Surgical Therapy of Cardiac Failure

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Surgical Therapy ofCardiac Failure

• Peter W. Cho, M.D.
• Division of Cardiac Surgery

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Causes of Low CO Syndrome

• Decreased LV preload
• Hypovolemia
• Cardiac tamponade
• Positive-pressure ventilation, PEEP
• RV dysfunction
• Tension pneumothorax

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Causes of Low CO Syndrome

• Decreased contractility
• Low EF
• Myocardial ischemia, stunning
• Hypoxia, hypercapnea, acidosis

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Causes of Low CO Syndrome

• Tachy- and bradyarrhythmias
• Tachycardia ? filling time
• Bradycardia
• A-fib/flutter loss of atrial contraction
• Ventricular arrhythmias

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Causes of Low CO Syndrome

• Increased afterload
• Vasoconstriction
• Fluid overload, LV distension
• LVOT obstruction (struts, leaflets)

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Causes of Low CO Syndrome

• Diastolic dysfunction
• Syndromes of CV instability, hypotension
• Sepsis
• Anaphylactic reaction
• Adrenal insufficiency
• Protamine reaction

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Assessment of Low CO Syndrome

• Physical examination
• Murmurs
• Breath sounds
• Peripheral pulses
• Warmth of extremities

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Assessment of Low CO Syndrome

• Hemodynamic measurements
• (Swan-Ganz catheter)
• Measure CO, filling pressures
• Calculate SVR
• Measure mixed venous saturation

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Assessment of Low CO Syndrome

• Blood tests
• Arterial blood gas
• Hematocrit
• Serum K

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Assessment of Low CO Syndrome

• Electrocardiogram
• Ischemia
• Arrhythmias
• Conduction abnormalities

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Assessment of Low CO Syndrome

• Chest radiograph
• Pneumothorax
• Hemothorax
• Position of ETT, IABP

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Assessment of Low CO Syndrome

• Urine output
• Chest tube drainage

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Assessment of Low CO Syndrome

• Echocardiogram
• LV systolic, diastolic dysfunction
• RV systolic dysfunction
• Cardiac tamponade
• TTE v. TEE

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Treatment of Low CO Syndrome

• Ensure oxygenation, ventilation
• Treat ischemia, coronary spasm

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Treatment of Low CO Syndrome

• Optimize preload
• Stabilize heart rate, rhythm
• Improve contractility
• Reduce afterload
• Maintain blood pressure
• Correct anemia

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Treatment of Right Ventricular Failure

• Optimize preload CVP 18-20 mm Hg
• Confirm AV conduction
• Maintain adequate systemic perfusion pressure

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Treatment of Right Ventricular Failure

• Lower RV afterload, improve RV contractility
• Correct hypothermia, hypoxia, hypercapnea,
  acidosis
• Inotrope/vasodilators (milrinone, dobutamine,
  etc.)
• Pulmonary vasodilator (nesiritide, NO,
  prostacyclin, etc.)
• Optimize LV function
• RVAD as last resort

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Hemodynamic Effects of Vaso-active Drugs
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Hemodynamic Effects of Vaso-active Drugs
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Surgical Therapy

• Revascularization
• Valve repair, replacement
• Ventricular remodeling
• Cardiomyoplasty

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Coronary Artery Bypass
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Laser Revascularization(TMR)
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Posterior Band Annuloplasty
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Ring Annuloplasty
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Posterior LeafletSliding-plasty
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Prosthetic Valves
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Dilated Ischemic Cardiomyopathy

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Ventricular Remodeling (Dor)
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Non-ischemic Dilated Cardiomyopathy
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Cor-Cap Device
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Cardiomyoplasty
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Surgical Therapy

• Intra-aortic balloon pump (IABP)
• Ventricular assist device (VAD)
• Temporary therapy
• Destination therapy
• Heart transplant
• Total artificial heart

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IABP
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Indications for Circulatory Assist Devices
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Peripheral Cannulation for CPS
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Hemopump Impeller
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Abiomed BVS 5000
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Ventricular Assist Device
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Thoratec HeartMate LVAD
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Destination VAD Therapy
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Heart Transplant
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Abiocor Artificial Heart