Don’t ForgetDon’t Forget

تنسوا تنسوا ال ال أقصاناأقصانا

Prof.Prof. A. ABU-HASHEMA. ABU-HASHEM(M.D. Cardiology)(M.D. Cardiology)

Zagazig, EgyptZagazig, Egypt

““In these hearts …… their reserve In these hearts …… their reserve

force lost and with it the power of force lost and with it the power of

meeting the demands in maintaining meeting the demands in maintaining

the circulation during severe the circulation during severe

exertion”…….exertion”…….

(Osler, 1892).(Osler, 1892).

“ “ A pathophysiological state in which an A pathophysiological state in which an

abnormality of cardiac function is abnormality of cardiac function is

responsible for the failure of the heart responsible for the failure of the heart

to pump blood at a rate commensurate to pump blood at a rate commensurate

with requirements of the metabolizing with requirements of the metabolizing

tissues”tissues”

(Braunlwald, 1986).(Braunlwald, 1986).

Most cases of CHF respond favorably to Most cases of CHF respond favorably to

pharmaco and non-pharmaco therapies.pharmaco and non-pharmaco therapies.

Some do not improve or suffered from Some do not improve or suffered from

rapid recurrence despite optimal therapy rapid recurrence despite optimal therapy

and have symptoms at rest or minimal and have symptoms at rest or minimal

exertion, can not perform daily activities, exertion, can not perform daily activities,

frequently suffering from anasarca and frequently suffering from anasarca and

cachexia and require repeated cachexia and require repeated

hospitalization; hospitalization; Refractory HFRefractory HF. .

EPIDEMIOLOGYEPIDEMIOLOGY

CHF is major cause of mortality and CHF is major cause of mortality and morbidity especially among elderly and is morbidity especially among elderly and is considered a serious health problem.considered a serious health problem.

4-7 million is USA have CHF.4-7 million is USA have CHF.

400,000 new cases every year.400,000 new cases every year.

CHF is the 1ry cause of death in 40,000 / CHF is the 1ry cause of death in 40,000 / year.year.

CHF is the most frequent cause of CHF is the most frequent cause of hospitalization in medicare population.hospitalization in medicare population.

RHF accounts for 5% of symptomatic RHF accounts for 5% of symptomatic HF.HF.

Incidence of RHF increases with age Incidence of RHF increases with age and is more in males.and is more in males.

Risk of death in mild CHF is 5-10% Risk of death in mild CHF is 5-10% annually.annually.

This increases much in RHF up to This increases much in RHF up to 50%.50%.

EPIDEMIOLOGYEPIDEMIOLOGY

The burden associated with RHF is The burden associated with RHF is

expected to increase due to :expected to increase due to :

I.I. Ageing of the population.Ageing of the population.

II.II.Increase numbers of elderly with CAD and Increase numbers of elderly with CAD and

HPN.HPN.

III.III.Improved diagnosis e.g echo.Improved diagnosis e.g echo.

EPIDEMIOLOGYEPIDEMIOLOGY

ETIOLOGY ETIOLOGY

Ischemic (extensive CAD, multiple MI).Ischemic (extensive CAD, multiple MI).

Non-ischemic CM (younger, some with Non-ischemic CM (younger, some with

family history).family history).

Hypertension. Hypertension.

Valvular.Valvular.

Viral myocarditis.Viral myocarditis.

Precipitating (Aggravating) FactorsPrecipitating (Aggravating) Factors..

1.1. Cardiac :Cardiac : arrhythmias, M.I. arrhythmias, M.I.

2.2. Non cardiac :Non cardiac : anemia, pul.embolism, anemia, pul.embolism,

infections, other illness.infections, other illness.

3.3. Treatment-related:Treatment-related: poor compliance, poor compliance,

NSAID, steroids, B.B.NSAID, steroids, B.B.

