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What is the New York heart Association (NHYA classification)

NHYA I: no limitations of physical activity and no symptoms with ordinary activity
NHYA II: slight limitation of physical activity but comfortable at rest or mild exertion
NYHA III: marked limitation of physical activity and comfortable only at rest
NYHA IV: symptoms of heart failure at rest


What is pathophysiology of chronic heart failure

neuro-endocrine activation, including
a) activation of the sympathetic nervous system/renin-angiotensin system
c) release of endogenous noradrenaline, antidiuretic hormone (vasopressin) and endothelin
d) Results in fluid retention and inappropriately high afterload.


What are main causes of heart failure

Increased pre-load (volume)
Reduced contractility
Increased afterload (AS, HTN, coarctation)
Impaired cardiac rhythm
Impaired ventricular filing
High-output failure (secondary to anemia, sepsis, pregnancy, hyperthyroidism, AV fistual)


What are principles of treatment of heart failure

Treat the cause: CABG (CASS/STICH)
Reduced pre-load: diuretics; aldosterone antagonist (RALES)
Left ventricular volume reduction: (RESTORE, SAVER)--controversial
Improve contractility: a. Cardiac resynchronization therapy (MUSTIC)
b. Implantable cardioverter defibrilatory (MADIT)
c. Ventricular assist devices (REMATCH)
d. Cardiac transplantation (COCPIT)*
e. Cellular cariomyoplasty (MAGIC) *
f. dynamic cardiomyoplasty (C-SMART*
Reduce afterload: a. ACE inibiitors (SOLDV; CONSENSUS)
c. Betablockers (COPERNICUS)
d. Intra-aortic balloon pump *short term*
e. ventricular septal myectomy for HOCM


What are indications for CABG in patients with heart failure

Reasonable target vessels to graft
myocardial ischemia
myocardial viability (>20% of left ventricles demonstrating viability)

CASS study
5 year survival of patients with ischemic cardiomyopathy being 41% with pts treated medically and 62% with surgery

Relative contra-indications to CABG are a. poor targets b. pulmonary HTN c. impaired right ventricle


List principles for biventricular pacing

Ventricular dysynchrony often results from LBBB as earlier controcation of the right ventricle and paradoxical ventricular septal motion leads to impaired left ventricular filling and imparied left ventricular systolic function.

Biventricular pacing induces simultaneous left and right verntricular contraction, thereby increasing the efficacy of ventricular contractility without increasing myocardial oxygen consumption


When is biventricular pacing indicated

Heart failure for at least 6 weeks on maximal medical therapy
NYHA functional status III or IV
Left ventricular ejection fraction < 35%
QRS interval > 150ms


What are the indications for implantable cardiodeibrillator in heart failure

Primary prevention: pts who have sustained a previous MY with an ejection fraction of < 35% with a. non-sustained v.tach; or b) inducible ventricular tachycardia on electro-phyiological studies

secondary prevention in pts with hemodynamically significant tachyarrhythmias and an ejection fraction of < 35%

treat any underlying causes including drug toxicity, electrolyte disturbance, reversible ischemia, before implanting an ICD


What are the principles of the surgical ventricular restoration procedure

SVR excludes areas of non-functional LF, resulting in reduced left ventricular volume and wall stress (Laplace Law) and return of an elliptical shape to the left ventricle.


What are the components of the heart failure survival score

Ischemic cardiomyopathy
Heart rate
LV ejection fraction
mean arterial blood pressure
interventricular conduction delay
serum sodium
peak myocardial oxygen consumption

those with medium or high-risk HFSS would benefit from transplantation as the 1 year survival of transplntatation is 85%


How does resynchronized therapy work

It allows the apex of the RV to be synchronous with lateral wall of the LV
Optimize the LA and LV timing


What is Non-ischemic dilated cardiomyopathy

Causes include viral, valvular, idiopathic
All muscle is viable to some degree
A variable degree of hypertrophy is also present
25% of patients have familial disease
the inheritance is x-linked
onset is early in men and late in women
Thromboembolism is a risk when LV is dilated and AF present


What medications can be used/useful for pregnant women with heart failure

Beta-blockers--- should be continued or inhaled during pregnany


What are important hemodynamic changes in normal pregnancy

Increase in blood volume
Increase Heart rate
Increase cardiac output
Decrease in peripheral vascular resistance and blood pressure


What is PPCM

Post partum cardiomyopathy
dilated cardiomyopathy (LVEF < 45%) with the development of HF in the last montth of pregnancy or within five months after delivery, in the absence of a demonstrable cause for HF


What are risk factors for PPCM

Multiple fetus gestations
Older maternal age
History of gestational hypertension
Maternal cocaine use
Long-term oral tocolytic


Potential reasons for PPCM

Viral infections
myocyte apoptosis
development of maternal cardiac autoantibodies
oxidative stress linked to proteolysis' cleavage of prolactin into a potent cariotoxic subfragment


Indications for Cardiac transplant

Systolic Heart failure
Ischemic heart disease with intractable angina
intractable arrhytmia
congenital heart disease in which severe fixed pulmonary hypertension is not a complication
cardiac tumor
Hypertrophic cardimyopathy


