface atmosphere from Mars would facilitate answers to several first-order science questions surrounding the formation and evolution of the planet. One of the important aspects of terrestrial planet formation in general is the role that primary atmospheres played in influencing the chemistry and structure of the planets and their antecedents. Studies of the martian atmosphere can be used to investigate the role of a primary atmosphere in its history. Atmosphere samples would also inform our understanding of the near-surface chemistry of the planet, and ultimately the prospects for life. High-precision isotopic analyses of constituent gases are needed to address these questions, requiring that the analyses are made on returned samples rather than in situ.
Cancer cell metabolism: special Reference to Lactate PathwayAADYARAJPANDEY1
Normal Cell Metabolism:
Cellular respiration describes the series of steps that cells use to break down sugar and other chemicals to get the energy we need to function.
Energy is stored in the bonds of glucose and when glucose is broken down, much of that energy is released.
Cell utilize energy in the form of ATP.
The first step of respiration is called glycolysis. In a series of steps, glycolysis breaks glucose into two smaller molecules - a chemical called pyruvate. A small amount of ATP is formed during this process.
Most healthy cells continue the breakdown in a second process, called the Kreb's cycle. The Kreb's cycle allows cells to “burn” the pyruvates made in glycolysis to get more ATP.
The last step in the breakdown of glucose is called oxidative phosphorylation (Ox-Phos).
It takes place in specialized cell structures called mitochondria. This process produces a large amount of ATP. Importantly, cells need oxygen to complete oxidative phosphorylation.
If a cell completes only glycolysis, only 2 molecules of ATP are made per glucose. However, if the cell completes the entire respiration process (glycolysis - Kreb's - oxidative phosphorylation), about 36 molecules of ATP are created, giving it much more energy to use.
IN CANCER CELL:
Unlike healthy cells that "burn" the entire molecule of sugar to capture a large amount of energy as ATP, cancer cells are wasteful.
Cancer cells only partially break down sugar molecules. They overuse the first step of respiration, glycolysis. They frequently do not complete the second step, oxidative phosphorylation.
This results in only 2 molecules of ATP per each glucose molecule instead of the 36 or so ATPs healthy cells gain. As a result, cancer cells need to use a lot more sugar molecules to get enough energy to survive.
Unlike healthy cells that "burn" the entire molecule of sugar to capture a large amount of energy as ATP, cancer cells are wasteful.
Cancer cells only partially break down sugar molecules. They overuse the first step of respiration, glycolysis. They frequently do not complete the second step, oxidative phosphorylation.
This results in only 2 molecules of ATP per each glucose molecule instead of the 36 or so ATPs healthy cells gain. As a result, cancer cells need to use a lot more sugar molecules to get enough energy to survive.
introduction to WARBERG PHENOMENA:
WARBURG EFFECT Usually, cancer cells are highly glycolytic (glucose addiction) and take up more glucose than do normal cells from outside.
Otto Heinrich Warburg (; 8 October 1883 – 1 August 1970) In 1931 was awarded the Nobel Prize in Physiology for his "discovery of the nature and mode of action of the respiratory enzyme.
WARNBURG EFFECT : cancer cells under aerobic (well-oxygenated) conditions to metabolize glucose to lactate (aerobic glycolysis) is known as the Warburg effect. Warburg made the observation that tumor slices consume glucose and secrete lactate at a higher rate than normal tissues.
What is greenhouse gasses and how many gasses are there to affect the Earth.moosaasad1975
What are greenhouse gasses how they affect the earth and its environment what is the future of the environment and earth how the weather and the climate effects.