The vicious circle of The vicious circle of pathophysiology pathophysiology

Chamber Chamber dilatationdilatation

Vent-Vent-Dysfunction Dysfunction

Wall stressWall stress

Renal Renal Vasoconstriction Vasoconstriction

HH22o and Na o and Na

retentionretention

Toxic effects Toxic effects

(Apoptosis, myocyte loss)(Apoptosis, myocyte loss)

Vasoconstriction Vasoconstriction (afterload)(afterload)

HR, ArrhythmiaHR, Arrhythmia Neuro-Neuro-hormoneshormones

Vent. Remodeling Vent. Remodeling

More functional deterioration More functional deterioration

Changes in geometry ( from prolate ellipse to Changes in geometry ( from prolate ellipse to more spherical shape), volume and architexturemore spherical shape), volume and architexture

Impairment of skeletal muscle metabolism.Impairment of skeletal muscle metabolism. TNF… muscle atrophy.TNF… muscle atrophy.Resulting in cachexia, and exercise intolerance Resulting in cachexia, and exercise intolerance

Changes is the biology and volume of myocytes Changes is the biology and volume of myocytes and non-myoctes components of the myocardiumand non-myoctes components of the myocardium

Symptoms of RHFSymptoms of RHF

1.1. Dyspnea III or IV .Dyspnea III or IV .

2.2. Orthopnea,PND,exertional and nocturnal Orthopnea,PND,exertional and nocturnal

dry cough.dry cough.

3.3. Fatigue, weakness.Fatigue, weakness.

4.4. Dizzy spells or palpitations due to Dizzy spells or palpitations due to

frequent tachyarrhythmias .frequent tachyarrhythmias .

5.5. Fluid retentions, LL edema, ascites….Fluid retentions, LL edema, ascites….

Physical exam.Physical exam.

1.1. Increased JVP with prominent V-wave.Increased JVP with prominent V-wave.

2.2. Generalized anasarca.Generalized anasarca.

3.3. Cardiac dilatation, galloping and Cardiac dilatation, galloping and

murmurs.murmurs.

4.4. Fine lung crepitations.Fine lung crepitations.

5.5. Tender hepatomegaly.Tender hepatomegaly.

Functional evaluationFunctional evaluation1.1. NYHA classification (insensitive, subjective)NYHA classification (insensitive, subjective)

2.2. Six-minute walk (<305 met. in 6 min. Six-minute walk (<305 met. in 6 min. bad bad prognosis).prognosis).

3.3. Peak maximal oxygen utilization (MVOPeak maximal oxygen utilization (MVO2 2 < 10 < 10

ml/kg/min in high risk pt.).ml/kg/min in high risk pt.).

4.4. Exercise testing: modified Bruce or Naughton Exercise testing: modified Bruce or Naughton protocols (reduced speeds and slow protocols (reduced speeds and slow increments).increments).

5.5. Metabolic equivalents and work capacity Metabolic equivalents and work capacity (METs) are reduced.(METs) are reduced.

Diagnostic investigationsDiagnostic investigations

1.1. Confirm the clinical diagnosis.Confirm the clinical diagnosis.

2.2. Identify an underlying causes.Identify an underlying causes.

3.3. Identify precipitating factors.Identify precipitating factors.

4.4. Guide therapy.Guide therapy.

5.5. Determine prognosis.Determine prognosis.

ECGECG

Nonspecific ST- T changes.Nonspecific ST- T changes.

Chambers enlargement.Chambers enlargement.

Old MI.Old MI.

BBB and other conduction defects.BBB and other conduction defects.

Tachyarrhythmias: AF, A fl, VPCs, VT….Tachyarrhythmias: AF, A fl, VPCs, VT….

Chest x-rayChest x-ray

Upper lobe congestion.Upper lobe congestion.

Interstitial edema.Interstitial edema.

Kerley’s A and B lines.Kerley’s A and B lines.

Pleural effusions.Pleural effusions.

Echo Doppler Echo Doppler

Dimensions, volumes, wall thickness.Dimensions, volumes, wall thickness.

Function: EF, FS, diastolic dysfunction.Function: EF, FS, diastolic dysfunction.

Valvular structure and function.Valvular structure and function.

Pressures: m PAP, RVSP.Pressures: m PAP, RVSP.

Spont. echo contrast, masses, thrombi.Spont. echo contrast, masses, thrombi.

Pericardial diseases.Pericardial diseases.

TEETEE

Inadequate TTE.Inadequate TTE.

Suspected IE.Suspected IE.

Prosthetic valve functionProsthetic valve function

LAA thrombi.LAA thrombi.

Echo Echo (cont.)(cont.)

DSE:DSE: at low dose for detection of at low dose for detection of

viable myocardium.viable myocardium.

Myocardial tissue contrast:Myocardial tissue contrast: to detect to detect

ischemia and viability.ischemia and viability.

Radionuclide scintigraphy Radionuclide scintigraphy

Non diagnostic echo studyNon diagnostic echo study

RV functionsRV functions

Viable myocardiumViable myocardium

PET is more sensitive than Thallium- PET is more sensitive than Thallium-

201 study.201 study.

