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AFRO-NETS> RFI: Left Ventricular Failure (2)



RFI: Left Ventricular Failure (2)
---------------------------------

Chirashree Ray wrote:
>
> Please may I have some details on the topic below:
> 
> Left ventricular failure - causes and management of acute ventricular 
> failure in ICU. Describe stepwise management. 

Dear Mr Chirashree,

Left ventricular failure can recognise lots of causes due to some ex-
tremely variable factors: age, sex, cardiac and non-cardiac associates 
pathologies (e.g.: congenital, idiopathic, ischaemic, valvular, infec-
tious heart disease, Chagas disease etc.). We actually know two great 
pathways for 1) Conventional and 2) Non-conventional treatment of acute 
left-heart failure in I.C.U. patients.

The conventional treatment requires a normal I.C.U. environment; after 
a general assessment of the patient and the institution of the required 
respiratory care, the patient should undergo to a non-invasive (ECG, 
blood pressure, temperature etc.) and invasive (BP, CVP, PCWP, etc.) 
monitorisation of cardiac and metabolic parameters. Once assessed the 
patient and recognised the characters of the failure, the treatment may 
consist in the i.v. administration of inotropic drugs, vasodilators, 
diuretics and the monitoring of their results on haemodynamic parame-
ters, metabolic acidosis and urinary output. 

In the unlikely event of an unsuccessful conventional treatment, we can 
adopt, in some cases, two pathways of non-conventional treatment, both 
of them need a surgical approach to the patient: 1) Mechanical devices 
and 2) Cardiomyoplasty and/or Batista procedure. The mechanical devices 
go from I.A.B.P. (Intra-Aortic-Balloon-Pumping, a percutaneous device 
containing a balloon inflating in thoracic Aorta during diastolic pe-
riod) to lots of L.V.A.D. (Left-Ventricle-Assist-Device) extra-
corporeal left-circulation in which the blood is drained from the left 
auricula and is pumped into systemic circulation through the ascending 
or thoracic Aorta or femoral artery) and finally to T.A.H. (Total-
Artificial-Heart), a right and left assist-device without or with an 
E.C.M.O. (Extra-Corporeal-Membrane-Oxygenator a true and proper Cardio-
Pulmonary By-Pass). 

These devices need a cardio-surgical theatre and a very skilled medical 
and nursing staff. Both cardiomyoplasty and Batista operation are a 
delicate surgical approach to the left-ventricular failure; they are 
generally performable in a secondary, chronical evolution of the dis-
ease, the first consists in the superimposition of a skeletal muscle, 
generally the Latissimus Dorsi around the heart and its electrical pac-
ing; the Batista operation is performed to reduce the internal left-
ventricular volume, by cutting a variable quantity of left-ventricular 
wall. This is aimed to reduce the wall tension generated by an exces-
sively dilated left ventricle and its consequent sub-endocardic ischae-
mia. 

I hope that this very general answer and my poor written English will 
however increase your cardiac-health programme. I will also be glad to 
collaborate having a better knowledge of your patients and of their 
most common problems. 

Have my regards,
Giuseppe Gramegna

--
Giuseppe Gramegna Ph.M.D
Cardiac-Surgeon, I.C.U. assistant
Osp. S. Ambrogio Milan
I.C.U. assistant
Osp. S. Raffaele, Rome, Italy
mailto:peppegra@tin.it

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