Comparing Evolved Extractive Text Summary Scores of Bidirectional Encoder Rep...University of Maribor
Slides from:
11th International Conference on Electrical, Electronics and Computer Engineering (IcETRAN), Niš, 3-6 June 2024
Track: Artificial Intelligence
https://www.etran.rs/2024/en/home-english/
(May 29th, 2024) Advancements in Intravital Microscopy- Insights for Preclini...Scintica Instrumentation
Intravital microscopy (IVM) is a powerful tool utilized to study cellular behavior over time and space in vivo. Much of our understanding of cell biology has been accomplished using various in vitro and ex vivo methods; however, these studies do not necessarily reflect the natural dynamics of biological processes. Unlike traditional cell culture or fixed tissue imaging, IVM allows for the ultra-fast high-resolution imaging of cellular processes over time and space and were studied in its natural environment. Real-time visualization of biological processes in the context of an intact organism helps maintain physiological relevance and provide insights into the progression of disease, response to treatments or developmental processes.
In this webinar we give an overview of advanced applications of the IVM system in preclinical research. IVIM technology is a provider of all-in-one intravital microscopy systems and solutions optimized for in vivo imaging of live animal models at sub-micron resolution. The system’s unique features and user-friendly software enables researchers to probe fast dynamic biological processes such as immune cell tracking, cell-cell interaction as well as vascularization and tumor metastasis with exceptional detail. This webinar will also give an overview of IVM being utilized in drug development, offering a view into the intricate interaction between drugs/nanoparticles and tissues in vivo and allows for the evaluation of therapeutic intervention in a variety of tissues and organs. This interdisciplinary collaboration continues to drive the advancements of novel therapeutic strategies.
Richard's aventures in two entangled wonderlandsRichard Gill
Since the loophole-free Bell experiments of 2020 and the Nobel prizes in physics of 2022, critics of Bell's work have retreated to the fortress of super-determinism. Now, super-determinism is a derogatory word - it just means "determinism". Palmer, Hance and Hossenfelder argue that quantum mechanics and determinism are not incompatible, using a sophisticated mathematical construction based on a subtle thinning of allowed states and measurements in quantum mechanics, such that what is left appears to make Bell's argument fail, without altering the empirical predictions of quantum mechanics. I think however that it is a smoke screen, and the slogan "lost in math" comes to my mind. I will discuss some other recent disproofs of Bell's theorem using the language of causality based on causal graphs. Causal thinking is also central to law and justice. I will mention surprising connections to my work on serial killer nurse cases, in particular the Dutch case of Lucia de Berk and the current UK case of Lucy Letby.
Seminar of U.V. Spectroscopy by SAMIR PANDASAMIR PANDA
Spectroscopy is a branch of science dealing the study of interaction of electromagnetic radiation with matter.
Ultraviolet-visible spectroscopy refers to absorption spectroscopy or reflect spectroscopy in the UV-VIS spectral region.
Ultraviolet-visible spectroscopy is an analytical method that can measure the amount of light received by the analyte.
2. “Heart failure is a complex syndrome
that can result from any structural or
functional cardiac disorder that impairs
the ability of heart to function as a pump
to support physiological circulation”
3.
4. AHA : STAGES OF HF
A : High risk for heart failure w/o structural dz
or sx of CHF.
B : Structural Heart dz w/o sx of HF.
C : Structural Heart dz with prior or current sx
of HF.
D : Refractory HF requiring specialized
interventions.
5.
6.
7.
8.
9. Harrison 19
General measures:
Reduce congestive state.
Control blood pressure.
Maintain atrial contraction and prevent
tachycardia.
Treat and prevent myocardial
ischemia.
Detect and treat sleep apnea
11. ADVANCED HEART
FAILURE
“A Stage of heart failure,characterized
by advanced structural heart disease
and marked symptoms of rest despite
dietary modification, salt restriction
and maximal medical therapy
including
ACE inhibitors, ARB’s,
digitalis,diuretics,
beta blockers.”
12. Harrison 19th:
HFrEF < 35%
Inability to tolerate full dose of
neurohormonal antagonism.
Escalating doses of diuretics.
Persistent hyponatremia
Renal insufficiency
Recurrent hospital admissions
(>1/6mon)
18. CARDIAC RESYNCHRONISATION
THERAPY :
Ischemic or diastolic CM show
DYSSYNCHRONY.
-Intraventricular (lbbb on ECG)
-interventricular
-atria and ventricle.
Occurs in 25% of HF patients and
confers high risk of worsening HF and
SCD.