What is UNOS (United network for organ sharing) criteria

Status 1A
- require mechanic circulatory support with one more of the following devices
- Life expectancy < 7 days
- mechanical ventilation
- continuous infusion of high-dose inotropes
Status 1B
- LVAD or RVA implanted for > 30 days
- continuous infusion of inotropes;pt is home?
Status II
- all others who do not meet status Ia or Ib


What are INTERMACS patient profiles

STAGE 1: Critical cardiogenic shock
STAGE 2: Progressive decline on inotrope support
STAGE 3: Stable but on inotrope support
STAGE 4: Resting symptoms but at home
STAGE 5: Exertion intolerant
STAGE 6: Exertion limited
STAGE 7: Advanced NYHA III symptoms


Myocardial ischemia occurs in the context of HOCM because

Intramural coroanries (bridging)
increased oxygen demand due to increase in muscle mass
increased wall tensions due to diastolic dysfunction
associated epicardial coronary artery disease


Mechanism of LVOT obstruction in HOCM

Reduced LVOT dimension
Anterior basal spetal hypertrophy
anterior displacement of the mitral valve
increased size and height of both mitral leaflets
Papillary muscle anomalies--insertion too close to the mitral valve


3 subsets that benefit the most from atrial kick

Obstruction to atrial emptying (mitral stenosis)
Non compliant left ventricle (AS with hypertrophy)
Heart failure (atrial kick can contribute up to 20-30% EF)


What is HOCM pattern of inheritance and penetrance

Autosomal dominant 1:500: 70% familial and 30% sporadic


What are other heart failure surgery surgery options

partial lef ventriculectomy (Batista procedure)
endoventricular circular patch plasty (Dor Procedure)
Surgical ventricular restoration procedure


What are pathological features of Heart Failure

Ventricular dilation
change from ellipsoidal to a more spherical chamber shape
cardiomyocyte hypertrophy
interstitial fibrosis
numberous alteration in biochemical and molecular functions


List steps of SVR

Operative procedure is performed for akinesia or dyskinesia of the anterior LV wall:
a. left ventriculotomy through scar tissue--2 cm lateral to the LAD
b. subtotal endocardial resection over the septum and posterior wall and cryotherapy at the limits of the resection for patients with recurrent ventricular arrhythmias
c. circumfrential endoventricular (Fotane) circular suture is passed 1-2cm outcomes the limit of healthy muscle and then tied around a balloon mannequin to reduce the size of the left ventricle to a diastolic volume of 50-60ml/M
d. the residual apical defect is closed with a dacron patch to produce an elliptical-shaped left ventricle
e. ventriculotomy is closed with two-layered teflon strips


List evidence for CRT in pts with heart failure

COMPANION trial demonstrated that CRT improved survival in individuals with NYHA class III or IV heart failure with a widened QRS complex on an electrocardiogram.

CARE-HF trial showed that patients receiving CRT and optimal medical therapy benefited from a 36% reduction in all cause mortality, and a reduction in cardiovascular-related hospitalization


List meds all heart failure pts should be taking


Nitrates can be used
oral BNP*nestertide*


4 major types of Cardiomyopathy

Hypertrophic cardiomyopathy
Restrictive Cardiomyopathy
Arrhythmogenic right ventricular cardiomyopathy


List 3 types of restrictive cardiomyopathy

*other types Loffler endocarditis/Endocardial fibroelastosis/post radiation


How do you diagnosis Amyloidosis

Free immunoglobin Lambda chains in serum


What is Loeffler Endocarditis

Loeffler endocarditis is a form of restrictive cardiomyopathy which affects the endocardium and occurs with white blood cell proliferation, specifically of eosinophils

eosinophilia and eosinophilic penetration of the cardiac myocytes leads to a fibrotic thickening of portions of the heart, large mural thrombi develop, commonly contracted in temperate climates (due to the favorable conditions for parasites), and is rapidly fatal.


What is Endocardial fiibroelastosis

characterized by a thickening of the inmost lining of the heart chambers (the endocardium) due to an increase in the amount of supporting connective tissue and elastic fibers.

uncommon cause of unexplained heart failure in infants and children, and is one component of HEC syndrome Fibroelastosis is strongly seen as a primary cause of restricted cardiomyopathy seen in children


What is Dilated Cardiomyopathy

one of cardiomyopathies, a group of diseases that primarily affect the myocardium with different causes and affect the heart in different ways.
In DCM a portion of the myocardium is dilated, often without any obvious cause. Left or right ventricular systolic pump function of the heart is impaired, enlargement and hypertrophy
Most common form of non-ischemic cardiomyopathy.


What are more details of DCM

Although in many cases no cause (etiology) is apparent, it is probably the result of damage to the myocardium produced by a variety of toxic, metabolic, or infectious agents


When should you consider Pulmonary thrombecomtomy in a chronic situation

Unresolved (unchanged V/Q scans over 8 to 12 weeks despite anticoagulation) Thromboembolic and significant functional limitations (NYHA III or IV) with compromised vascular bed.

Proximal extent of the organized thrombotic material should at least at the level of the lobar pulmonary arteries and resting PA pressure should be greater then 30 mm Hg.


List signs of right heart failure

peripheral edema
Hepatic congestion
Distended varicose/JVP systemic veins
Pleural effusions

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