La Sindrome cardiorenale nel paziente critico

La Sindrome cardiorenale nel paziente critico Lo scompenso cardiaco nel paziente postcardiochirurgico F.L. Lorini

DEFINITION AHF is a critical inability of the myocardium to maintain a cardiac output sufficient to meet the demands of the peripheral circulation.

DEFINITION AHF is a critical inability of the myocardium to maintain a cardiac output sufficient to meet the demands of the peripheral circulation. with or without previous cardiac disease. systolic or diastolic dysfunction abnormalities in cardiac rhythm pre-load and after-load mismatch

DEFINITION AHF is a critical inability of the myocardium to maintain a cardiac output sufficient to meet the demands of the peripheral circulation. It is often life threatening and requires urgent treatment.

Acute Exacerbations May Contribute to the Progression of the Disease Ventricular function Acute event With each event, hemodynamic alterations and myocardial damage contribute to progressive ventricular dysfunction Time From Gheorghiade. Am J Cardiol 2005 (modified)

Complications in Cardiac Surgery 18 12 11 4 3 5 CIrculatory I stroke lung kidney bleeding sepsis

REVIEW Clinical Profiles According to ESC Guidelines Clinical review: Practical recommendations on the management Italian of perioperative Survey on Acute Heart heart Failure failure in cardiac surgery Cardiac surgery failure 19% Cardiac surgery normal 81%

Clinical Profiles According to ESC Guidelines Italian Survey on Acute Heart Failure

Clinical Profiles According to ESC Guidelines Italian Survey on Acute Heart Failure 30,00 22,50 In Hospital Death 25,4 15,00 7,50 0 3,2 6,8 5,1 Hypertensive HF cardiogenic shock Pulmonary edema Acute decompensated HF

Clinical Profiles According to ESC Guidelines Italian Survey on Acute Heart Failure 30,00 In Hospital Death 50,00 6 Months Death 22,50 25,4 37,50 43,0 15,00 7,50 0 3,2 6,8 5,1 25,00 12,50 0 12,0 22,0 23,0 Hypertensive HF cardiogenic shock Pulmonary edema Acute decompensated HF Hypertensive HF cardiogenic shock Pulmonary edema Acute decompensated HF

REVIEW Clinical review: Practical recommendations on the management of perioperative heart failure in cardiac surgery Figure 1. Kaplan Meier curves showing survival rates of ICU patients with different acute heart failure (HF) syndromes over time, starting at the day of ICU admission. The small vertical lines indicate the time points when patients had their last follow-up. The survival curves between the groups are signifi cantly different (log rank P < 0.001). Data were derived from [10].

Hemodynamic variables during acute HF Cardiac Index Wedge Pressure 50 6 40 4 CI l/min/m 2 * 2 * 30 Wedge mmhg 20 10 0 Cardiogenic shock Pulmonary edema HTN crisis Exacerbated Systolic HF Normal Septic shock 0 Cotter et al: Eur J Heart Fail, 2003

Hemodynamic variables during acute HF 12000 Systemic vascular resistance index (Dyne/ m 2 ) 8000 SVR 4000 0 Cardiogenic shock Pulmonary edema HTN crisis Exacerbated Systolic HF Normal Septic shock Cotter et al: Eur J Heart Fail, 2003

Diagnosis of different clinical syndromes

Diagnosis of different clinical syndromes Acute CHF

Diagnosis of different clinical syndromes Acute CHF Cardiogenic shock

Diagnosis of different clinical syndromes Acute CHF Pulmonary edema Cardiogenic shock

Diagnosis of different clinical syndromes Acute CHF Pulmonary edema Cardiogenic shock RV failure

Diagnosis of different clinical syndromes Acute CHF Pulmonary edema Cardiogenic shock RV failure High output failure

Diagnosis of different clinical syndromes Acute CHF Pulmonary edema Cardiogenic shock Hypertensive AHF RV failure High output failure