Cardiac magnetic resonanceCardiac magnetic resonance

The most accurate for volumes, The most accurate for volumes,

thickness and masses.thickness and masses.

Detection of myocardial necrosis, Detection of myocardial necrosis,

perfusion and function.perfusion and function.

Quantitative biochemical information: Quantitative biochemical information:

myocardial energetics.myocardial energetics.

Other testsOther tests

Routine laboratory: Routine laboratory: ESR, anemia, ESR, anemia,

serum iron, thrombocytopenia. serum iron, thrombocytopenia.

Electrolyte: NaElectrolyte: Na++, k, k++, Mg, Mg++++ . .

Liver and kidney function tests.Liver and kidney function tests.

Thyroid function.Thyroid function.

Viral study (serum or myocardial Viral study (serum or myocardial

biopsy).biopsy).

Serum ANP or urinary proatrial Serum ANP or urinary proatrial

natriuretic peptide (N-ANP) or (N-BNP).natriuretic peptide (N-ANP) or (N-BNP).

Spirometry and respiratory function Spirometry and respiratory function

tests in selected cases.tests in selected cases.

Other testsOther tests

Invasive testsInvasive tests

Usually not required, but may be Usually not required, but may be

needed to elucidate the cause of RHF.needed to elucidate the cause of RHF.

Coronary angiography.Coronary angiography.

Hemodynamic monitoring.Hemodynamic monitoring.

Endomyocardial biopsy.Endomyocardial biopsy.

Diagnostic criteria of RHFDiagnostic criteria of RHF

Major :Major :

1.1. Resting LVEF < 30%.Resting LVEF < 30%.

2.2. NYHA III or IV.NYHA III or IV.

3.3. Peak VOPeak VO22<14ml/kg/min on symptom limited <14ml/kg/min on symptom limited

testing (4-5 METs).testing (4-5 METs).

Minor :Minor :1.1. No or minimal response after at least 3m of full No or minimal response after at least 3m of full

standard therapy (ACEI,digoxin, diuretics) .standard therapy (ACEI,digoxin, diuretics) .

2.2. Serum Na < 130 mq./L. in pt. not treated with Serum Na < 130 mq./L. in pt. not treated with ACEIs.ACEIs.

3.3. Plasma norepinephrine > 900 pg/ml.Plasma norepinephrine > 900 pg/ml.

Contributing :Contributing :1.1. More than one hospitalization for worsening HF More than one hospitalization for worsening HF

in the past 6 ms.in the past 6 ms.

2.2. Cardiac cachexia.Cardiac cachexia.

Diagnostic criteria of RHFDiagnostic criteria of RHF

Management of RHFManagement of RHFPrevention of RHFPrevention of RHF

The basic aims of prevention are to :The basic aims of prevention are to :

Limit myocardial damage.Limit myocardial damage.

Modulate and reduce neuroendocrine Modulate and reduce neuroendocrine activation.activation.

This includes :This includes :

Treatment of risk factors (smoking/ lipids/ Treatment of risk factors (smoking/ lipids/ HPN…).HPN…).

Revascularization for cases with significant Revascularization for cases with significant reversible ischemia.reversible ischemia.

Life style modificationLife style modification

Diet : small meals, less fat, high fiber diet.Diet : small meals, less fat, high fiber diet.

Limited dietary sodium Limited dietary sodium 2 gm/day. 2 gm/day.

Reduced fluid intake.Reduced fluid intake.

Avoidance of traveling to high altitude, Avoidance of traveling to high altitude,

very hot or humid places. Short air flights very hot or humid places. Short air flights

are preferred to other means of transport.are preferred to other means of transport.

Management of RHFManagement of RHF

Non pharmacological therapy Non pharmacological therapy

1.1. Exercise and rehabilitation :Exercise and rehabilitation :

Regular physical activity is recommended Regular physical activity is recommended according to the patient’s condition.according to the patient’s condition.

Walking or cycling for 10-30 min/day 3-Walking or cycling for 10-30 min/day 3-7d/w.7d/w.

Moderate – intensity resistance training Moderate – intensity resistance training improves strength, endurance, HR improves strength, endurance, HR variability, and forearm blood flow.variability, and forearm blood flow.

2.2. Rest:Rest:

Necessary in severe RHF.Necessary in severe RHF.

Passive mobilization and respiratory Passive mobilization and respiratory

exercise are advised.exercise are advised.

3.3. EducationEducation of the patient and relatives of the patient and relatives

about disease condition, life style about disease condition, life style

modification,drug side effects.modification,drug side effects.

