RESUMO
Cardiac resynchronization therapies (CRTs) have been demonstrated to improve the clinical management and prognosis of selected patients with heart failure. CRT devices include both CRT pacemakers (CRT-P) and CRT defibrillators (CRT-D), with the latter being used to treat life-threatening ventricular arrhythmias. A significant advantage of CRTs is the ability to monitor several vital parameters which, thanks to advanced technology, may be remotely assessed. Personalized programming options allow patients to receive the maximum benefit from these treatments. In this review we report the main diagnostic and therapeutic algorithms used in clinical practice.
Assuntos
Terapia de Ressincronização Cardíaca/métodos , Desfibriladores Implantáveis , Insuficiência Cardíaca/terapia , Algoritmos , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Arritmias Cardíacas/terapia , Cardiologistas , Desenho de Equipamento , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Marca-Passo Artificial , PrognósticoRESUMO
OBJECTIVES: The need for a central venous catheter has limited the widespread use of ultrafiltration in daily clinical practice for the treatment of acute heart failure (AHF) with overt fluid overload. We evaluated the feasibility of a new ultrafiltration device, the CHIARA (Congestive Heart Impairment Advanced Removal Approach) system, that utilizes a single-lumen cannula (17G, multi-hole) inserted in a peripheral vein of the arm. METHODS: In this multicenter, prospective, feasibility study, consecutive ultrafiltration treatments (lasting ≥6 hours and with an ultrafiltration rate ≥100ml/h) with the CHIARA device and a single peripheral venous approach were performed at 6 Italian hospitals. For each session, we evaluated the performance of the venous access, the ultrafiltrate volume removed, and the cause of its interruption. RESULTS: One-hundred-three ultrafiltration sessions were performed in 55 patients with AHF (average 1.9±1.7 treatment/patient). The overall median length of ultrafiltration treatment was 14h (interquartile range 7-21) with removal of 3266±3088ml of fluid (183±30ml/hour). The treatment was successfully completed in 92 (89%) sessions and in 80% of patients. The mean suction flow rate from the vein was 70±20ml/min, while the mean re-injection flow rate was 98±26ml/min. There were no clinically relevant complications related to the venous access and/or to the anticoagulant therapy with heparin. CONCLUSIONS: The study demonstrated that the CHIARA system satisfies clinical applicability and efficacy criteria in the treatment of AHF, in terms of adequate fluid removal through a single peripheral venous access.
Assuntos
Cateterismo Periférico/métodos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Hemofiltração/métodos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Líquidos Corporais , Diuréticos/administração & dosagem , Estudos de Viabilidade , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Estudos Prospectivos , Ultrafiltração/métodosRESUMO
Noninvasive ventilation (NIV), including both continuous and bilevel positive airway pressure, plays a pivotal role in the treatment of acute respiratory failure secondary to acute heart failure. For an appropriate use of NIV, it is essential to consider the underlying pathophysiological principles, the differences between the different modes of ventilation, the main indications, contraindications and complications. The aim of this review is also to give practical guidance on how and when to start NIV at the bedside, how to monitor the response and how to choose the most appropriate interface. A review of the literature supports the use of NIV in terms of efficacy (reduction in intubation and mortality) and safety (in particular, the risk of myocardial infarction associated with its use, suggested by a previous study, has been definitely confuted). Nevertheless, NIV is still largely underused in contemporary clinical practice, as reported by data from real-world registries. This may be due to several factors, including lack of knowledge/confidence, reluctance of application in particular settings (acute coronary syndromes) and the risk of adverse effects (hypotension), which need to be reappraised.
