【体外膜肺ECMO课件】-Healing-the-Heart-When-Failure-is-N

HealingtheHeart:WhenFailureisNotanOptionSeptember12,2013GoToWebinarHousekeeping:attendeeparticipationOpenandhideyourcontrolpanelJoinaudio:Choose“Mic&Speakers”touseVoIPChoose“Telephone”anddialusingtheinformationprovided

SubmitquestionsandcommentsviatheQuestionspanelNote:Today’spresentationisbeingrecordedandwillbeprovidedwithin48hours.YourParticipationOurPanelistsNazaninMoghbeli,MD,MPH,CardiologistSalilShah,MD,CardiothoracicSurgeonHeartFailureNazaninMoghbeli,MD,MPH,FACCSeptember10,2013Overview Whatisheartfailure?WhyshouldIknowaboutit?Whatarethecausesofheartfailure?Whatarethesignsandsymptoms?Howdoyoutreatthisdisease?WhatcanIdotopreventworseningheartfailure?DefinitionofHeartFailureHeartfailure:iscausedbydamagetotheheartandcanbecausedbymanydifferentreasons.i.e.heartattackoruncontrolledhighbloodpressure.Heartfailureinthiscase-doesnotmeanthehearthasfullystopped.TheheartispumpingwithlessstrengththanusualUnderstandingwhatisgoingonwiththeheart…Bloodmovesthroughthebodyataslowerrate.Asaresult,theheartcannotpumpenoughoxygenandnutrientstomeetthebody'sneeds.Asaresult,thekidneysmayrespondbycausingthebodytoretainfluid(water)andsalt.Oftenfluidbuildsupinthearms,legs,ankles,feet,lungs,orotherorgans,thebodybecomescongested(fulloffluid);hencethetermcongestiveheartfailuretodescribethecondition.HowcommonisHeartFailure?Heartfailureaffectsnearly5.7millionAmericans.Roughly670,000peoplearediagnosedwithheartfailureeachyear.Itistheleadingcauseofhospitalizationinpeopleolderthan65.1inevery5peoplewilldevelopheartfailureintheUS.MortalityData*80%ofmenand70%ofwomenwithlessthan65yearsofageandHFwilldiewithin8yearsUpto42%ofpatientsdieofHFwithin5yearsofhospitalizationofHF.Suddencardiacdeathis6to9timesmorelikelyinaHFpatientascomparedtothegeneralpopulation.WhatcausesHeartFailure(HF)?HFiscausedbyconditionsthatdamagetheheart:Coronaryarterydisease(CAD)=adiseaseofthearteriesoftheheart.Ifarteriesoftheheartbecomeblockedornarrowed,theheartcanbedamagedbylackofoxygenandnutrients.Heartattack=occurswhentheheartarteriesbecomesuddenlyblocked,stoppingtheflowofbloodtotheheartmuscle.Thisdamagestheheartmuscle,resultinginascarredareathatnolongerfunctionswell.OthercausesofHF:AlcoholHighbloodpressureValvediseaseThyroiddiseaseHeartdefectspresentatbirthcanallcauseheartfailurePreeclampsia

SymptomsassociatedwithCHF:Congestedlungs:

Shortnessofbreath:atrest,withexercise,oriflyingflatLungcongestioncancauseadryhackingcough/wheezingFluidandwaterretention.

Lessbloodreleasedbykidneyscausesfluidandwaterretention,resultinginswollenankles,legs,abdomen(callededema),andweightgain.Maycauseanincreasedneedtourinateduringthenight.Stomachbloatingmaycausealossofappetiteornausea.SymptomsoftenfoundinHF:Dizziness,fatigue,andweakness.

Lessbloodtomajororgansandmusclescancausefatigue/weaknessLessbloodtothebraincancausedizzinessorconfusion.Rapidorirregularheartbeats.

