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High RiskHigh RiskHypertension, coronary disease, diabetes, renal disease, family history, etc.Hypertension, coronary disease, diabetes, renal disease, family history, etc.
Ammar et al Circulation 2007; 115: 1563Ammar et al Circulation 2007; 115: 1563
Kono et al. Am J Cardiol. 1991Kono et al. Am J Cardiol. 1991
Mitral Regurgitation in LV Systolic Mitral Regurgitation in LV Systolic DysfunctionDysfunction
Local LV remodeling Local LV remodeling (apical and posterior displacement of papillary muscles)(apical and posterior displacement of papillary muscles) leads to excess valvular tenting independent of global LV remodeling leads to excess valvular tenting independent of global LV remodeling
which, in turn, impacts global remodelling.which, in turn, impacts global remodelling.
posterior
apical
LV enlarges-loss of LV enlarges-loss of elliptical shape; more elliptical shape; more
sphericalspherical
Mitral annulus dilates
Papillary muscles displace
Chordae tether leaflets
Valve leaflets are not in coaptation…
Functional Functional Mitral Mitral
RegurgitationRegurgitation
Increased LV end Increased LV end diastolic pressurediastolic pressure
Functional MR begets MR in cardiomyopathy:Functional MR begets MR in cardiomyopathy:from local to global remodelling from local to global remodelling
SAVE Study: SAVE Study: Comparison of Ventriculographic Variables.Comparison of Ventriculographic Variables.
Lamas et al. Circulation 96:827 (97)Lamas et al. Circulation 96:827 (97)
202202 ++ 68 68
120120 ++ 47 47
3838 ++ 7 7
2828 ++ 7 7
99 ++ 6 6
239239 ++ 84 84
148148 ++ 65 65
4141 ++ 10 10
3434 ++ 11 11
77 ++ 7 7
.001.001 .001.001 .001.001 .001.001 .001.001
LV LV SphericitySphericity diastolic %diastolic %
SAVE Study: SAVE Study: Comparison of Survival on the basis of (mild) MRComparison of Survival on the basis of (mild) MR
Lamas et al., Lamas et al., CirculationCirculation 1997, 96: 827 1997, 96: 827
LVEF% 31+ 7
LVEF% 32 + 7
MR absent
MR present
Relationship between LV SIZE and VT Relationship between LV SIZE and VT
Sutton J et Al.Circulation 2003;
107:2577
Ventricular Shape and Function and Ventricular Shape and Function and Electric VulnerabilityElectric Vulnerability
Electrical Storm
NYHA f.cl. INYHA f.cl. I
Predicting the Long-Term effects of cardiac Predicting the Long-Term effects of cardiac resynchronization therapy on mortalityresynchronization therapy on mortality
Cleland J et al. J Am Coll Cardiol 2008Cleland J et al. J Am Coll Cardiol 2008
Predicting Causes of death in heart failurePredicting Causes of death in heart failureCARE HF post hoc analysisCARE HF post hoc analysis
Uretsky et al. J of Cardiac Fail 2008 Uretsky et al. J of Cardiac Fail 2008
2.2. Ventricular remodelling leading Ventricular remodelling leading to mitral regurgitation and/or to mitral regurgitation and/or electric instability electric instability
dP/dT
diameter
By the La Place law : By the La Place law :
the energy the energy generationgeneration depends by ventricular depends by ventricular wall wall muscle thicknessmuscle thickness
the energy the energy transfer transfer into intracavitary blood into intracavitary blood (pressure(pressure) depends by ) depends by chamber curvature chamber curvature (zero curvature = no energy transfer).(zero curvature = no energy transfer).
Remodelling and dysfunction Remodelling and dysfunction
Heart and Kidney Heart and Kidney InteractionInteraction
Renal blood flow is maintained over a Renal blood flow is maintained over a wide range of blood pressures auto-wide range of blood pressures auto-regulating mechanisms.regulating mechanisms.
It does not fall until the mean arterial It does not fall until the mean arterial pressure falls below the critical level pressure falls below the critical level ((around 80mm Hgaround 80mm Hg).).
Renal fraction of cardiac output Renal fraction of cardiac output normally constitutes about 20% of normally constitutes about 20% of cardiac output.cardiac output.
With low cardiac output, blood is With low cardiac output, blood is shunted from the kidneys to shunted from the kidneys to heart and brain circulation: heart and brain circulation:
the renal fraction of cardiac output is the renal fraction of cardiac output is thereby lowered in a non proportional thereby lowered in a non proportional way.way.