Non pharmacological therapy Non pharmacological therapy

Specific pharmacological therapy Specific pharmacological therapy

Diuretics Diuretics

Loop diuretics, thiazides and potassium Loop diuretics, thiazides and potassium

sparing.sparing.

RALESRALES mortality study : mortality study :

(low dose spironolactone + ACEIs + loop (low dose spironolactone + ACEIs + loop

diuretics) markedly and progressively diuretics) markedly and progressively

improved survival in RHF irrespective of improved survival in RHF irrespective of

etiology.etiology.

Treatment of diuretics resistance :Treatment of diuretics resistance :

Fluid restriction.Fluid restriction.

Change the route (oral to i.v.) and timing Change the route (oral to i.v.) and timing

(single multiple & continuous infusion)(single multiple & continuous infusion)

Combination therapy (Furosemide . HCZ)Combination therapy (Furosemide . HCZ)

Furosemide + HSSFurosemide + HSS

High dose Furosemide (i.v. infusion for 500-High dose Furosemide (i.v. infusion for 500-

1000 mg) plus hypertonic saline solution (150 1000 mg) plus hypertonic saline solution (150

ml 1.4-4.6% NaCl) bid in 30 min for 6-12 days.ml 1.4-4.6% NaCl) bid in 30 min for 6-12 days.

Improved clinical and hemodynamic Improved clinical and hemodynamic

parameters, reduced hospitalization, and parameters, reduced hospitalization, and

maintained the obtained results over time in maintained the obtained results over time in

comparison with the use of high dose comparison with the use of high dose

Furosemide as bolus.Furosemide as bolus.

ACEIsACEIs

Start with small doses with gradual Start with small doses with gradual

increments. increments.

Regular check up of renal function and KRegular check up of renal function and K++..

Significantly improved survival and reduce Significantly improved survival and reduce

hospitalization.hospitalization.

Many trials Many trials (SOLVD, SAVE, PROMISE, (SOLVD, SAVE, PROMISE,

PROVED,…)PROVED,…)

Dry cough, hypotension, Dry cough, hypotension, K K++, renal , renal

insufficiency are side effects.insufficiency are side effects.

ARBS: are the best substitute in the ARBS: are the best substitute in the

presence of side effects presence of side effects (CHARM study). (CHARM study).

Combination therapy remains to be Combination therapy remains to be

defined defined (ON TARGET).(ON TARGET).

ACEIsACEIs

Vasodilators Vasodilators

Isosorbide dinitrate and hydralazine in Isosorbide dinitrate and hydralazine in

combination in combination in V-HeFTV-HeFT trial yield trial yield

significant survival benefit in comparison significant survival benefit in comparison

to placebo and prazocin.to placebo and prazocin.

Digitalis Digitalis

Routine for CHF and AF.Routine for CHF and AF.

In SR : debates regarding its beneficial In SR : debates regarding its beneficial

effects vs toxic effects( DIG trial).effects vs toxic effects( DIG trial).

Smaller doses, in elderly, renal or Smaller doses, in elderly, renal or

hepatic insufficiency.hepatic insufficiency.

Serum digoxin levels and electrolyte Serum digoxin levels and electrolyte

check up.check up.

Dobutamine, Dopamine and Milrinone.Dobutamine, Dopamine and Milrinone.

The routine use in RHF is not The routine use in RHF is not

recommended.recommended.

Best indicated in: acute HF, bridge to Best indicated in: acute HF, bridge to

definitive treat. (revascularization or definitive treat. (revascularization or

transplantation) or palliation in end stage transplantation) or palliation in end stage

RHF.RHF.

Inotropes Inotropes

Combination of B-blockers and Combination of B-blockers and

phosphodiesterase inhibitors (milrinone phosphodiesterase inhibitors (milrinone

and enoximone) seems to be beneficial, and enoximone) seems to be beneficial,

with less side effects.with less side effects.

Inotropes Inotropes

B- BlockersB- BlockersHF is associated with enhanced HF is associated with enhanced adrenergic activity with its direct and adrenergic activity with its direct and indirect toxic myocardial effects.indirect toxic myocardial effects.

B-B is indicated in mild-moderate HF B-B is indicated in mild-moderate HF pretreated with standard therapy.pretreated with standard therapy.

CAPRICORNCAPRICORN study using study using CarvedilolCarvedilol and and MERITMERIT heart failure trial using heart failure trial using Metoprolol,Metoprolol, showed reduction in total mortality by 34% showed reduction in total mortality by 34% and SCD by 41%.and SCD by 41%.

