1. By Dr. Ahmad Y. Alansi
Althawra Modern General Hospital
Cardiac surgery department
Anesthesia & ICU unite

2.  Definitions
 Which heart failure patient should be
admitted in ICU?
 Monitoring
 Classification and plan
 Medical treatment
 Mechanical support
 The future
 Summary

3. Definition of Advanced HF
A subset of patients with chronic HF will
continue to progress and develop persistently
severe symptoms despite maximum therapy
.Various terminologies have been used to
describe this group of patients who are
classified with ACCF/AHA stage D
HF, including “advanced HF,” “end-stage
HF,” and “refractory HF.

8. Decompensated
chronic heart failure
(advanced heart
failure)
Acute heart failure
ACS
Sepsis
Post CPR
Toxic
VO2 Oxygen uptake from tissues
MRO2 Metabolic requirement for
oxygen

9. ● Nonadherence with medication regimen, sodium and/or fluid restriction
● Acute myocardial ischemia
● Uncorrected high blood pressure
● AF and other arrhythmias
● Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem,
beta blockers)
● Pulmonary embolus
● Initiation of drugs that increase salt retention (e.g., steroids, thiazolidinediones,
NSAIDs)
● Excessive alcohol or illicit drug use
● Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism)
● Concurrent infections (e.g., pneumonia, viral illnesses)
● Additional acute cardiovascular disorders (e.g., valve disease endocarditis,
myopericarditis, aortic dissection

10. Hypotension systolic BP < 90 mmHg
SpO2 < 90 %
PH < 7.35
Lactate > 2.0
Oliguria, BUN > 30
Worsening renal function
VsO2 < 50 %

11. So the following patients should be admitted to
ICU :
 All pateints with NYHA class III-IV.
 Suspected or diagnoseed ACS .
 Potential life threatening arrhythmia (VF, VT, high
grade a- v block, persistent symptomatic tachy or
brady).
 Requiring or at risk of requiring invasive ventilatory
support .
 Cardiogenic shock or otherwise requiring chemical
or mechanical circulatory support (dopmamine
, dobutamine,….IABP,LVAD….etc)
 Multisystem Failure .

12. monitoringinvasiveNon
i.e. temperature, respiratory rate,
arterial pressure, continuous
ECG, pulse oximetry, daily I/O
chart and body weight are
required in all patients

13. Invasive monitoring:
1- Arterial pressure monitoring :
continues BP monitoring
repetitive blood gas analysis
.
2- Central venous catheter :
Monitoring right-sided filling pressure
Delivering vasoactive medication
Rapid volume replacement

14. 3- Pulmonary artery catheterization
(PAC)
Indicated in patients with left ventricular
dysfunction
. In patients requiring inotropic or
vasoconstrictor drugs.
For monitoring
Cardiac output
Estimation of systemic vascular resistance
Mixed venous oxygen saturation
Lost popularity because of Invasiveness and no different in
mortality rate

15. 4- Transoesophageal Echocardiography
Recently gained popularity as a haemodynamic
monitoring tool for ventilated intensive care patients.
It provides valuable information about morphology
and haemodynamic state,
but interpretation of data requires considerable
training and experience.
So Transthoracic Echo
Is more performed and remain the main tool .

16.  Low Output Failure in which there is decreased
contractility of heart leading to decreased
cardiac output
 High Output Failure in which demands of body
are high, which are not met even with increased
cardiac output like in case of severe Anemia ,
Thyrotoxicosis and Thiamine deficiency

18.  Which side of heart is affected
– Left (more common)
– Right (right-sided MI, pulmonary HTN)
 Which heart function is affected
– Systolic (↓ contraction and EF, dilated LV)
– Diastolic (↓ relaxation,)
 Failure of LV filling
 Contractile function and EF usually normal

21. The management of heart failure described here
is meant for patients with advanced or
decompensated heart failure. The approach
here is specifically designed for ICU patients: it
is based on invasive hemodynamic
measurements rather than symptoms and uses
only drugs that are given by continuous
intravenous infusion

22. Left-Sided (Systolic) Heart Failure :
1- High Blood Pressure
2- Normal Blood Pressure
3- Low Blood Pressure

23. Left-Sided (Systolic) Heart Failure :
1- High Blood Pressure (e.g. early period
after cardiopulmonary bypass surgery )
Profile: High PCWP/Low CO/High BP
Treatment: Vasodilator therapy with
nitroprusside or nitroglycerin. If the PCWP remains
above 20 mm Hg, add diuretic therapy with
furosemide.

24. Left-Sided (Systolic) Heart Failure :
2- Normal Blood Pressure: e.g. ischemic
heart disease, acute myocarditis, and the advanced
stages of chronic cardiomyopathy.
Profile: High PCWP/Low CO/Normal BP
Treatment: Inodilator therapy with dobutamine or
milrinone, or vasodilator therapy with nitroglycerin. If
the PCWP does not decrease to <20 mm Hg, add diuretic
therapy with furosemide.

25. Left-Sided (Systolic) Heart Failure :
3- Low Blood Pressure is the sine qua
non of cardiogenic shock. e.g. associated
with cardiopulmonary bypass surgery, acute myocardial
infarction, viral myocarditis, and pulmonary embolus.
Profile: High PCWP/Low CO/Low BP
Treatment: Dopamine in vasoconstrictor doses or
combination with Dubtamin.
Mechanical assist devices can be used as a temporary
measure in selected cases.

26. Diastolic Heart Failure :
Incidence of purely diastolic HF in nature is not
known.
no general agreement about the optimal treatment but
two recommendations seems to be valid :
1- positive inotropic agents have no role in the
treatment of diastolic heart failure.
2- diuretic therapy can be counterproductive,
vasodilator agents, such as nitroglycerin and milrinone,
Calcium channel blockers like verapamil are effective.

