The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
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J. Heart Lung Transplant. · Aug 2000
Review Case ReportsOutpatient parenteral inotropic therapy for advanced heart failure.
Patients with advanced heart failure generally have hemodynamic perturbation characterized by low cardiac output and high ventricular filling pressures. This creates a clinical milieu with profound symptomatology that includes weakness, fatigue, and fluid-retention states causing peripheral edema, mesenteric congestion, and dyspnea syndromes. Great morbidity including hospital admissions and readmissions as well as high mortality rates ensue. Though medication and/or surgical intervention often attenuate heart failure symptomatology, morbidity, and mortality, some patients reach more advanced stages despite aggressive maneuvers. Indeed, patients presenting with acute decompensation of chronic congestive heart failure frequently receive parenteral inotropic drugs during their hospitalization with clinical improvement. Because these agents generally increase cardiac output and reduce pre-load and afterload, they can be lifesaving. Some patients, however, have symptomatic and hemodynamic rebound to worsened heart failure states during or shortly after inotrope weaning. ⋯ Data from a few small clinical trials and anecdotal case experience suggest that these drugs result in both hemodynamic and clinical improvement that is generally sustained during chronic administration, and even noted long after discontinuation of infusions in some patients. Some reports have suggested that intermittent infusion therapy in outpatients (so-called pulsed therapy) is effective in attenuating congestive heart failure symptoms long term, with more data supporting chronic infusion of these agents. Though questions regarding safety of these agents have been raised, a reasonable compendium of data published to date supports the contention that inotropic drugs used in this fashion ameliorate symptoms. Legitimate concern may be raised regarding exacerbation of arrhythmias with subsequent sudden cardiac death syndrome; however, in severely symptomatic heart failure patients, the trade-off between symptomatic amelioration and the chance of sudden cardiac death may be worthwhile. Unfortunately, precise guidance regarding the best drug, dose, optimal administration technique, weaning protocol, and actual risk/benefit ratio are not well characterized. Practice as been guided, in large part, by anecdotal experience. However, it appears that chronic or pulsed outpatient parenteral inotropic infusion therapy is frequently prescribed and that this treatment option is an effective alternative for carefully selected patients with severely symptomatic and advanced heart failure. Formulating optimal protocols for home inotropic drug infusion therapy by conducting properly designed clinical trials will be an essential endeavor.
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J. Heart Lung Transplant. · Aug 2000
ReviewSudden death in heart failure patients: effects of optimized medical therapy.
Although medical therapy, particularly with angiotensin-converting enzyme (ACE) inhibitors, has been demonstrated to prolong life in patients with chronic heart failure, the effect of standard medical therapy on sudden unexpected death in patients with heart failure is less well understood. Recent clinical trials have provided new insights into this growing problem. The impact of modern medical therapy for heart failure, including ACE inhibitors, beta-adrenergic antagonists, digoxin, calcium channel antagonists, and antiarrhythmic interventions will be discussed.
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J. Heart Lung Transplant. · Aug 2000
ReviewLeft ventricular assist device implantation: short and long-term surgical complications.
Long-term implanted left ventricular assist devices (LVADs) have significantly improved the care of patients awaiting heart transplantation and will provide an alternative therapy to select patients with heart failure. However, although the technology and clinical results continue to improve, LVAD implantation is still associated with a significant level of complications. ⋯ Beyond the perioperative period, late complications consist primarily of infection, thromboembolism, and primary device failure. An improved understanding of the mechanisms involved should aid the clinician in further reducing the incidence of these occurrences.