However, symptomatic benefit may be However, symptomatic benefit may be

delayed and initial worsening may delayed and initial worsening may

occur.occur.

It is an important issue in decision It is an important issue in decision

making about starting B.B in severely making about starting B.B in severely

symptomatic cases.symptomatic cases.

B- BlockersB- Blockers

Antithrombotics Antithrombotics

RHF is associated with increased risk of RHF is associated with increased risk of

thromboembolism.thromboembolism.

The annual risk of stroke in controlled CHF The annual risk of stroke in controlled CHF

is 1-2%.is 1-2%.

In stroke prevention in AF (SPAF), it was In stroke prevention in AF (SPAF), it was

10.3% in chronic and 17.7% recent CHF.10.3% in chronic and 17.7% recent CHF.

Anticoagulants definitely reduced risk of Anticoagulants definitely reduced risk of

stroke in the presence of AF, while this stroke in the presence of AF, while this

not yet proved in SR. not yet proved in SR.

Intracardiac thrombi and probably SEC Intracardiac thrombi and probably SEC

are strong indications for long term oral are strong indications for long term oral

anticoagulants.anticoagulants.

Antithrombotics Antithrombotics

AntiarrhythmicsAntiarrhythmics

A.A. For SVT: AF, flutter, SVT.For SVT: AF, flutter, SVT.

1.1. Digoxin to control vent.rate at rest only.Digoxin to control vent.rate at rest only.

2.2. B-blockers: to control vent.rate during B-blockers: to control vent.rate during

exercise.exercise.

3.3. Amiodarone if B-B are contraindicated. Amiodarone if B-B are contraindicated.

4.4. AVN ablation, AF ablation(PV isolation) in AVN ablation, AF ablation(PV isolation) in

refractory cases.refractory cases.

B.B. For vent tachy.: non sust.VT,sust.VT, For vent tachy.: non sust.VT,sust.VT,

SCD.SCD.

1.1. B-blockers.B-blockers.

2.2. Amiodarone.Amiodarone.

3.3. ICD.ICD.

4.4. Radiofrequency ablation (not yet of Radiofrequency ablation (not yet of

proven efficacy)proven efficacy)

AntiarrhythmicsAntiarrhythmics

Statins in CHFStatins in CHF

Among the cholesterol – independed Among the cholesterol – independed

effects of statins is the antihypertrophic effects of statins is the antihypertrophic

on the heart on the heart

Limited studies showed that statins Limited studies showed that statins

improved the quality of life and exercise improved the quality of life and exercise

capacity in patient with nonischemic CM.capacity in patient with nonischemic CM.

Thus statins may be a promising novel Thus statins may be a promising novel

treatment strategy in RHF.treatment strategy in RHF.

Drugs under investigationsDrugs under investigations

1. Vasopeptidase inhibitors (Omapatrilat)1. Vasopeptidase inhibitors (Omapatrilat)

Block not only ACE but also neutral Block not only ACE but also neutral

endopeptidase which leads to enhanced endopeptidase which leads to enhanced

activity of endogenous vasodilators (ANP).activity of endogenous vasodilators (ANP).

Used in HPN and CHF.Used in HPN and CHF.

In a small scale study they improved In a small scale study they improved

morbidity and mortality in RHF.morbidity and mortality in RHF.

May be superior to ACEIs.May be superior to ACEIs.

2.2. Cytokine antagonists (TNF antagonists):Cytokine antagonists (TNF antagonists):

Etanercept or Infliximab.Etanercept or Infliximab.

In a short term pilot study Etanercept in In a short term pilot study Etanercept in

CHF showed improvement in clinical status CHF showed improvement in clinical status

and and EF and EF and LV size. LV size.

Drugs under investigationsDrugs under investigations

3. Endothelin antagonists:3. Endothelin antagonists:

Serum endothelin-1 is elevated in RHF.Serum endothelin-1 is elevated in RHF.

It has a potent vasoconstrictive action with It has a potent vasoconstrictive action with

adverse effects in the structure and function adverse effects in the structure and function

of the heart and peripheral vessels.of the heart and peripheral vessels.

Bosentan in a small dose is an endothelin Bosentan in a small dose is an endothelin

receptor antagonist, with promising initial receptor antagonist, with promising initial

results in a large-scale ongoing study.results in a large-scale ongoing study.

