Indications and patient selection for circulatory support

A wide variety of temporary and long-term mechanical support devices are now available in affluent health care systems. Blood pumps resuscitate an ever-increasing number of patients who have heart failure by LVAD or BIVAD support with or without cardiac transplantation. The goal of postcardiotomy circulatory support is to restore normal hemodynamics and oxygen delivery in patients in whom the native heart is temporarily unable to sustain this function despite IABP and inotropic support....

Surgical treatment for an index acute myocardial infarction

In the setting of an index AMI, a patient's condition can vary from STEMI, non ST elevation myocardial infarction (NSTEMI) (subendo-cardial), or cardiogenic shock. The approach begins with medical management (previously outlined) and then proper diagnosis. Surgery is an essential part of the treatment armamentarium in approaching all clinical scenarios. With a STEMI, PCI can identify and address the culprit vessel. With NSTEMI, PCI is less likely to identify a single culprit lesion, and CABG...

Surgery for Heart Failure Now Something for Everyone

Oxford Heart Centre, John Radcliffe Hospital, Headington Oxford, UK The year 2007 marks the 50th anniversary of two major advances destined to become pivotal in the treatment of heart failure. In 1957 Charles Bailey reported a small series of left ventricular aneurysm resections performed by side clamping of the dyskinetic scar and suture without cardio-pulmonary bypass. Performed with low mortality, the operation provided immediate symptomatic relief from breathlessness 1 . The same year,...

The management of patients at risk for low cardiac output syndrome

Three categories of patients are at substantial risk. First are those who present urgently for surgery, already in cardiogenic shock, often with a complication of myocardial infarction or infective endocarditis. Second is the group submitted for high-risk nontransplant heart failure surgery who have LVEF less than 20 together with renal impairment or aortoiliac disease, which precludes the use of an IABP. The third category includes patients who sustain an unanticipated negative event during...

Elective transfer from cardiopulmonary bypass to centrifugal blood pump support in very highrisk cardiac surgery

The decision to preemptively deploy an LVAD must balance safety with efficacy. To improve outcome in borderline survival situations following high-risk cardiac surgery the Oxford Group decided to wean directly from CPB to a new temporary centrifugal blood pump designed to reduce bleeding and thromboembolic complications 98 . The rationale for elective LVAD deployment is straightforward. The failing heart beats more than 120,000 times per day pumping in excess of 7000 L of blood against an...

Extracorporeal centrifugal blood pumps

Centrifugal pumps impart momentum to fluid by fast-moving blades, impellers, or concentric cones 92 . Fluid enters the pump axially from an inlet pipe or tubing and is caught up between veins or stages and whirled outward (Fig. 6). Rotation of the impeller causes the velocity of blood to change while it moves toward the periphery of the pump. As blood exits through the outlet port, pressure is increased. Centrifugal pumps can provide high flow rates with low pressure increases but are...

Methods for reperfusion

Thrombolysis is the simplest and least-invasive way to achieve reperfusion of acutely occluded coronary arteries by dissolving thrombus. Throm-bolytics, given in 40 of patients after AMI, is the most common means of reperfusion 85 . Numerous multicenter trials showed that thromboly-sis with streptokinase (SK) or tPA is safe and effective in treating early AMI 86 . The GISSI trial (Gruppo Italiano per lo studio della Strepto-chinasi nell'Infarto miocardio) showed SK decreases in-hospital...

Outcome after circulatory support for postcardiotomy cardiogenic shock

Pae and colleagues 93 from the Pennsylvania State University reviewed combined registry data on the use of first-generation temporary LVADs between 1985 and 1990. A total of 965 patients were treated for postcardiogenic shock, of whom 45 were weaned from the system and 25 were discharged from the hospital. Notably 90 of patients who survived to leave the hospital were weaned from the pump within 1 week. Those requiring univentricular support alone faired better irrespective of whether pulsatile...

Indications and preoperative assessment for surgery

What the surgeon needs to know from the imager about acute myocardial infarction Echocardiography is an important tool in acute myocardial infarction for determining infarct size and location, detecting mechanical complications (acute mitral regurgitation from papillary muscle rupture, ventricular septal defect, cardiogenic shock), and stratifying risk. Surgical intervention in acute myocardial infarction has become increasingly common what the surgeon wants to know from the imager is the...

Inhaled nitric oxide gas and elevated pulmonary vascular resistance

Pulmonary vascular resistance (PVR) is the primary clinical determinant of right ventricular afterload and an important cause of right ventricular failure and low cardiac output syndrome in high-risk cases. Intravenous drugs, including sodium nitroprusside, nitroglycerine, dobutamine phosphodiesterase inhibitors, and prostaglandin E1, are used clinically as pulmonary vasodilators, but cause vasodilatation and hypotension in the systemic circulation. Hypotension may then impair coronary...

George M Comas MD Barry C Esrig MD Mehmet C Oz MD

College of Physicians and Surgeons, Columbia University, New York, NY, USA Acute myocardial infarction (AMI) and acute coronary syndrome are major causes of morbidity and mortality in the United States. Most recent statistics estimate that 1.375 million patients have a coronary attack per year with the annual incidence of AMI at 865,000. Total-mention mortality due to coronary heart disease is 653,000 per year, making coronary heart disease the largest killer of Americans (males and females)....

What constitutes the heart failure population

Congestive heart failure is the final common pathway for many diseases that affect the myocardium (Table 1). Advanced heart failure is defined by symptoms that limit daily activity despite attempted maximum medical therapy (New York Heart Association NYHA Functional Class III or IV, or Stage D) 7 . Different clinical conditions predominate in different parts of the world. Although coronary artery disease accounts for more than 65 of cases in North America and Europe (Fig. 3), Chagas disease...