Diastolic Heart Failure

Transcription

1 Chronic Heart Failure Prevalence overall = 2-3 % Diastolic Heart Failure Patrick Wouters University Hospital Ghent Belgium (Heart Failure + Asymptomatic Ventricular Dysfunction) Prevalence > 70 y = % 4 y mortality = 50 % 2 % of health expenditure 2 d mortality & hospital readmission Perioperative outcome -159,327 procedures in patients > 65 y - age matched controls - Incidence of HF : 20 % - Incidence of CAD : 34 % Mortality HF : 1,63 H.R. (1,52-1,74) CAD : 1,08 H.R. (1,01-1,16) Hospital Readmission HF : 1,51 H.R. (1,45-1,58) CAD : 1,16 H.R. (1,12-1,20) Anesthesiology 2008; 108: Anesthesiology 2010; 112:

2 Pressure 1/7/2011 Chronic Heart Failure Diastolic Heart Failure Heart failure with preserved EF (HFNEF-HFPEF) 50 % of new diagnoses CHF Older patients - 70 % women Rate of hospitalization INCREASING Mortality SAME AS with systolic HF J Am Coll Cardiol 2004;43: Diastolic Heart Failure 3 ESSENTIAL CRITERIA : Systolic dysfunction Diastolic dysfunction 1. EF > 45 % and LV EDV < 97 ml.m - ² 2. Clinical Signs & Symptoms of HF 3. Abnormality in LV filling / diastolic function ESPVR EDPVR Volume 7 2

3 Pathophysiology Relaxation - active P = Ae -t/ + c ΔV / Δ P Compliance - passive 20g E. Braunwald 20g 9 Pathophysiology Pathophysiology Ca ++ Reuptake in SR Circ. Res. 2004;94; J Mol Cell Cardiol ; Circ Res. 2009;104:

4 Torrent Guasp : VMB Twisting - Untwisting Circulation 2008; 118: Diagnosis Invasive Pressure/Volume measurements Tau, dp/dt min stiffness Echo-Doppler Transmitral inflow profile Pulmonary venous flow profile Tissue Doppler imaging Color Doppler M-mode Circulation 2007;116:

5 ml /sec mmhg 1/7/2011 Relaxation Compliance P = Ae -t/ + c LA - LV Pressure gradient LVP Mitral flow profile Sampling at Tip of MV leaflets LAP E A dv/dt ECG! Early Filling Diastasis Atrial Systole E peak velocity : 0,6-1,3 m/s Decel Time : ms A peak velocity :0,4-0,8 m/s IRt : ms E/A : 1,4 5

6 mmhg ml /sec ml /sec mmhg 1/7/2011 Impaired LV Relaxation LVP LAP dv/dt E A Early Filling Diastasis Atrial Systole Adaptation to impaired relaxation = pseudonormalisation LVP LAP dv/dt E A Early Filling Diastasis Atrial Systole E or Em - Differentiation between restriction and constriction Garcia et al JACC 1996; 27: 108 6

7 Mean LVDP mm Hg Velocity (cm/sec) 1/7/2011 Tissue Velocities mitral annular plane excursion IVR IVC Systole Diastole Em Am 0 Sm - Em Inversely related to LV pressure decay : tau Oki et al Am J Cardiol 1997; 79: 928 Estimation of LV Filling Pressure Ratio of Mitral E velocity Mitral ann. E velocity vs LV filling pressure EF > 50% EF < 50% Ommen et al, Circulation

8 Treatment Treatment Majority of trials failed Alagebrium chloride breaks glucose crosslinks Rho-kinase and rapamycin inhibitors Sildenafil Antioxidants Enhancers of Calcineurin inhibitory proteins Histone deacetylase blockers BH4 Resynchronization 29 Circulation. 2010;121: Circulation. 2010;121: DHF and fluid management Critical Care 2006, 10:R174 Once adjustment was made for confounding variables, the choice of monitoring technique did not predict outcome, but a positive fluid balance was a significant predictor of greater mortality 8

9 University 87 Hospitals y female Ghent OPCAB surgery DHF summary MAP (mmhg) 60 sec SV (ml) :51:07 15:51:50 15:52:34 15:53:17 15:54:00 15:54:43 15:55:26 15:56: % of patients with CHF Geriatric population! Diagnostic tools gradually adapted in clinical practice : Echocardiography! Monitoring + Understanding of physiology essential for optimal fluid management Rate / Rhythm control Avoid vasodilation Avoid inotropes Specific therapy??? ~ pathophysiology 34 To read! EAE/ASE Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography European Journal of Echocardiography 2009 ; 10 : Current Perspectives on Cardiac Function in Patients with Diastolic Heart Failure Circulation 2009 ; 119 :