This document discusses the management of refractory heart failure through various medical and mechanical methods. Medical management includes intravenous inotropes and vasodilators for short-term relief of symptoms. Mechanical circulatory support options range from temporary counterpulsation devices to long-term left ventricular assist devices. Other management strategies include ultrafiltration, cardiac surgery, and cardiac transplantation for eligible patients. End-of-life care options should also be considered and discussed with patients and families.

1. Management of refractory heart
failure
Dr. shrishail
MIMS,calicut

2. Introduction
•
Definition : Patients who do not improve or
experience rapid recurrence of symptoms at
rest or on minimal exertion and often require
repeated prolonged hospitalizations for
intensive management.

3. MANAGEMENT
•
Medical management
•
Mechanical circulatory support
•
Surgery
•
Cardiac Transplant
•
Other
•
Consideration of End of Life

4. Intravenous inotropes and vasodilators
•
Vasoactive and positive inotropic drugs can
acutely improve hemodynamics and relieve
symptoms.
•
Dobutamine, dopamine, milrinone,
inamrinone, nitroprusside, nitroglycerin, and
nesiritide
•
Hemodynamic monitoring — Flow-directed
pulmonary artery (PA) catheters (Swan-Ganz
catheters) needed.

5. Ultrafiltration
•
Extracorporeal ultra filtration removes
intravascular fluid, resulting in a
compensatory movement of fluid from the
interstitial compartment.
•
Ultra filtration may restore responsiveness to
loop diuretics and decrease proinflammatory
cytokine levels

6. Mechanical circulatory support
I. Counter pulsation devices (intra aortic
balloon pump and non invasive counter
pulsation)
II. Cardiopulmonary assist devices
III. Left ventricular assist devices

7. 1.Intra aortic balloon (IABP)
•
The intraaortic balloon (IABP) is the most commonly
used mechanical support device.
•
Mechanism: Removing a certain blood volume from
the femoral artery during systole and replacing this
volume rapidly during diastole  Increase Venous
return  COP.
•
Advantage:Also by increasing coronary perfusion
pressure  augment cardiac output and unload the
functioning heart simultaneously

8. 2.Cardiopulmonary assist device
•
It provides full cardiopulmonary support
(including hemodynamic support and
oxygenation of venous blood) analogous to
that provided by bypass during cardiac
surgery.
•
Disadvantage:Limited use outside the cardiac
catheterization laboratory.

9. 3.Left ventricular devices
•
1.Intermediate
•
Intermediate left ventricular assist devices can
provide temporary support until other
replacement therapy
•
Used in patients with chronic HF who have a
poor long-term prognosis

10. •
2.Long-term left ventricular devices
•
Permanent mechanical assistance
("destination therapy") in selected patients
who are not cardiac transplant candidates

11. Surgery
•
Surgical approaches to end-stage HF under
active investigation.
•
Reconstructive cardiac surgery,
cardiomyoplasty, and mitral valve repair

12. Cardiac transplantation
Indication:
1. A history of repeated hospitalizations for HF
2.Escalation in the intensity of medical therapy
3.Refractory cardiogenic shock
4.Dependence on intravenous inotropes

13. END OF LIFE CARE
•
Options for end of life care should be
discussed with patients
•
Discussions with the patient and family about
quality of life
•
Refractory end-stage HF and implantable
cardioverter defibrillator (ICD) should be
informed about the option to inactivate the
device