Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 235--237

Heart failure: Advances and Issues

Praveen Kumar Neema 
 Professor and Head Anaesthesiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Correspondence Address:
Praveen Kumar Neema
Professor and Head Anaesthesiology, All India Institute of Medical Sciences, Raipur- 492 099 (CG)

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Neema PK. Heart failure: Advances and Issues.Ann Card Anaesth 2013;16:235-237

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Neema PK. Heart failure: Advances and Issues. Ann Card Anaesth [serial online] 2013 [cited 2021 Dec 4 ];16:235-237
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Heart failure affects an estimated 4.7 million Americans, with 550,000 new cases diagnosed annually. [1],[2] The aggregate 5-year survival rate of patients with heart failure is approximately 50%. The 1-year mortality rate of those with advanced heart failure may exceed 50%. [1] The corresponding figures for Indian patients with heart failure are not available. Patients with mild-to-moderate heart failure are managed with pharmacologic drug therapy including digoxin, diuretics, β-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, inotropic agents, and aldosterone antagonists. The survival and the quality of life of patients with severe heart failure remain restricted despite drug therapy. Cardiac transplantation is the only treatment that provides substantial individual benefit; however, the poor availability of donor heart has remained a big obstacle in the overall growth of transplantation program. In fact, the number of heart transplants has remained static worldwide and the number of heart transplants performed each year in the United States has plateaued at about 2100 for the past few years. [1] The overall number of heart transplants performed in India has not grown beyond 100 and only a handful of centers in India are offering the facility for transplantation. The limitations of transplantation have stimulated interest in alternative approaches to support the failing heart and the circulation.

The artificial heart program was started at the National Institutes of Health (NIH) in 1964. Since then, various circulatory support devices have been developed for short-term use in patients with end-stage heart failure. [3] On 2 December 1982, Dr. Kolff implanted the Jarvik 7 artificial heart into a dentist from Seattle. The patient lived for 112 days tethered to an external pneumatic compressor, a device weighing some 400 pounds (180 kg). During that time, he suffered prolonged periods of confusion and a number of instances of bleeding, and asked several times to be allowed to die. [4] Presently, ventricular assist devices (VAD), which do not replace the human heart but complement it by taking up much of its function, have taken over the artificial heart program. The first Left Ventricular Assist Device (LVAD) system was created by Domingo Liotta at Baylor College of Medicine in Houston in 1962. [5] The developments in the field of VAD have been very rapid. In 1994, the Food and Drug Administration (FDA) approved pneumatically driven LVAD as a bridge to transplantation (BT). Short-term use of these devices in patients awaiting transplantation normalizes hemodynamics, allows patients to be sent home, and provides a reasonable quality of life with a relatively low incidence of major adverse events. The initial assist devices emulated the pulsating heart; the newer versions, such as the HeartMate II LVAS, [6] developed by The Texas Heart Institute of Houston, and HeartWare, provide continuous flow. These devices have gained status of alternative to heart transplant in patients with severe heart failure and considered as destination therapy (DT). The Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial [7] demonstrated significantly improved survival, functional capacity, symptoms, and quality of life in patients with advanced end-stage heart failure with LVAD, as compared with optimal medical management. Presently, HeartMate II is US Food and Drug Administration (FDA) approved; it has gained status of alternative to heart transplant in patients with severe heart failure and is considered as DT. In 2007, the website for cardiovascular specialists reported 7-year survival for an LVAD patient; the patient received a continuous flow Jarvik 2000 LVAD (Jarvik Heart Inc. New-York, NY). [8] In India, AIIMS New Delhi, Sir Ganga Ram Hospital, Fortis-Escorts New Delhi, and Fortis Malar Hospital Chennai have performed LVAD implants. At present, perhaps, the total number of LVAD implantation in India is restricted to about 25. The cost of implant (VAD) is US$ 100,000 and it is obviously a factor in slow growth of LVAD assistance program for patients of severe heart failure. The exponential growth and availability of these devices will ensure better life for the patients with severe heart failure, albeit these patients will present with different sets of clinical problems hitherto unknown.