INSUFFICIENZA VASCOLARE O CARDIACA? 1. Insorgenza acuta, conservata FE 2. Insorgenza meno acuta, Fe depressa 3. Insuff. cardiaca + ipoperfusione

Danno miocardico bioumorale:tnf-endotelio-peptidi meccanico-adattamento

LIVELLI DI CITOCHINE E GRAVITA DELLO SCOMPENSO Aukrust P; Am J Cardiol 1999; 83: 376-382

LIVELLI DI CITOCHINE E GRAVITA DELLO SCOMPENSO Aukrust P; Am J Cardiol 1999; 83: 376-382 20,00 TNF AO CS ICD 18 15,00 16 15 10,00 12 11 12 5,00 8 7 7 0 NYHA II NYHA III NYHA IV

LIVELLI DI CITOCHINE E GRAVITA DELLO SCOMPENSO Aukrust P; Am J Cardiol 1999; 83: 376-382 TNF IL 6 pcg/ml 20,00 AO CS ICD 8,00 AO CS ICD 8 15,00 18 16 15 6,00 6 7 7 6 10,00 12 11 12 4,00 5 5,00 8 7 7 2,00 2 0 NYHA II NYHA III NYHA IV 0 1 NYHA II 1 NYHA III NYHA IV

LIVELLI DI CITOCHINE E GRAVITA DELLO SCOMPENSO Bonaduce D, Am Hearth J 2000; 1

LIVELLI DI CITOCHINE E GRAVITA DELLO SCOMPENSO 6,00 4,50 3,00 1,50 0 IL-10 pcg/ml 5,1 3,0 3,2 1,0 Controls NYHA II NYHA III NYHA IV Bonaduce D, Am Hearth J 2000; 1

LIVELLI DI CITOCHINE E GRAVITA DELLO SCOMPENSO 6,00 4,50 3,00 IL-10 pcg/ml 5,1 3,0 3,2 Controls NYHA II NYHA III NYHA IV 40 30 20 31 25 23 Controls NYHA II NYHA III NYHA IV 1,50 0 1,0 10 0 10 Bonaduce D, Am Hearth J 2000; 1

LIVELLI DI CITOCHINE E GRAVITA DELLO SCOMPENSO 6,00 4,50 3,00 IL-10 pcg/ml 5,1 3,0 3,2 Controls NYHA II NYHA III NYHA IV 40 30 20 31 25 23 Controls NYHA II NYHA III NYHA IV 1,50 0 1,0 10 0 10 50 38 25 41 32 25 Controls NYHA II NYHA III NYHA IV 13 14 0 Bonaduce D, Am Hearth J 2000; 1

Kirklin JK, Kirklin JW. Cardiopulmonary bypass for cardiac surgery. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest, 5th ed. Philadelphia: WB Saunders, 1990; 1107-25 Kirklin and colleagues found that plasma C3a levels measured 3 h post-cpb could predict the occurrence of complications.

Kirklin JK, Kirklin JW. Cardiopulmonary bypass for cardiac surgery. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest, 5th ed. Philadelphia: WB Saunders, 1990; 1107-25 Kirklin and colleagues found that plasma C3a levels measured 3 h post-cpb could predict the occurrence of complications. 40 30 20 10 CPB SURGERY 0 30 60 90 120 180

Kirklin JK, Kirklin JW. Cardiopulmonary bypass for cardiac surgery. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest, 5th ed. Philadelphia: WB Saunders, 1990; 1107-25 Kirklin and colleagues found that plasma C3a levels measured 3 h post-cpb could predict the occurrence of complications. 40 30 20 10 CPB SURGERY 0 4 2 30 60 90 120 180

Kirklin JK, Kirklin JW. Cardiopulmonary bypass for cardiac surgery. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest, 5th ed. Philadelphia: WB Saunders, 1990; 1107-25 Kirklin and colleagues found that plasma C3a levels measured 3 h post-cpb could predict the occurrence of complications. 40 30 20 10 14 CPB SURGERY 0 4 4 2 30 60 90 120 180