27. Right Heart Failure
The strategies below pertain only to primary right
heart failure (e.g., following acute myocardial
infarction) and not to right heart failure secondary
to chronic obstructive lung disease:
1- If PCWP is below 15 mm Hg, infuse volume until the PCWP
or CVP increases by 5 mm Hg or either one reaches 20 mm Hg .
2- If the RVEDV is less than 140 mL/m2, infuse volume until
the RVEDV reaches 140 mL/m2 .
3- If PCWP is above 15 mm Hg or the RVEDV is 140 mL/m2 or
higher, infuse dobutamine, beginning at a rate of 5
mg/kg/minute .
In the presence of AV dissociation or complete heart block,
institute sequential A-V pacing and avoid ventricular pacing .

28. Diuretics in Hospitalized Patients: Recommendations
Class I
1. Patients with HF admitted with evidence of significant fluid overload
should be promptly treated with intravenous loop diuretics to reduce
morbidity (Level of Evidence: B)
2. If patients are already receiving loop diuretic therapy, the initial
intravenous dose should equal or exceed their chronic oral daily dose and
should be given as either intermittent boluses or continuous infusion.
Urine output and signs and symptoms of congestion should be serially
assessed, and the diuretic dose should be adjusted accordingly to relieve
symptoms, reduce volume excess, and avoid hypotension (Level of
Evidence: B)
3. The effect of HF treatment should be monitored with careful
measurement of fluid intake and output, vital signs, body weight that is
determined at the same time each day, and clinical signs and symptoms
of systemic perfusion and congestion. Daily serum electrolytes, urea
nitrogen, and creatinine concentrations should be measured during the
use of intravenous diuretics or active titration of HF medications. (Level of
Evidence: C)

29. Diuretics in Hospitalized Patients: Recommendations
Class IIa
1. When diuresis is inadequate to relieve symptoms, it is reasonable
to intensify the diuretic regimen using either:
a. higher doses of intravenous loop diuretics (Level of Evidence: B);
b. addition of a second (e.g., thiazide) diuretic (Level of Evidence: B).
Class IIb
Low-dose dopamine infusion may be considered in addition
to loop diuretic 1 therapy to improve diuresis and better
preserve renal function and renal blood flow (Level of
Evidence: B)

30. Short term therapeutic options
( Nondurable)Bridge to recovery
Long term therapeutic options
Bridge to transplantation ( durable)
Destination therapy (permanent)
Percutaneous devices
IABP
Impella
ECMO and centrifugeal pump devices
Implantable devices (cardiotomy)
LVAD, RVAD, BiVAD, total artificial heart (different models, different
indications)

31. Class IIa
MCS is beneficial in carefully selected* patients with stage
D HFrEF in whom definitive management (e.g., cardiac
transplantation) or cardiac recovery is anticipated or planned
. (Level of Evidence: B)
Nondurable MCS, including the use of percutaneous and
extracorporeal ventricular assist devices (VADs), is
reasonable as a “bridge to recovery” or “bridge to decision”
for carefully selected* patients with HFrEF with acute,
profound hemodynamic compromise . (Level of Evidence: B)
Durable MCS is reasonable to prolong survival for carefully
selected* patients with stage D HFrEF (672-675). (Level of
Evidence: B)

32. selected* patients are those with
LVEF <25% and NYHA class III-IV functional
status despite GDMT, when CRT indicated , with
either high predicted 1- to 2-y mortality or
dependence on continuous parenteral inotropic
support.

33. Intra-Aortic Balloon Counterpulsation
Intra-aortic balloon counterpulsation was introduced
in 1968 as a method of promoting coronary blood
flow .
It is available in various lengths to match body height.
Hemodynamic Effects
Inflation begins at the onset of diastole, just after the aortic
valve closes that cause Increase in diastolic pressure
which should also augment coronary blood
flow, because the bulk of coronary flow occurs during
diastole.
Deflation at the onset of ventricular systole, just before the
aortic valve opens so Deflation of the balloon reduces
the end-diastolic pressure, This decreases ventricular
afterload and promotes ventricular stroke output.

34. IABP Indication:
when cardiac pump failure is life-threatening and
either pump function is expected to improve
spontaneously, or a corrective procedure is planned.
Cardiogenic shock following CPB
Acute MI .
Unstable angina,
Acute mitral insufficiency,
Planned cardiac transplantation.
Support PCI & reduce size of Infarction
??!!! controversy

36. Yemeni future
Get to international standards of treatment (new drugs,
assist devices programs)
Transplantation
International future
Genetics
Stem cell cultures and implantation
Truly viable total artificial heart

37.  The approach to advanced or decompensated heart failure in the ICU
is best guided by invasive hemodynamic measurements and by the
type of heart failure involved (systolic, diastolic, left-sided, or right-
sided failure).
 The management of acute, decompensated heart failure should
augment cardiac output and reduce ventricular filling pressures
while producing little or no increase in myocardial O2 consumption.
 Patients with HF admitted with evidence of significant fluid overload
should be promptly treated with intravenous loop diuretics to
reduce morbidity .
 Diuretic therapy should not play a major role in the management of
acute heart failure, particularly if the failure is due to diastolic
dysfunction.
 Low-dose dopamine infusion may be considered in addition to loop
diuretic 1 therapy to improve diuresis and better preserve renal
function and renal blood flow .
 If cardiogenic shock is identified, mechanical cardiac support should
be initiated as soon as possible, if indicated.