Theheartbeatsfastertopumpenoughbloodtothebody.Thiscancausearapidorirregularheartbeat.Howdowetreatheartfailure Medicationsthatlowerbloodpressureandheartrate,therebydecreasingthestrainontheheartRestrictionofwaterandsaltTreatingdiabetes,highbloodpressure,coronaryarterydiseaseExerciseSmokingcessationAdvancedtreatmentoptionsforHFMechanicalDevicesHearttransplantation(completelyreplacingthecurrentnonfunctioningheartwithabetterfunctioningheart).LeftVentricularAssistDevice(LVAD)HeartTransplantation*Hearttransplantpatientscanliveanear-normalqualityoflifeandfunctionalcapacity.50%ofallpatientswillliveatleast9-10years.Goldstandardforappropriatelyselectedpatientswithadvanced-stageHFHeartTransplantationOnly2000peopleayearreceivetransplantsintheU.SOver10%ofpeopleonthewaitinglistdieeachyearwaitingonahearttobecomeavailable.Henceadditionaloptionsmustbesoughttoimproveoutcomesandavoiddeathsforthesepatients.WhatcanIdo?ExerciseCholesterolcontrolWeightmanagementMedicationsasneededAvoidoverthecountermedicationssuchasMotrin,decongestantsAvoidalcoholexcessEinsteinHeartFailureServicesDiagnosisandworkupofheartfailure:Treatment,includingcarefulmonitoringofheartfailuremedicationsEducationTeamapproach:PCP,patient,heartfailureteamMechanicalsupport,transplantevaluationandreferralSurgicalTreatmentofHeartFailureSeptember12,2013DifferentiatebetweenacuteandchronicheartfailureSurgicalmanagementofacuteheartfailureDeviceoptionsandefficacySurgicalManagementofChronicHeartFailureVentricularRemodelingDeviceplacementandmanagementTheFutureObjectivesAcutevsChronicHeartFailureAcuteAsuddenchangeinheartfunctionrelatedtosomeneweventthathascauseddamagetotheheart.ChronicAgradualdeclineofheartfunctionoveraperiodoftime.(Oftenthebodycompensatesslowlyforthelossofheartfunction).CausesofAcuteHeartFailure:MyocardialInfarction(akaHeartattack)PulmonaryEmbolism(Bloodclotinthelungs)Myocarditis(Inflammation)Post-partumCardiomyopathy(Enlargedheartafterpregnancy)Chronicheartfailurewithacute(new)flareTrauma(i.e.directinjurytotheheart)AcuteHeartTransplantRejectionManagementMostimportantly,treatmentistopreventorstopthefailureofotherorgansthataredependentonbloodflowfromtheheart.Thiscanbedonemedicallyorwithmechanicaldevices.Intra-AorticBalloonpumpDeviceplacedviathefemoralartery(intheleg)toincreaseheartbloodflow.Pros: Canbeplacedandremovedbyacatheter.WillallowincreasedheartandbrainbloodflowCons:DoesnotincreasetheamountofbloodpumpedbytheheartHasneverbeenshowntoimprovesurvival.TandemHeartCentrifugalflowpumpplacedpercutaneouslyDesignedtoaugmentleftventricularoutputandrestleftventricleCanaugmentcardiacoutputupto5LPMPros:Canfullyaugmentleftventricular cardiacoutput PlacedandremovedpercutaneouslyCons:Musthaveskilledpersontoplace thecannulatrans-septal Cannulapositionisdifficulttocontrol andcannulacanmigrateTandemHeartManycasestudiesandretrospectivereviewstoshowefficacy,butnoPRCTtoshowefficacyversusconvertionaltherapy.Theoreticaladvantagetoallowingtheleftventricletorestandprovidethebodywithsupport.Nomechanismtodealwithrightventricularfailure.TrialstartingnowtodetermineefficacyversusotherdevicesImpellaAxialflowdevice2.5-5.0L/minActiveforwardflowSingleVascularaccess5Minutesetup\Percutaneousorsurgicalcut-downforplacementMultipleconfigurationspossibleOperationindependentofcardiacfunctionorrhythmImpellaConsoleImpellaLD/LP5.0ImpellaLP2.5PumpsImplantationImpellaCPImpellaCPImpellaRPNewTechnologyInvestigationalMyocardialProtectionHemodynamicSupportInflow(ventricle)Outflow(aorticroot)aorticvalve

O2Demand

O2SupplyCardiacPowerOutputEDV,EDPAOPFlowMyocardialProtectionSystemicHemodynamicSupportPhysiologyofImpella31ImpellaUnloadingEffectECMOExtracorporealMembraneousOxygenationBloodisremovedfromthevenoussystemeitherperipherallyviacannulationofafemoralveinorcentrallyviacannulationoftherightatrium,OxygenateExtractcarbondioxideBloodisthenreturnedbacktothebodyeitherperipherallyviaafemoralarteryorcentrallyviatheascendingaorta.ECMOCadillacofmechanicalsupportFullcardiopulmonarybypassProvidesbodywithoxygenatedbloodProvidesbodywithfullcardiacoutputAllowsheartandlungstorestasbodyrecoversfrominjuryandinsultECMOPros:Canbeplacedpercutaneously anywhereProvidesfullheartandlungsupportAllowsforbridgetodecisionCons:MustberemovedsurgicallyNeedtrainedstafftomonitorandadjust24hrs/daywhileonsupportHaveincreasedbleedingandvascularcomplicationsBottomlineAlltherapieshavetheirplaceIfchosenandusedcorrectlywilltakeanalmostuniformlydeadlysituationandprovideachanceforrecoveryThereareindicationsforeachdeviceandalldevicesareapprovedtobeusedinacutecardiogenicshocksituations.ChronicHeartFailureDeclineofheartfunctionoveraperiodoftimewherethebodycompensatesslowlyforthedecrementinheartfunction.Treatment:Medication-Ionotropes,afterloadreductionVentricularRemodelingMechanicalSupport-LVAD/RVADHeartTransplantationHeartmateIIContinuousaxialflowpumpConnectsLVapextoAortaBypassesbloodflowfromtheleftventricleOnlyhasexteriorizeddriveline connectedtoexternalmonitor andpowersourceMustbeplacedsurgicallyCanbeusedasbridgetotransplantorasdestinationtherapyHeartmateIIPros:ExcellentflowdeviceVerydurableEasilyimplantableHasexcellentlongtermefficacyanddataCons:DifficulttoexplantNeedchronicanticoagulationDevicedoeshavedefinedlif