Management of left heart failure

GUIDELIN

ES FOR

MANAGEMENT OF

LEFT HEART F

AILURE

IN C

ARDIAC S

URGERY

PATIE

NTS

BY- DR. A

RMAAN SIN

GH

POSTOPERATIVE CARDIO-CIRCULATORY DYSFUNCTION

Indicators of cardiocirculatory failure:

• Cardiac index < 2.0 L/min/m2

• SvO2 < 60%

• Mean arterial pressure < 60 mmHg

• Urine output < 0.5 ml/h, existing for longer than an hour

• Plasma lactate > 2.0 mmol/L

• Peripheral vasoconstriction with delayed capillary refill and cool extremities

Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.

POSTOPERATIVE CARDIO-CIRCULATORY DYSFUNCTION

When LAP/PAD/CVP decrease :

• Evaluate response to an increase in preload. • Autotransfusion by means of passive leg raising. • Administration of colloid or crystalloid solution

(maximum of 10 ml/kg body weight).


GUIDELINES FOR MANAGEMENT OF LEFT HEART FAILURE

IN CARDIAC SURGERY PATIENTS

• If a preload increase does not lead to hemodynamic stabilization, an echocardiogram is indicated.

• In unstable patients, a 12-lead ECG to rule out acute ischemia, and lactate level should be obtained.




No history of pre-existing cardiac failure:

1. Normalization of preload 2. Afterload reduction (NTG, nicardipine)3. Choice of pharmacological inotropes:

• DOBUTAMINE should be regarded as being of medium efficacy • EPINEPHRINE is highly effective




Patients with dilated or ischemic cardiomyopathy:

1. Down-regulation of cardiac ß receptors 2. Reduced response to endogenous & exogenous catecholamines 3. Catecholamines with α-mimetic effects may decrease cardiac output




Goal directed therapy:

• Increase preload

• Optimize heart rate & rhythm (avoid tachycardia & arrhythmias)

• Vasodilating agents (NTG, nicardipine, nesiritide)

• Inotropic agents (milrinone or dobutamine)

• Mixed vasoactive agents (epinephrine, norepinephrine)

• Drug combinations (inotropic + vasopressor agents)

Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.



Drug combinations:

• Dobutamine + norepinephrine

• Milrinone + norepinephrine

• Milrinone + ephinephrine

• Milrinone + vasopressin or phenylephrine (if diastolic dysfunction)


GUIDELINES FOR DIAGNOSIS AND TREATMENT OF ACUTE AND CHRONIC HEART FAILURE

Decompensated congestive heart failure:

Dickstein K, et al: ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur Heart J. 2008;29:2388-2442.


Immediate goals of treatment:

•Improve hemodynamics •Improve organ perfusion •Restore oxygenation •Limit cardiac & renal damage •Treating the cause of heart failure



Treatment:

•Vasodilators (class of recommendation I, level of evidence B)

•Dobutamine / milrinone (class of recommendation IIa, level of evidence B)

•Levosimendan (class of recommendation IIa, level of evidence B)

•Dopamine (class of recommendation IIb, level of evidence C)

•Vasopressors (class of recommendation IIb, level of evidence C)


GUIDELINES FOR MANAGEMENT OF DECOMPENSATED LEFT HEART FAILURE

Levosimendan (Simdax):

• Standard Dilution:

[12.5 mg/5 ml] [500 ml D5W]

• Loading dose:

6-12 mcg/kg over 10 min

• Followed by 0.1 mcg/kg/min

• Continuous infusion x 24-48 hours

• In US: REVIVE 2 trial

GUIDELINES FOR MANAGEMENT OF DECOMPENSATED LEFT HEART FAILURE


•Supportive care of the heart & lungs •Obtain ABG, CXR, EKG, TTE or TEE •IV loop diuretics, morphine •Agents with positive inotropic activity can increase mortality despite acute hemodynamic improvement •Vasodilating agents (NTG > 1 mcg/kg/min, Nesiritide) •Levosimendan •± Ventilatory support


Young JB. Intravenous Nesiritide vs Nitroglycerin for Treatment of Decompensated Congestive Heart Failure. A Randomized Controlled Trial. JAMA 2002;287:1531-1540.



Treatment of LV diastolic dysfunction:

• Optimize preload (LAP 14-18 mmHg) • Avoid tachycardia• Optimize heart rate (80/min) & increase AV delay (180 ms) • Aggressive treatment of atrial fib & tachyarrhythmias • Milrinone (0.5 mcg/kg/min) ± Vasopressin (0.04 units/min)

or phenylephrine (1-2 mcg/kg/min) [avoid tachycardia] • Levosimendan (if MAP > 60 mmHg) • IABP


MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION


Nesiritide:

Hemodynamic benefits: ↓ PAP, ↓ CVP, ↑ CO Improves postop renal function Decreases respiratory failure and AF Decreases LOS Decreases mortality

Blais DM. Nesiritide Compared with Milrinone for Cardiac Surgery. Ann Pharmacother 2007;41:502-504.

Mentzer RM, et al: Effects of Perioperative Nesiritide in Patients With Left Ventricular Dysfunction Undergoing Cardiac Surgery. The NAPA Trial. J Am Coll Cardiol 2007;49:716-726.



Nesiritide:

Pulmonary, coronary, and renal arterial vasodilation Lusitropic effects on ventricular myocardium Improves echocardiographic indices of diastolic function Increases cardiac output without direct inotropic effects Not pro-arrhythmic

Young JB. Intravenous Nesiritide vs Nitroglycerin for Treatment of Decompensated Congestive Heart Failure. A Randomized Controlled Trial. JAMA 2002;287:1531-1540

Gordon GR, et al: Nesiritide for treatment of perioperative low cardiac output syndromes in cardiac surgical patients: an initial experience. J Anesth 2006; 20:307-311.



Nesiritide :

Perioperative management of patients with severe MR, severe LV dysfunction and secondary pulmonary hypertension

Expected mortality by EuroSCORE 26% Preoperative treatment with Nesiritide for 13-55 hr (mean=24 hr) Postoperative treatment with Nesiritide for 2-80 hr (mean=22 hr) Improves postop renal function and survival

Salzberg SP, et al: High-Risk mitral valve surgery. Perioperative hemodynamic optimization with Nesiritide (BNP). Ann Thorac Surg 2005;80:502-506.



Salzberg SP, et al: High-Risk mitral valve surgery. Perioperative hemodynamic optimization with Nesiritide (BNP). Ann Thorac Surg 2005;80:502-506.



NAPA (Nesiritide Administered Peri-Anesthesia in Patients Undergoing Cardiac Surgery) Trial:

Perioperative management of CABG patients with LV systolic & diastolic dysfunction

Patients received Nesiritide vs placebo for 24 to 96 h after induction of anesthesia

Decreases preload, afterload and PVR Improves postop renal function and survival




NAPA (Nesiritide Administered Peri-Anesthesia in Patients Undergoing Cardiac Surgery) Trial:




Nesiritide (Natrecor):

• Standard Dilution:

[1.5 mg] [250 ml D5W, D5½S or NS]

• Loading dose:

2 mcg/kg over 20 min

• Followed by 0.01 mcg/kg/min

• Continuous infusion x 48 hours

Health & Medicine

Management of left heart failure