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

Healing the Heart:When Failure is Not an OptionSeptember 12,2013GoToWebinar Housekeeping:attendee participationOpen and hide your control panelJoin audio:Choose“Mic&Speakers”to use VoIPChoose“Telephone”and dial using the information providedSubmit questions and comments via the Questions panelNote:Todays presentation is being recorded and will be provided within 48 hours.Your ParticipationOur PanelistsNazanin Moghbeli,MD,MPH,CardiologistSalil Shah,MD,Cardiothoracic SurgeonHeart FailureNazanin Moghbeli,MD,MPH,FACCSeptember 10,2013OverviewWhat is heart failure?Why should I know about it?What are the causes of heart failure?What are the signs and symptoms?How do you treat this disease?What can I do to prevent worsening heart failure?Definition of Heart FailureHeart failure:is caused by damage to the heart and can be caused by many different reasons.i.e.heart attack or uncontrolled high blood pressure.Heart failure in this case-does not mean the heart has fully stopped.The heart is pumping with less strength than usualUnderstanding what is going on with the heartBlood moves through the body at a slower rate.As a result,the heart cannot pump enough oxygen and nutrients to meet the bodys needs.As a result,the kidneys may respond by causing the body to retain fluid(water)and salt.Often fluid builds up in the arms,legs,ankles,feet,lungs,or other organs,the body becomes congested(full of fluid);hence the term congestive heart failure to describe the condition.How common is Heart Failure?Heart failure affects nearly 5.7 million Americans.Roughly 670,000 people are diagnosed with heart failure each year.It is the leading cause of hospitalization in people older than 65.1 in every 5 people will develop heart failure in the US.Mortality Data*80%of men and 70%of women with less than 65 years of age and HF will die within 8 yearsUp to 42%of patients die of HF within 5 years of hospitalization of HF.Sudden cardiac death is 6 to 9 times more likely in a HF patient as compared to the general population.What causes Heart Failure(HF)?HF is caused by conditions that damage the heart:Coronary artery disease(CAD)=a disease of the arteries of the heart.If arteries of the heart become blocked or narrowed,the heart can be damaged by lack of oxygen and nutrients.Heart attack=occurs when the heart arteries become suddenly blocked,stopping the flow of blood to the heart muscle.This damages the heart muscle,resulting in a scarred area that no longer functions well.Other causes of HF:AlcoholHigh blood pressureValve disease Thyroid diseaseHeart defects present at birth can all cause heart failurePreeclampsia Symptoms associated with CHF:Congested lungs:Shortness of breath:at rest,with exercise,or if lying flatLung congestion can cause a dry hacking cough/wheezingFluid and water retention.Less blood released by kidneys causes fluid and water retention,resulting in swollen ankles,legs,abdomen(called edema),and weight gain.May cause an increased need to urinate during the night.Stomach bloating may cause a loss of appetite or nausea.Symptoms often found in HF:Dizziness,fatigue,and weakness.Less blood to major organs and muscles can cause fatigue/weaknessLess blood to the brain can cause dizziness or confusion.Rapid or irregular heartbeats.The heart beats faster to pump enough blood to the body.This can cause a rapid or irregular heartbeat.How do we treat heart failureMedications that lower blood pressure and heart rate,thereby decreasing the strain on the heartRestriction of water and saltTreating diabetes,high blood pressure,coronary artery diseaseExerciseSmoking cessationAdvanced treatment options for HFMechanical DevicesHeart transplantation(completely replacing the current nonfunctioning heart with a better functioning heart).Left Ventricular Assist Device(LVAD)Heart Transplantation*Heart transplant patients can live a near-normal quality of life and functional capacity.50%of all patients will live at least 9-10 years.Gold standard for appropriately selected patients with advanced-stage HF Heart TransplantationOnly 2000 people a year receive transplants in the U.SOver 10%of people on the waiting list die each year waiting on a heart to become available.Hence additional options must be sought to improve outcomes and avoid deaths for these patients.What can I do?ExerciseCholesterol controlWeight managementMedications as neededAvoid over the counter medications such as Motrin,decongestants Avoid alcohol excess Einstein Heart Failure ServicesDiagnosis and workup of heart failure:Treatment,including careful monitoring of heart failure medicationsEducationTeam approach:PCP,patient,heart failure teamMechanical support,transplant evaluation and referralSurgical Treatment of Heart FailureSeptember 12,2013Differentiate between acute and chronic heart failureSurgical management of acute heart failureDevice options and efficacySurgical Management of Chronic Heart FailureVentricular RemodelingDevice placement and managementThe FutureObjectivesAcute vs Chronic Heart FailureAcuteA sudden change in heart function related to some new event that has caused damage to the heart.ChronicA gradual decline of heart function over a period of time.