Kidney perfusionKidney perfusionDemand Demand
Car
diac
Out
put
(L/m
in)
Left Ventricular Filling Pressure (mm Hg)
Normal
Heart Failure
Decreas
ed Renal
Function
Decreased
Congestion
0 15 30
5.0
2.5
0
Robert W. Schrier, MDCirc Heart Fail. 2008;1:2-5
Diuretic use may decrease Diuretic use may decrease cardiac outputcardiac output
and impair renal function.and impair renal function.The “Bill”The “Bill”
Lungs congestionLungs congestionusually occurs earlier thanusually occurs earlier thanSBL fall below 80 mm Hg SBL fall below 80 mm Hg
Diuretics and Mortality - PRAISE1Diuretics and Mortality - PRAISE1
0%
25%
50%
75%
100%
0 1 2 3
Years
Figure 2 -KM Survival - Daily Diuretic Dose mg/kg
4 mg/kg
3-4 mg/kg
2-3 mg/kg
1-2 mg/kg
0.5-1 mg/kg
<0.5 mg/kg
p<0.0001
Levy et al Circ 2006Levy et al Circ 2006
Advanced Heart Failure Defined Advanced Heart Failure Defined by:by:
2.2. Progression of LV remodelling leading Progression of LV remodelling leading to mitral regurgitation to mitral regurgitation and/or electric and/or electric instability. instability.
3.3. Fluid retention indexed by diuretic Fluid retention indexed by diuretic need and declining Kidney function.need and declining Kidney function.
EchocardiographyEchocardiography
Mitral regurgitation leads leads to high LV end-diastolicto high LV end-diastolicpressure (ROA 0,22 cmpressure (ROA 0,22 cm22))
Time to death, transplantation, or LVAD implantationTime to death, transplantation, or LVAD implantation in in
patients with patients with lowlow and and highhigh RV systolic pressureRV systolic pressureTedrow UB et al Am J Cardiol. 2006 Jun 15;97(12):1737-40 Tedrow UB et al Am J Cardiol. 2006 Jun 15;97(12):1737-40
Color Doppler:Color Doppler:
• Tricuspid RegurgitationTricuspid Regurgitation
• TAPSE 8TAPSE 8
• Right ventricular Right ventricular
impairment leads toimpairment leads to
progressiveprogressive
Venous congestionVenous congestion
EchocardiographyEchocardiography
Increased MyocardialIncreased MyocardialWall Stress and Wall Stress and EdomyocardialEdomyocardial
IschemiaIschemia
Increased MyocardialIncreased MyocardialWall Stress and Wall Stress and EdomyocardialEdomyocardial
IschemiaIschemia
Right Ventricular Right Ventricular Dilatation andDilatation andRemodelingRemodeling
Right Ventricular Right Ventricular Dilatation andDilatation andRemodelingRemodeling
2.2. Progression of LV remodelling leading to Progression of LV remodelling leading to mitral regurgitation mitral regurgitation and/or electric instability. and/or electric instability.
3.3. Fluid retention indexed by diuretic need and Fluid retention indexed by diuretic need and declining kidney function.declining kidney function.
4.4. Pulmonary hypertension leading to Pulmonary hypertension leading to progressive right ventricular dysfunction and progressive right ventricular dysfunction and venous congestionvenous congestion
p < .05
p < .05Raised Venous Pressure:
A direct cause of renal sodium retention
Effect of Increasing Central Venous Pressure on GFR in Dogs Effect of Increasing Central Venous Pressure on GFR in Dogs with Constant BPwith Constant BP
2.2. Progression of LV remodelling leading to mitral Progression of LV remodelling leading to mitral regurgitation and/or electric instability. regurgitation and/or electric instability.
3.3. Fuid retention indexed by diuretic need and Fuid retention indexed by diuretic need and declining Kidney function.declining Kidney function.
4.4. Pulmonary hypertension leading to progressive right Pulmonary hypertension leading to progressive right ventricular dysfunction and venous congestionventricular dysfunction and venous congestion
5.5. Increasing venous congestion further impacting Increasing venous congestion further impacting renal failurerenal failure
LVDysfLVDysf
Hemodynamic Derangement and HF Mortality: Hemodynamic Derangement and HF Mortality: a Matter of Multi-Systems Failurea Matter of Multi-Systems Failure% %
Hypoperfusion small intestine Hypoxic damageHypoxic damage
= MOF – starter
Gut related Gram-movement:sepsi
(Systemic inflammatory response syndrome)
Intrahepatic cholestasis
(Pierro:seminar 2004)(Pierro:seminar 2004)
(Moore:J trauma 1994)(Moore:J trauma 1994)
(Crawford:Hepatology1998)
Centrilobular Necrosis (Wadia JHLT 2005)
LVDysfLVDysf
LVDysfLVDysf
Hemodynamic Derangement and HF Mortality: Hemodynamic Derangement and HF Mortality: a Matter of Multi-Systems Failurea Matter of Multi-Systems Failure% %