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1、Limpiego di device nello scompenso cardiaco avanzato,S. Valente DAI Cuore e Vasi, AOU Careggi, Firenze,Definition,Chronic but not necessarily irreversible condition. Regardeless of its etiology, it is usually characterised by persistence of severe symptoms, functional limitation and cardiac dysfunct
2、ion despite optimal therapy.,European Journal of Heart Failure 9 (2007) 684-694,Severe symptoms of HF (NYHA III or IV) Fluid retention and/or low cardiac output at rest Objective evidence of severe cardiac dysfunction: low LVEF ( 30%) and/or elevated filling pressures and/or elevated NT pro BNP leve
3、ls Severe impairment of functional capacity: inability to exercise and/or 6-MWD distance 300m and/or peak VO2 12-14 ml/kg/min At least one hospitalisation in the past 6 months Presence of all the previous features despite optmal medical therapy unless it is poorly tolerated or controidicated and CRT
4、 if indicated,Definition of AHF modified from the Heart Failure association of the ESC definition,OF Abouzzedine, MM Redfield Congest Heart Fail 2011,INTERMACS Heart Failure classification,Progress in Cardiovascular Diseases 54 (2011) 78-85,The AHA estimates that there are 550,000 new cases of HF an
5、nually, most of which occurs among the elderly. Annual incidence of HF approaches 10 per 1,000 persons after the age of 65 years and reaches as high as more than 40 per 1,000 persons in those older than 85 years.,Incidence,Progress in Cardiovascular Diseases 54 (2011) 78-85,Prevalence,Although the H
6、F incidence appears to be relatively stable, the prevalence of HF has been rising dramatically and has culminated in the current HF epidemic. It is estimated that there are 5,8 million peopler currently living with symptomatic HF in the United States, and this number is expected to increase. 200,000
7、 patients have refractory end stage disease (stage D) with a 1-year mortality between 70 and 90%.,OF Abouzzedine, MM Redfield Congest Heart Fail 2011,Device nello scompenso cardiaco avanzato,Cardiac support,Renal supportPulmonary support,Cardiac resincronizaton therapy,Length of support Short term:
8、24 h Medium term : 2 weeks Permanent Goalsbridge to HTxbridge to recoverybridge to decisiondestination therapy,Type of support LVAD RVADBVADSite paracorporealintracorporealFlow pattern pulsatile continuous,VAD CLASSIFICATION,IABP,In cardiogenic shock IABP should be considered (Class I, C),Circulator
9、y support in the perioperative cardiac surgeryHigh risk PCIBridge to transplantation Intractable ventricular arrhythmiasAdvanced Heart Failure,ECMO,Centrifugal pump that provides a continuous flow. Percutaneous approach It does not decompress the LV It is lifesaving for patients with abrupt haemodyn
10、amic collapse in the cath lab. Its use is limited by the high incidence of associated complications,ECMO VENO-ARTERIOSO,Indicazioni ECMO in UTIC,Cardiomiopatia end-stage in terapia medica massimale, in attesa di trapianto cardiaco; Infarto miocardico acuto complicato da shock cardiogeno refrattario
11、Miocardite acuta con severa insufficienza dorgano o aritmie ventricolari subentranti non controllabili con terapia medica e IABP; Embolia polmonare massiva con grave compromissione della funzionalit ventricolare destra e shock cardiogeno o ACR Arresto cardiaco nel paziente giovane adulto con precoce
12、 rianimazione cardiopolmonare (con verosimile ottima prognosi neurologica) refrattario a terapia rianimatoria medica ed elettrica. La durata del supporto con ECMO dovr essere il pi breve possibile (sconsigliato per pi di 3 giorni). Da associare ad altre strategie di neuroprotezione come lipotermia t
13、erapeutica Grave depressione della funzione cardiaca da intossicazione di farmaci o sepsi;,Indicazioni ECMO in UTIC,Lindicazione allECMO, nel caso di grave scompenso cardiaco non pi responsivo a terapia medica massimale, dovr tenere conto della prognosi, in particolare ripresa della funzionalit dell
14、organo bridge-to-recovery, delleleggibilit per un trapianto cardiaco bridge-to-transplantation, della possibilit di posizionamento di assistenze meccaniche pi o meno a lunga durata (come Levitronix CentriMag, Jarvik 2000, Cardiowest) bridge-to-bridge. Ma anche bridge to decision.,CASISTICA ECMO: 11
15、PAZIENTI-Rottura di cuore in corso di STEMI anteriore in 1 pz-STEMI complicato da shock cardiogeno: 3 pz-Occlusione TC in corso di VCG: 1 pz-NSTE-SCA (occlusione del TC): 1 pz-Ipertrofica: in 1 pz- Dilatativa: 2 pz- Embolia polmonare: 1 pz- Sindrome di Tako-Tsubo: 1 pz,CASISTICA ECMO: 11 PAZIENTISho
16、ck cardiogeno: 5 pzACR: 4 pzScompenso cardiaco END-STAGE: 2 pz,Et media 54 anni Rapporto M/F 8:3 IABP, CRRT e ventilazione meccanica in tutti i pazienti,INIZIALE ESPERIENZA ECMO in UTIC,5 pz,2 pz,Sala di Emodinamica,DEA,4 pz,UTIC,Latenza media inizio ACLS-inizio ECMO (in ACR): 57 minuti (min. 22, max 110 min)Durata media del supporto con ECMO: 198 ore (min. 24, max. 504 ore)Decorso: 6 pazienti deceduti durante supporto ECMO.5 pazienti svezzati da ECMO.,