Resynchrony of myocardial
contraction can be done through
biventricular pacing.
19. Whom to choose for CRT
Age ≥ 18 years
NYHA class III or IV
"High standard" pharmacologic therapy.
Left ventricular ejection fraction (LVEF)
≤ 35%
Left ventricular end-diastolic dimension
(LVEDD) ≥ 30 mm
QRS interval ≥ 120 ms
Confirmed by echocardiography for
patients with QRS interval 120-149 ms
and 2+ additional echocardiographic
criteria
20. Patients with a QRS interval of 120 to
149 msec were required to meet two
of three additional echocardiographic
criteria for dyssynchrony:
An aortic preejection delay of more
than 140 msec,
An interventricular mechanical delay
of more than 40 msec, or
Delayed activation of the
posterolateral left ventricular wall.
21. Speckle tracking radial dyssynchrony
is able to characterize septal to
posterior wall dyssynchrony in LBBB
HF patient, which is acutely improved
post CRT. These improvements in
radial dyssynchrony by speckle
tracking persist at later follow up.
22.
23. Effect of CRT was evaluated in a
randomized controlled trial (RethinQ
study) in patients with
narrow QRS (< 120 msec)
Patients with heart failure and narrow
QRS intervals may not benefit from
CRT.
24.
25. Implantable Defibrillator (ICD)
Sudden cardiac death is the main
cause of death in less severe heart
failure.
Even after an appropriate shock,
patients with advanced heart failure
may die from electromechanical
dissociation.
SCD-HEFT trial - Among patients with
NYHA class II heart failure, there was a 46
per cent relative reduction in the risk of
death with ICD therapy as compared to
26.
27.
28. However, in patients with advanced
heart failure there was no apparent
reduction in the risk of death with ICD
therapy.
In the COMPANION trial either CRT
alone or CRT with ICD (combo device)
reduced the rate of death from any
cause or hospitalization for any cause
by approximately 20 per cent as
compared with the group that received
optimal pharmacologic therapy alone
29.
30.
31. ICD therapy is indicated in
patients:
Level of Evidence: A
With LVEF ≤ 35% due to prior MI who
are at least 40 days post-MI and are in
NYHA Functional Class II or III.
With LV dysfunction due to prior MI who
are at least 40 days post-MI, have an
LVEF ≤ 30%, and are in NYHA
Functional Class I
Who are survivors of cardiac arrest due
to VF or hemodynamically unstable
sustained VT after evaluation to define
the cause of the event and to exclude
any completely reversible causes.
32.
33. Percutaneous and Surgical
Interventions
Heart transplantation remains the
most effective and proven therapy.
The other interventions aim to either
repair or reshape the heart or replace
the heart function.
34.
35.
36. Coronary Revascularization
Procedures
Coronary artery disease is common in
patients with advanced heart failure, with
some studies suggesting a prevalence of
50%-70%.
Coronary revascularization with coronary
artery bypass surgery or percutaneous
coronary intervention as appropriate
should be considered in patients with
heart failure and suitable coronary
anatomy presenting with significant
angina, or acute coronary syndrome.
37. Revascularization is indicated in
patients who show evidence of
myocardial viability or the presence of
inducible ischemia in areas of
significant obstructive coronary
disease.
Imaging technics to detect
noncontractile but viable myocardium
including nuclear imaging, stress
echocardiography and magnetic
resonance imaging.
38. Benefit of routine coronary
revascularization in patients with heart
failure and obstructive coronary artery
disease.. ?????
ONGOING TRAIL :
STICH trial
39.
40. Stem Cell Therapy
Myocardial regeneration with either
percutaneously or surgically delivered
stem cell is promising.
Intracoronary stem cell injection is
undergoing evaluation at AIIMS and
other centers, and the initial results
are promising.
Improvement in ventricular function
and symptoms are shown with
autologous bone marrow stem cell
injection.
41. Mitral Valve Interventions
In patients with heart failure, mitral
regurgitation occurs commonly due to
annular dilation.