In this issue of Annals of Cardiac Anaesthesia, Patangi et al. [9] present "Management issues during HeartWare LVAD implantation and the role of transesophageal echocardiography" and Goudra and Singh [10] report on "Anesthesia for gastrointestinal endoscopy in patients with LVAD." Multiple issues can jeopardize functioning of LVADs intraoperatively and need to be considered during LVAD implantation. Patent foramen ovale (PFO), which is present in almost 25% individuals, can cause severe hypoxemia after LVAD implantation. However, its diagnosis by routine methods is difficult in patients with severe LV failure. The method described by Huang and Bouvette [11] can be useful in the detection of PFO during prebypass period. It is noteworthy that diagnosis of PFO is important, as its presence makes bicaval cannulation mandatory; else, air will be entrained in the extracorporeal circuit during cardiopulmonary bypass. Similarly, presence of aortic regurgitation (AR) is difficult to diagnose, as the pressure gradient across the aortic valve during diastole is limited because of severe LV failure. The AR can increase significantly after LVAD implantation as the LVAD creates a low sub-physiologic pressure in the LV. The presence of AR increases the LVAD preload and causes an increase in pump flow and a fall in systemic blood flow. Apparently, AR should be assessed after separation from cardiopulmonary bypass. In case it is present, aortic valve should be closed. Adequate right ventricular (RV) function is vital for adequate filling of the LVAD, and thus, it is important to assess tricuspid valve and RV function during prebypass period. High LVAD flow can distort the interventricular septum, tether the tricuspid valve, and exacerbate the pre-existing tricuspid regurgitation (TR). Excessive preload also can aggravate TR. Transesophageal echocardiography can diagnose all these clinical conditions and is vital for successful outcome of LVAD implantation. These and many other issues and their management are discussed in detail in the article cited above.

The newer generation of the LVADs generates continuous flow, and the pulsatility of the flow depends on the contractile function of the native heart. The effects of continuous flow, if the aortic valve was closed during LVAD implantation, or reduced pulse pressure on the vasculature and various organs are yet to be thoroughly studied. An interesting outcome from the research into LVADs at Oxford Radcliffe was the discovery that if one takes away the pulse pressure with a continuous flow device, the aorta thins and could be a clue to aneurysm disease. [8] Needless to emphasize, increase in the population of patients with LVAD will provide enormous opportunity for the research in the areas hitherto scantily explored.

Goudra and Singh [10] explore the anesthetic issues for gastrointestinal (GI) endoscopy in patients with LVAD presenting with GI bleeding. The anesthesia techniques for GI endoscopy are not different from routinely employed techniques. The anesthetic considerations include ensuring appropriate perioperative anticoagulation, ensuring the device is plugged into main AC power in the OR, avoidance of significant hypovolemia, appropriate antibiotic coverage, appropriate perioperative management of cardiac rhythm devices, avoidance of chest compressions to prevent inadvertent dislodgement of intracardiac cannulae. The perioperative physician will have to understand the effects of blood loss, hypovolemia, and vascular tone changes. The LVAD flow is dependent on venous return, and decreased intravascular volume due to hypovolemia or vasodilation will result in decreased cardiac output. It is also possible that an under-filled LV can be "sucked down" by a continuous-flow LVAD; transesophageal echocardiography can help to diagnose this problem. Vasoconstriction secondary to noxious stimulations can result in increased venous return and RV failure. The other major challenges are related to perioperative monitoring. As stated earlier, in patients with newer generation LVADs, the pulsatility of the flow remains limited depending upon the contractility and functions of the native heart. Consequently, monitoring methods should be selected based on limited pulsatility or continuous flow. Goudra and Singh [10] have shown that in the presence of residual heart function, with optimal device settings, non-invasive hemodynamic monitoring can be reliably used in these patients. However, in patients with very poor residual heart function, the flow data obtained from the system control, controlling the LVAD, is used to assess the adequacy of flow. Cerebral Oximetry will be useful as pulsatility of flow is not important with cerebral oximeter. [12] Similarly, in the absence of pulsatility, invasive arterial pressure measurement is needed for patients supported by a continuous flow LVAD. Finally, the technique to resuscitate a patient in case of cardiovascular collapse is yet to develop. It should be noted that chest compression is contraindicated due to the position of the inflow cannula directly beneath the sternum. [13] The Interactive Cardiovascular Thoracic Surgery e-community conducted a discussion to address whether abdominal only cardiopulmonary resuscitation (AO-CPR) could be used instead of external cardiac massage (ECM) to either protect the recent sternotomy or while chest compressions are not possible during re-sternotomy. [14] After reviewing the evidence, Dunning et al. [15] concluded that AO-CPR theoretically has the potential to provide adequate systemic perfusion while an emergency re-sternotomy is being performed, but further evidence is needed before it can be recommended for routine use. Needless to emphasize, the availability of a cardiac anesthesiologist, TEE, and dedicated VAD support staff may be helpful to assist with intraoperative management, if hemodynamic instability develops.


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