(Often the body compensates slowly for the loss of heart function).Causes of Acute Heart Failure:Myocardial Infarction(aka Heart attack)Pulmonary Embolism(Blood clot in the lungs)Myocarditis(Inflammation)Post-partum Cardiomyopathy(Enlarged heart after pregnancy)Chronic heart failure with acute(new)flareTrauma(i.e.direct injury to the heart)Acute Heart Transplant RejectionManagementMost importantly,treatment is to prevent or stop the failure of other organs that are dependent on blood flow from the heart.This can be done medically or with mechanical devices.Intra-Aortic Balloon pumpDevice placed via the femoral artery(in the leg)to increase heart blood flow.Pros:Can be placed and removed by a catheter.Will allow increased heart and brain blood flowCons:Does not increase the amount of blood pumped by the heartHas never been shown to improve survival.Tandem HeartCentrifugal flow pump placed percutaneouslyDesigned to augment left ventricular output and rest left ventricle Can augment cardiac output up to 5 LPMPros:Can fully augment left ventricular cardiac output Placed and removed percutaneouslyCons:Must have skilled person to place the cannula trans-septal Cannula position is difficult to control and cannula can migrateTandem HeartMany case studies and retrospective reviews to show efficacy,but no PRCT to show efficacy versus convertional therapy.Theoretical advantage to allowing the left ventricle to rest and provide the body with support.No mechanism to deal with right ventricular failure.Trial starting now to determine efficacy versus other devicesImpellaAxial flow device2.5-5.0 L/min Active forward flowSingle Vascular access5 Minute setupPercutaneous or surgical cut-down for placementMultiple configurations possibleOperation independent of cardiac function or rhythmImpellaConsoleImpella LD/LP 5.0Impella LP2.5PumpsImplantationImpella CPImpella CPImpella RPNew TechnologyInvestigationalMyocardial Protection Hemodynamic SupportMyocardial Protection Hemodynamic SupportInflowInflow(ventricle)(ventricle)OutflowOutflow(aortic root)(aortic root)aorticaorticvalvevalve O2 O2 DemandDemand O2 O2 SupplySupply Cardiac Power Output Cardiac Power OutputEDV,EDPEDV,EDP AOP AOP Flow FlowMyocardial ProtectionMyocardial ProtectionSystemic Hemodynamic SupportSystemic Hemodynamic SupportPhysiology of Impella 31Impella Unloading EffectECMOExtracorporeal Membraneous OxygenationBlood is removed from the venous system either peripherally via cannulation of a femoral vein or centrally via cannulation of the right atrium,OxygenateExtract carbon dioxide Blood is then returned back to the body either peripherally via a femoral artery or centrally via the ascending aorta.ECMOCadillac of mechanical supportFull cardiopulmonary bypassProvides body with oxygenated bloodProvides body with full cardiac outputAllows heart and lungs to rest as body recovers from injury and insultECMOPros:Can be placed percutaneously anywhereProvides full heart and lung supportAllows for bridge to decisionCons:Must be removed surgicallyNeed trained staff to monitor and adjust 24 hrs/day while on support Have increased bleeding and vascular complicationsBottomlineAll therapies have their placeIf chosen and used correctly will take an almost uniformly deadly situation and provide a chance for recoveryThere are indications for each device and all devices are approved to be used in acute cardiogenic shock situations.Chronic Heart FailureDecline of heart function over a period of time where the body compensates slowly for the decrement in heart function.Treatment:Medication-Ionotropes,afterload reductionVentricular RemodelingMechanical Support-LVAD/RVADHeart TransplantationHeartmate IIContinuous axial flow pumpConnects LV apex to AortaBypasses blood flow from the left ventricleOnly has exteriorized driveline connected to external monitor and power sourceMust be placed surgicallyCan be used as bridge to transplant or as destination therapyHeartmate IIPros:Excellent flow deviceVery durableEasily implantable Has excellent long term efficacy and dataCons:Difficult to explant Need chronic anticoagulation Device does have defined lifespan Patient must be of a certain size to accommodate deviceThe FutureHeartwareImpella RPinflowoutflowHeartwareContinuous axial flow pumpConnects LV apex to AortaBypasses blood flow from the left ventricleOnly has exteriorized driveline connected to external monitor and power sourceMust be placed surgicallyCan be used as bridge to transplant or as destination therapySmall device can be placed in any body habitusCan be used for biventricular long-term supportCurrently on trialCatheter-based percutaneous VAD(22 Fr pump mounted on a 11 Fr catheter)Treatment:Right ventricular dysfunctionFlow:4 L/minDuration of support:up to 14 daysPump Inflow:Inferior Vena Cava(IVC)Pump Outflow:Pulmonary Artery(PA)inflowoutflowImpella RPThank You!Dr.ShahSalil G.Shah215-456-85435501 Old York RoadKlein 409Philadelphia,PADr.MoghbeliEinstein Advance Heart Failure Program Location5501 Old York RoadPhiladelphia,PA 19141To talk to one of our team,call the Heart Failure Hotline at 215-292-1958Contact Information