Assuntos
Ventilação não Invasiva , Algoritmos , Barotrauma/etiologia , Barotrauma/prevenção & controle , Ensaios Clínicos como Assunto , Pressão Positiva Contínua nas Vias Aéreas/métodos , Pressão Positiva Contínua nas Vias Aéreas/estatística & dados numéricos , Insuficiência Cardíaca/terapia , Humanos , Metanálise como Assunto , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/prevenção & controle , Ventilação não Invasiva/efeitos adversos , Ventilação não Invasiva/métodos , Ventilação não Invasiva/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Edema Pulmonar/etiologia , Edema Pulmonar/terapia , Insuficiência Respiratória/terapia , RiscoRESUMO
Noninvasive ventilation (NIV) has gained increased acceptance inside the critical area, since it has been shown to be effective in reducing or avoiding the need for oro-tracheal intubation. NIV efficacy is dependent on the selection of the appropriate patients and on their compliance to therapy. Actually, full collaboration is not easily reached especially in agitated patients.Sedation during NIV is useful to reduce the rate of treatment failure, but robust data to guide the development of best practice are limited and sometimes local customs appear to exert a strong influence on patterns of care. Different sedative drugs are ready for use but none of currently available agents fulfill the criteria for the ideal drug. Knowledge of the pharmacological and hemodynamic characteristics of every single sedative agent is crucial to choose the right drug for every clinical scenario. Close monitoring is mandatory to avoid adverse effects. The aim of this article is to review the currently available literature, to recognize the contraindications for sedation use and to provide practical guidance.
Assuntos
Hipnóticos e Sedativos/uso terapêutico , Ventilação não Invasiva , Analgésicos/uso terapêutico , Hemodinâmica/efeitos dos fármacos , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/farmacologia , Entorpecentes/efeitos adversos , Entorpecentes/farmacologia , Entorpecentes/uso terapêutico , Cooperação do Paciente , Seleção de Pacientes , Agitação Psicomotora/tratamento farmacológico , Tranquilizantes/efeitos adversos , Tranquilizantes/farmacologia , Tranquilizantes/uso terapêuticoRESUMO
The application of a positive end-expiratory pressure (PEEP), the cornerstone of noninvasive ventilation (NIV), causes hemodynamic changes in the cardiovascular system. To understand the benefits of NIV it is necessary to resume concepts of cardiovascular physiology and pathophysiology about cardiac function determinants, venous return, ventricular interdependence and heart-lung interaction, and to understand how PEEP interacts with them. The hemodynamic effects of PEEP are mediated by the increase in transpulmonary pressure, which results in increased pulmonary vascular resistance and in an attending small reduction of venous return in conditions of euvolemia, in a substantial reduction of left ventricular afterload and a potential positive effect on left ventricular stroke volume.The aim of this review is to describe how the application of PEEP does not necessarily induce detrimental hemodynamic effects, but may decrease oxygen consumption and improve cardiac performance. These effects can justify the use of NIV in hemodynamically unstable patients.
Assuntos
Hemodinâmica , Respiração com Pressão Positiva , Coração/fisiologia , Humanos , Oxigênio/sangue , Consumo de Oxigênio , Pressão Parcial , Fenômenos Fisiológicos Respiratórios , Resistência VascularRESUMO
Cardiogenic shock (CS) is a life-threatening condition that occurs in response to reduced cardiac output, in the presence of adequate intravascular volume, and results in tissue hypoxia. CS can occur as a result of several etiologies but the most common is acute myocardial infarction. Despite the introduction of emergency revascularization for CS complicating acute myocardial infarction, mortality still remains exceptionally high, particularly in patients with refractory CS. The diagnosis of CS is sometimes challenging and it is based on clinical, hemodynamic, and biochemical signs. A multidisciplinary technical platform as well as specialized and experienced medical teams are crucial to treat this group of patients.We briefly summarize the main aspects of diagnosis, etiology and pathophysiology with a particular focus on macro- and microhemodynamic parameters that are essential for the diagnosis and treatment of this patient population.
Assuntos
Choque Cardiogênico/diagnóstico , Choque Cardiogênico/terapia , Circulação Sanguínea , Diagnóstico Precoce , Humanos , Choque Cardiogênico/etiologia , Choque Cardiogênico/fisiopatologiaRESUMO
Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to reduced cardiac output, despite adequate filling status. The development of multiorgan dysfunction is believed to be the major contributor to the high early mortality. Little evidence exists as to which vasopressor or inotrope should best be used for early treatment; however, customized pharmacological therapy, tailored on hemodynamic monitoring, is essential to achieve normal peripheral perfusion. Moreover, an increasing number of mechanical circulatory support devices are available for hemodynamic support in patients with CS but, at present, data derived from randomized clinical trials on the effectiveness, safety, differential indications for mechanical support devices, and optimal implant timing are limited.The aim of this review is to offer an overview of the pharmacological and device options, providing a practical approach to the treatment of patients with CS.