Kirklin JK, Kirklin JW. Cardiopulmonary bypass for cardiac surgery. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest, 5th ed. Philadelphia: WB Saunders, 1990; 1107-25 Kirklin and colleagues found that plasma C3a levels measured 3 h post-cpb could predict the occurrence of complications. 40 30 20 10 0 14 CPB 4 4 2 25 30 60 90 120 180 7 SURGERY

Kirklin JK, Kirklin JW. Cardiopulmonary bypass for cardiac surgery. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest, 5th ed. Philadelphia: WB Saunders, 1990; 1107-25 Kirklin and colleagues found that plasma C3a levels measured 3 h post-cpb could predict the occurrence of complications. 40 30 20 10 0 14 CPB 4 4 2 25 30 60 90 120 180 7 SURGERY 30 8

Kirklin JK, Kirklin JW. Cardiopulmonary bypass for cardiac surgery. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest, 5th ed. Philadelphia: WB Saunders, 1990; 1107-25 Kirklin and colleagues found that plasma C3a levels measured 3 h post-cpb could predict the occurrence of complications. 40 30 20 10 0 14 CPB 4 4 2 25 30 60 90 120 180 7 SURGERY 30 8 35 9

ENDOTELINA Yanagisawa M, Nature;1988;332:411-15

VASODILATAZIONE ARTERIOSA DOPO INFUSIONE DI L-NMMA Belardinelil R. J Cardiol 2001; 81:1-8

DISFUNZIONE ENDOTELIALE NELLO SCOMPENSO Belardinelli R. Int J Cardiol 2001; 81:1-8

PRINCIPALI MECCANISMI DETERMINANTI DELLA FORZA DI CONTRAZIONE DEL MIOCARDIO

The management strategy Drugs O2 Fluid Balance Surgery/Devices

Cellular architecture: the sarcomere at TITIN Passive tension Z disk M line Thin filament: ACTIN Active tension Thick filament: MYOSIN

The variation in isometric tension with sarcomere length in muscle fibers Tension peak at 2.2 µm of length

RELAZIONE VELOCITÀ DI ACCORCIAMENTO CARICO DI UN MUSCOLO PAILLARE Braunwald E, Mechanism of contraction 2nd Edition 1976

EFFETTI DELLA NORADRENALINA (NE) SULLA RELAZIONE F/V NEL MUSCOLO PAPILLARE Braunwald E, Mechanism of contraction 2nd Edition 1976

RELAZIONE TRA CONSUMO MIOCARDICO DI O2 ED ENERGIA MECCANICA PRODOTTA 0,08 0,06 0,04 0,02 0 0 500 1000 GIBBS CL, Am J Physiol 1985;249:H199-06

RELAZIONE TRA CONSUMO MIOCARDICO DI O2 ED ENERGIA MECCANICA PRODOTTA MVO2 0,08 0,06 NORMALE >>CONTRATTILITA SCOMPENSO 0,04 0,02 0 0 500 1000 APV (Joule*beat) GIBBS CL, Am J Physiol 1985;249:H199-06

EFFETTI EMODINAMICI INDOTTI DALL ESPANSIONE ACUTA DI VOLUME SOGGETTI NORMALI VOLPE M, CIRCULATION 1995;92:2511-18 CARDIOMIOPATIA DILATATIVA IN CLASSE NYHA I-II

FISIOPATOLOGIA E TERAPIA SIGNIFICATO PROGNOSTICO DELLE CATECOLAMINE CARDIACHE > Kaye DM J Am Coll Cardiol 1995; 26:1257-63

FISIOPATOLOGIA E TERAPIA SOPRAVVIVENZA E LIVELLI DI NORADRENALINA Cohn JN, N Engl J Med 1984;311:822

www. Anestesiacardiovascolare.it

Complications in Cardiac Surgery 18 12 11 4 3 5 CIrculatory I stroke lung kidney bleeding sepsis

STATUS OF THE ART Buckberg G. Congestive heart failure: treat the disease, not the symptoms return to normalcy J Thorac Cardiovasc Surg 2001;121:628-37