Drugs under investigationsDrugs under investigations

Future prospects Future prospects

New methods to promote angiogenesis New methods to promote angiogenesis

(gene therapy), stem cell implantation and (gene therapy), stem cell implantation and

autogenous myocyte cultures.autogenous myocyte cultures.

Given intracoronary or intrapericardial Given intracoronary or intrapericardial

hoping to increase vascularity and hence hoping to increase vascularity and hence

viability and function of the myocardium.viability and function of the myocardium.

Ultrafilteration Ultrafilteration

Is employed in resistant cases with Is employed in resistant cases with fluid retention. fluid retention.

To remove excess water and sodium, To remove excess water and sodium, thus escape from the cardiorenal thus escape from the cardiorenal vicious circle.vicious circle.

Intermittent hemofilteration and Intermittent hemofilteration and hemodialysis.hemodialysis.

More effectively using extracorporeal More effectively using extracorporeal or slow isolated ultrafilteration.or slow isolated ultrafilteration.

Pacemakers is RHFPacemakers is RHF

Resynchronization therapyResynchronization therapy Based on the presence of intravent. Based on the presence of intravent. conduction disturbance resulting in conduction disturbance resulting in discoordinated vent.conduction in 30% of CHF.discoordinated vent.conduction in 30% of CHF.

Resynchronization using biventricular or Resynchronization using biventricular or multisites pacing, enhances vent. contraction multisites pacing, enhances vent. contraction and reduces MR.and reduces MR.

Although complex procedure, marked Although complex procedure, marked improvement in symptoms and exercise improvement in symptoms and exercise tolerance is achieved tolerance is achieved (MUSTIC study).(MUSTIC study).

LV assist Devices LV assist Devices

Used as a Used as a temporary bridge to temporary bridge to

cardiac transplantation or recovery cardiac transplantation or recovery

of the heart post-cardiac surgeryof the heart post-cardiac surgery or or

from a major cardiac insult.from a major cardiac insult.

Biomechanical assistance of LV and / or Biomechanical assistance of LV and / or

RV can be achieved with a variety of devices RV can be achieved with a variety of devices

ranging from enhanced external counter ranging from enhanced external counter

pulsation pulsation (EECP),(EECP), IABC IABC

to to Vent. Assist systemsVent. Assist systems and and to totally to totally

implantable artificialimplantable artificial heart. heart.

LV assist Devices LV assist Devices

Surgery for RHFSurgery for RHF

1.1. Revascularization in IHD with viable Revascularization in IHD with viable

myocardium: CABG or transmural laser myocardium: CABG or transmural laser

revascularization (TLR).revascularization (TLR).

2.2. Mitral reconstruction (MVR or replacement) Mitral reconstruction (MVR or replacement)

in severe MR, with excellent short and in severe MR, with excellent short and

intermediate term outcome.intermediate term outcome.

3.3. Aneurysmectomy.Aneurysmectomy.

4.4. Cardiomyoplasty via stimulated skeletal Cardiomyoplasty via stimulated skeletal

muscle wraps and recently via muscle wraps and recently via

nonstimulated synthetic wraps.nonstimulated synthetic wraps.

5.5. Partial left ventriculectomy (Batista) in Partial left ventriculectomy (Batista) in

trial to restore normal cardiac trial to restore normal cardiac

dimensional physiology.dimensional physiology.

Surgery for RHFSurgery for RHF

5. Cardiac transplantation :5. Cardiac transplantation :

Indications :Indications :NYHA IV, VONYHA IV, VO22 max < 10 ml /kg/min max < 10 ml /kg/min

Recurrent uncontrolled VT..Recurrent uncontrolled VT..

Severe ischemia not amenable to Severe ischemia not amenable to revascularization.revascularization.

EF < 20%.EF < 20%.

Contraindications :Contraindications :Age > 65 years old.Age > 65 years old.

Active infections, malignancy, DM, renal or hepatic Active infections, malignancy, DM, renal or hepatic failure.failure.

Fixed severe PH.Fixed severe PH.

Surgery for RHFSurgery for RHF

Although cardiac transplantation is the Although cardiac transplantation is the

most effective therapy for end-stage RHF, most effective therapy for end-stage RHF,

yet it is limited by yet it is limited by donor organ supplydonor organ supply and and

need for immunosuppression.need for immunosuppression.

Xenotransplantation:Xenotransplantation: especially porcine or especially porcine or

non human primate hearts may represent non human primate hearts may represent

a solution to the organ shortage.a solution to the organ shortage.

Surgery for RHFSurgery for RHF