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L impiegodidevicenelloscompensocardiacoavanzato S ValenteDAICuoreeVasi AOUCareggi Firenze Definition Chronicbutnotnecessarilyirreversiblecondition Regardelessofitsetiology itisusuallycharacterisedbypersistenceofseveresymptoms functionallimitationandcardiacdysfunctiondespiteoptimaltherapy EuropeanJournalofHeartFailure9 2007 684 694 SeveresymptomsofHF NYHAIIIorIV Fluidretentionand orlowcardiacoutputatrestObjectiveevidenceofseverecardiacdysfunction lowLVEF 30 and orelevatedfillingpressuresand orelevatedNTproBNPlevelsSevereimpairmentoffunctionalcapacity inabilitytoexerciseand or6 MWDdistance 300mand orpeakVO2 12 14ml kg minAtleastonehospitalisationinthepast6monthsPresenceofallthepreviousfeaturesdespiteoptmalmedicaltherapyunlessitispoorlytoleratedorcontroidicatedandCRTifindicated DefinitionofAHFmodifiedfromtheHeartFailureassociationoftheESCdefinition OFAbouzzedine MMRedfieldCongestHeartFail2011 INTERMACSHeartFailureclassification ProgressinCardiovascularDiseases54 2011 78 85 TheAHAestimatesthatthereare550 000newcasesofHFannually mostofwhichoccursamongtheelderly AnnualincidenceofHFapproaches10per1 000personsaftertheageof65yearsandreachesashighasmorethan40per1 000personsinthoseolderthan85years Incidence ProgressinCardiovascularDiseases54 2011 78 85 Prevalence AlthoughtheHFincidenceappearstoberelativelystable theprevalenceofHFhasbeenrisingdramaticallyandhasculminatedinthecurrentHFepidemic Itisestimatedthatthereare5 8millionpeoplercurrentlylivingwithsymptomaticHFintheUnitedStates andthisnumberisexpectedtoincrease 200 000patientshaverefractoryendstagedisease stageD witha1 yearmortalitybetween70and90 OFAbouzzedine MMRedfieldCongestHeartFail2011 Devicenelloscompensocardiacoavanzato Cardiacsupport RenalsupportPulmonarysupport Cardiacresincronizatontherapy LengthofsupportShortterm 24hMediumterm 2weeksPermanentGoalsbridgetoHTxbridgetorecoverybridgetodecisiondestinationtherapy TypeofsupportLVAD RVADBVADSiteparacorporealintracorporealFlowpatternpulsatilecontinuous VADCLASSIFICATION IABP IncardiogenicshockIABPshouldbeconsidered ClassI C CirculatorysupportintheperioperativecardiacsurgeryHighriskPCIBridgetotransplantationIntractableventriculararrhythmiasAdvancedHeartFailure ECMO Centrifugalpumpthatprovidesacontinuousflow PercutaneousapproachItdoesnotdecompresstheLVItislifesavingforpatientswithabrupthaemodynamiccollapseinthecathlab Itsuseislimitedbythehighincidenceofassociatedcomplications ECMOVENO ARTERIOSO IndicazioniECMOinUTIC Cardiomiopatiaend stageinterapiamedicamassimale inattesaditrapiantocardiaco InfartomiocardicoacutocomplicatodashockcardiogenorefrattarioMiocarditeacutaconseverainsufficienzad organooaritmieventricolarisubentrantinoncontrollabiliconterapiamedicaeIABP Emboliapolmonaremassivacongravecompromissionedellafunzionalit ventricolaredestraeshockcardiogenooACRArrestocardiaconelpazientegiovaneadultoconprecocerianimazionecardiopolmonare converosimileottimaprognosineurologica refrattarioaterapiarianimatoriamedicaedelettrica LaduratadelsupportoconECMOdovr essereilpi brevepossibile sconsigliatoperpi di3giorni Daassociareadaltrestrategiedineuroprotezionecomel ipotermiaterapeutica Gravedepressionedellafunzionecardiacadaintossicazionedifarmaciosepsi IndicazioniECMOinUTIC L indicazioneall ECMO nelcasodigravescompensocardiacononpi responsivoaterapiamedicamassimale dovr tenerecontodellaprognosi inparticolareripresadellafunzionalit dell organo bridge to recovery dell eleggibilit peruntrapiantocardiaco bridge to transplantation dellapossibilit diposizionamentodiassistenzemeccanichepi omenoalungadurata comeLevitronixCentriMag Jarvik2000 Cardiowest bridge to bridge Maanche bridgetodecision CASISTICAECMO 11PAZIENTI RotturadicuoreincorsodiSTEMIanteriorein1pz STEMIcomplicatodashockcardiogeno 3pz OcclusioneTCincorsodiVCG 1pz NSTE SCA occlusionedelTC 1pz Ipertrofica in1pz Dilatativa 2pz Emboliapolmonare 1pz SindromediTako Tsubo 1pz CASISTICAECMO 11PAZIENTIShockcardiogeno 5pzACR 4pzScompensocardiacoEND STAGE 2pz Et media54anniRapportoM F8 3IABP CRRTeventilazionemeccanicaintuttiipazienti INIZIALEESPERIENZAECMOinUTIC 5pz 2pz SaladiEmodinamica DEA 4pz UTIC LatenzamediainizioACLS inizioECMO inACR 57minuti min 22 max110min DuratamediadelsupportoconECMO 198ore min 24 max 504ore Decorso 6pazientidecedutidurantesupportoECMO 5pazientisvezzatidaECMO SedeimpiantoECMO INIZIALEESPERIENZAECMOinUTIC Thestudyrandomlyassigned129pzwithend stageheartfailureinelegibleforcardiactransplantationtoreceivealeftventricularassistdevice 68pz oroptimalmedicalmanagement 61pz NewEnglandJournalMedicine 2001 HeartMateLVADPropelbloodinapulsatilefashion 10l min OnlyleftventricularsupportAnticoagulationcanbeavoidedThepatientscanbedischarged ComparisonofPulsatileflowandContinuousflowLVADs PKhazanie JGRogersCongestHeartFail2011 TemporalChangesinVADindications PatientSelection Multidisciplinaryteamevaluation Cardiologist Anesthesiologist CardiacSurgeon Multi systemwork upHeartdisease Echo Cath etc RespiratoryfunctionRenalfunctionLiverfunctionCoagulationcascadeandplateletfunction Conclusions MechanicalcirculatorysupportrepresentsaconcreteandreliableoptionindifferentscenariosofsevereacuteandchronicheartfailureEncouragingresultsrelatedtonewdevicesandpropermanagementincreasingcenter relatedexperienceadequatedecisionmakingimplantationbeforeonsetofovertcardiogenicshockInseverelyillpts rapidimplantationofsimplesupport i e ECMO asbridgetodecision Necessit di NumerotelefonicodedicatoEquipeimpiantoECMOH24Disponibilit postolettodedicato HUBdiriferimento UTICSPOKE Necessit di valutazioneindicazionistabilizzazioneepreparazionedelpazienteinaccordoconcentroHUB MezzoditrasportodedicatoH24 Priorit EquipeECMOincentroSPOKEValutazioneseimpiantoECMOincentroSPOKEeinqualesede UTIC emodinamica salaoperatoria Stabilizz