Apical displacement of one or both
papillary muscles causing restricted
leaflet motion.
Mitral valve annuloplasty in dilated
and ischemic cardiomyopathy is
shown to be safe with low mortality
(2%) and morbidity.
42. Considering the high recurrence rate
with ring annuloplasty, some centers
advocate mitral valve replacement rather
than repair in functional and ischemic
cardiomyopathy.
The coronary sinus is anatomically very
near the mitral annulus. By placing a
series of progressively stiffer rods or
‘cinching’ devices in the coronary sinus
can move the posterior mitral apparatus
forward, thereby reducing the mitral
annulus and regurgitation.
49. LV Assist Devices
LV assist devices (LVADs) improve survival
and quality of life in patients ineligible for a
heart transplant.
LVADs also serve as a “bridge” to transplant
and ventricular recovery. Recently LVADs
are being used more as end-stage or
“destination therapy”.
5 In a prospective, multicenter study, 129
end-stage HF patients, ineligible for heart
transplantation, were randomized to receive
either an LVAD or optimal medical therapy.
After 1 year, a 48% reduction in death and
improved quality of life were shown with
LVAD group as compared to medical therapy
50.
51.
52. INDICATIONS FOR LVADs
Patients awaiting heart transplantation
who have become refractory to all
means of medical circulatory support as
a bridge to transplant.
Selected patients with severe HF
refractory to conventional therapy who
are not candidates for heart
transplantation, particularly those who
cannot be weaned from intravenous
inotropic support at an experienced HF
center.
53.
54.
55.
56. Cardiac Reshaping Surgeries
In patients with dilated cardiomyopathy, partial left
ventriculectomy (Batista procedure) was a very popular
technic some years ago.
Despite a sound theoretical basis, Batista procedure is no
longer used since the long term results are disappointing.
In patients with ischemic heart disease with dyskinetic
regions of left ventricle, such ventricle reshaping procedures
may be of benefit.
Aneurysmectomy and endoventricular circular patch plasty
(Dor procedure) is a promising technique.
(ACORN) trial evaluated an innovative passive cardiac
restraint device in patients with end-stage HF that suggested
modest improvement in ventricular remodeling but no benefit
in mortality.
58. HEART TRANSPLANTATION
Cardiac transplantation remains the most
effective treatment to improve the
prognosis of patients with truly refractory
heart failure.
INDICATIONS:
- Refractory cardiogenic shock,
- Dependency on intravenous inotropic
drugs
- Persistent NYHA class IV symptoms
with oxygen consumption less than 10
mL/kg/min
59. ABSOLUTE CONTRAINDICATIONS
Fixed pulmonary hypertension
Active systemic infection
Severe cerebral or carotid vascular disease not
amenable to surgery
Severe chronic obstructive pulmonary disease
or severe chronic bronchitis
Irreversible and severe hepatic or renal
dysfunction
Unmanageable and/or severe psychiatric
disease •
The patient is unable to understand the issues
related to transplantation and unable or unwilling
to take medications as instructed
Active peptic ulcer disease
Positive HIV test
60. OTHERS
Ultrafiltration :
Safe removal of excess fluid is one of the most demanding
challenges in the management of patients refractory to diuretic
therapy.
The use of peritoneal dialysis for refractory heart failure has
been advocated for many years.
◦ In the UNLOAD trial 34 200 patients with acute
decompensated heart failure with volume overload
were randomized to veno-venous ultrafiltration
and ravenous diuretic therapy. Ultrafiltration was
shown to produce greater fluid and weight loss
during index hospitalization.
61. At present, ultrafiltration should be
reserved for patients at high risk of
complications with diuretic therapy
who need extensive fluid removal.
CPAP:
A significant number of patients with
advanced heart failure have
obstructive sleep apnea. Continuous
positive airway pressure (CPAP) is an
effective treatment for sleep apnea
62. CPAP has been evaluated as a
therapy in advanced HF patients with
sleep apnea. Small prospective
controlled trials have shown that
CPAP improves LV EF, reduce urinary
norepinephrine levels, and improve
cardiac output.