PERICARDIAL PUNCTURE: WHEN AND HOW?

Pericardial effusion is a very common condition, due to the accumulation of fluid in the pericardial cavity (the impact depends on the volume, rate of accumulation and elasticity of the pericardium), it results in a: 1. Increased intrapericardial pressure. 2. Increase in intracardiac pressure 3. Decrease in ventricular filling 4. Decrease in ejection volume 5. Decrease in cardiac output The etiologies of effusions are diverse. Tamponade requires emergency decompression of the pericardium to achieve hemodynamic stabilization. Two techniques are possible, either percutaneous puncture with or without ultrasound guidance, or surgical drainage. The choice of drainage method depends on the medical-surgical teams, their experience with each method and the etiology.

Sacubitril-Valsartan, Clinical Benefits and Related Mechanisms of Action in Heart Failure With Reduced Ejection Fraction. A Review

Heart failure (HF) is a clinical syndrome characterized by the presence of dyspnea or limited exertion due to impaired cardiac ventricular filling and/or blood ejection. Because of its high prevalence, it is a major health and economic burden worldwide. Several mechanisms are involved in the pathophysiology of HF. First, the renin-angiotensin-aldosterone system (RAAS) is over-activated, causing vasoconstriction, hypertension, elevated aldosterone levels and sympathetic tone, and eventually cardiac remodeling. Second, an endogenous compensatory mechanism, the natriuretic peptide (NP) system is also activated, albeit insufficiently to counteract the RAAS effects. Since NPs are degraded by the enzyme neprilysin, it was hypothesized that its inhibition could be an important therapeutic target in HF. Sacubitril/valsartan is the first of the class of dual neprilysin and angiotensin receptor inhibitors (ARNI). In patients with HFrEF, treatment with sacubitril/valsartan has demonstrated to significantly reduce mortality and the rates of hospitalization and rehospitalization for HF when compared to enalapril. This communication reviews in detail the demonstrated benefits of sacubitril/valsartan in the treatment of patients with HFrEF, including reduction of mortality and disease progression as well as improvement in cardiac remodeling and quality of life. The hemodynamic and organic effects arising from its dual mechanism of action, including the impact of neprilysin inhibition at the renal level, especially relevant in patients with type 2 diabetes mellitus, are also reviewed. Finally, the evidence on the demonstrated safety and tolerability profile of sacubitril/valsartan in the different subpopulations studied has been compiled. The review of this evidence, together with the recommendations of the latest clinical guidelines, position sacubitril/valsartan as a fundamental pillar in the treatment of patients with HFrEF.

Recurrent Episodes of Fluid Retention in a Patient with Heart Failure and Chronic Kidney Disease: The Additional Value of Implantable Monitoring Systems

The additional role of continuous monitoring of filling pressures and impedance in heart failure patients with chronic kidney disease remains undetermined. In this case report, the effects of diuretic therapy and renal replacement therapy by hemodialysis upon right ventricular filling pressures and impedance are described in a patient with end-stage heart failure and end-stage chronic kidney disease (grade 5). We demonstrated that unloading of the heart by hemodialysis partly restored the blunted Frank-Starling relationship.

CardioMEMS™: a tool for remote hemodynamic monitoring of chronic heart failure patients

Remote monitoring is becoming increasingly important for management of chronic heart failure patients. Recently, hemodynamic monitoring by measuring intracardiac filling pressures has been gaining attention. It is believed that hemodynamic congestion precedes clinical congestion by several weeks and that remote hemodynamic monitoring therefore enables clinicians to intervene in an early stage and prevent heart failure hospitalizations. The CardioMEMS HF system (Abbott, CA, USA) is a sensor capable of measuring pulmonary artery pressures as a surrogate of left ventricular filling pressures. Clinical evidence for CardioMEMS has been convincing in terms of efficacy and safety. This article provides detailed information on the CardioMEMS HF system and summarizes all available evidence of this promising technique.

Techniques, indications and complications of pericardiocentesis

The main aim of pericardiocentesis is to remove excess fluid in the pericardial space and enhance the functions of the heart to intervene against the development of many complications. Accordingly, the procedure is usually performed to manage cardiac tamponade to correct secondary hypotension that attributes to the low stroke volume as a result of the external pressure of the pericardial fluid on the chambers of the heart. In the present literature review, we have discussed the techniques, indications, and complications of pericardiocentesis. Furthermore, the main techniques and approaches include computed tomography-guided pericardiocentesis, echo-guided, and fluoroscopy-guided techniques. These modalities can be successfully used for hemodynamically unstable patients to adequately remove excess fluid to normalize ventricular filling and maintain adequate cardiac output to the peripheral tissues. Considerations for using the modality have been made for small effusions and many authors suggest that it should not be routinely used in these situations. Many major and minor complications can occur secondary to conducting pericardiocentesis. The major complications might include lacerations of the intercostal vessels of the coronary arteries, injury to the cardiac chambers, death, puncture of the peritoneal cavity or abdominal viscera, pneumopericardium, pneumothorax which might require chest intubation, pericardial decompression syndrome, and ventricular arrhythmias. Therefore, carefully approaching these patients and deciding the best management plan, in addition to providing proper interventional approaches for the potential development of these complications is essential to enhance the intended outcomes and enhance the quality of care.

Frank-Starling mechanism, fluid responsiveness, and length-dependent activation: Unravelling the multiscale behaviors with an in silico analysis

The Frank-Starling mechanism is a fundamental regulatory property which underlies the cardiac output adaptation to venous filling. Length-dependent activation is generally assumed to be the cellular origin of this mechanism. At the heart scale, it is commonly admitted that an increase in preload (ventricular filling) leads to an increased cellular force and an increased volume of ejected blood. This explanation also forms the basis for vascular filling therapy. It is actually difficult to unravel the exact nature of the relationship between length-dependent activation and the Frank-Starling mechanism, as three different scales (cellular, ventricular and cardiovascular) are involved. Mathematical models are powerful tools to overcome these limitations. In this study, we use a multiscale model of the cardiovascular system to untangle the three concepts (length-dependent activation, Frank-Starling, and vascular filling). We first show that length-dependent activation is required to observe both the Frank-Starling mechanism and a positive response to high vascular fillings. Our results reveal a dynamical length dependent activation-driven response to changes in preload, which involves interactions between the cellular, ventricular and cardiovascular levels and thus highlights fundamentally multiscale behaviors. We show however that the cellular force increase is not enough to explain the cardiac response to rapid changes in preload. We also show that the absence of fluid responsiveness is not related to a saturating Frank-Starling effect. As it is challenging to study those multiscale phenomena experimentally, this computational approach contributes to a more comprehensive knowledge of the sophisticated length-dependent properties of cardiac muscle.

Understanding the pharmacology of heart failure

Heart failure (HF) is a common clinical syndrome with ever-increasing prevalence in the Western world. It is associated with extensive morbidity and mortality, as well as being a significant burden on global healthcare systems. It is due to impairment of ventricular filling or contraction, resulting in a constellation of physical symptoms and signs, primarily due to salt and water retention. An understanding of the pharmacological options to manage the condition is imperative to quickly alleviate symptoms and avert a rapidly progressive downward spiral, improving not only quality but also quantity of life.