Biventricular failure

Biventricular failure often follows left ventricular failure and consequently oedema develops in the peripheral tissues, causing swelling of the legs, and in the lungs, causing breathlessness. 

Mixed form—weakened muscle and dilated ventricular walls that are unable to relax resulting in poor ejection fraction (< 35 percent), high pulmonary pressures, and biventricular failure... 

The total artificial heart (TAH) is designed for orthotopic heart replacement, and is thus capable of replacing the function of the entire heart. The artificial pumps are implanted orthotopically after the patient s diseased native heart has been removed. Currently there are only pulsatile designs available (CardioWest TAH, AbioCor IRH, Penn State TAH). A total artificial heart is indicated in patients with severe aortic valve insufficiency, intractable ventricular arrhythmias, an acquired ventricular septal defect, or irreversible biventricular failure requiring a high pump output (Renlund 2004). 

A series of pilot studies began with multisite pacing for patients with heart failure and dilated cardiomyopathy in the early 1990s [52, 105-111]. An improvement in LV function and symptoms of heart failure were demonstrated. This provided the interest in biventricular pacing for heart failure. The term cardiac resynchronization therapy was coined to refer to pacing therapies that attempt to enhance cardiac performance by using pacing to correct electrical conduction abnormalities in the heart. The most common form of this therapy is atrial-synchronous... 

Galizio NO, Pesce R, Valero E, et al. Which patients with congestive heart failure may benefit from biventricular pacing Pacing Clin. Electrophysiol. 2003 26 158-61. 

Linde C, Leclercq C, Rex S, et al. Long-term benefits of biventricular pacing in congestive heart failure results from the MUltisite STimulation in cardiomyopathy (MUSTIC) study, [see comment]. J. Am. Coll. Cardiol. 2002 40 111-8. 

Bakker PF, Meijburg HW, de Vries JW, et al. Biventricular pacing in end-stage heart failure improves functional capacity and left ventricular function. J. Interv. Card. Electrophysiol. 2000 4 395 404. 

Leclercq C, Cazeau S, Le Breton H, et al. Acute hemodynamic effects of biventricular DDD pacing in patients with end-stage heart failure. J. Am. Coll. Cardiol. 1998 32 1825-31. 

Leclercq C, Cazeau S, Ritter P, et al. A pilot experience with permanent biventricular pacing to treat advanced heart failure, [see comment]. Am. Heart J. 2000 140 862-70. 

Cazeau S, Leclercq C, Lavergne T, et al. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N. Engl. J. Med. 2001 344 873-80. 

Sogaard P, Kim WY, Jensen HK, et al. Impact of acute biventricular pacing on left ventricular performance and volumes in patients with severe heart failure. A tissue doppler and three-dimensional echocardio-graphic study. Cardiology 2001 95 173-82. 

Oguz E, Dagdeviren B, Bilsel T, et al. Echocardio-graphic prediction of long-term response to biventricular pacemaker in severe heart failure. Eur. J. Heart Fail. 2002 4 83-90. 

Reuter S, Garrigue S, Barold SS, et al. Comparison of characteristics in responders versus nonresponders with biventricular pacing for drug-resistant congestive heart failure. Am. J. Cardiol. 2002 89 346-50. 

Patients with normal sinus rhythm and a wide QRS interval, eg, greater than 120 ms, have impaired synchronization of ventricular contraction. Poor synchronization of left ventricular contraction results in diminished cardiac output. Resynchronization, with left ventricular or biventricular pacing, has been shown to reduce mortality in patients with chronic heart failure who were already receiving optimal medical therapy. 

A 10-year-old child had status epilepticus controlled with a combination of valproate, oxcarbazepine, and 48 hours of propofol infusion in a dose of 5.5 mg/kg/ hour. After weaning from propofol, a classic ketogenic diet was instituted in an attempt to provide long-term control of the seizures. A day later status epilepticus recurred and propofol was restarted at a rate of 6-9 mg/ kg/hour to suppress seizure activity (the diet, valproate, and oxcarbazepine were also continued). Shortly thereafter, he developed the classical constellation of malignant ventricular arrhythmias, hyperlipidemia, rhabdomyolysis, lactic acidosis, and biventricular cardiac failure. He did not survive. 

A 64-year-old woman with systemic lupus erythematosus took chloroquine for 7 years (cumulative dose 1000 g). She developed sjmcope, and the electrocardiogram showed complete heart block a permanent pacemaker was inserted. The next year she presented with biventricular cardiac failure, skin hyperpigmentation, proximal muscle weakness, and chloroquine retinopathy. Coronary angiography was normal. An echocardiogram showed a restrictive cardiomyopathy. A skeletal muscle biopsy was characteristic of chloroquine myopathy. Chloroquine was withdrawn and she improved rapidly with diuretic therapy. 

A 78-year-old woman with a history of biventricular heart failure developed cardiogenic shock after she took a single tablet of verapamil 80 mg. She was resuscitated with artificial ventilation, dobutamine, noradrenaline, and calcium gluconate. Toxicological analysis showed an unexpectedly high plasma verapamil concentration, which was attributed to liver failure. 

Recent studies demonstrate that cardiac resynchronization therapy (CRT) offers a promising approach to selected patients with chronic heart failure. Delayed electrical activation of the left ventricle, characterized on the ECG by a QRS duration that exceeds 120 ms, occurs in approximately one-third of patients with moderate to severe systolic heart failure. Since the left and right ventricles normally activate simultaneously, this delay results in asynchronous contraction of the left and right ventricles, which contributes to the hemodynamic abnormalities of this disorder. Implantation of a speciahzed biventricular pacemaker to restore synchronous activation of the ventricles can improve ventricular contraction and hemodynamics. Recent trials show improvements in exercise capacity, NYHA classification, quality of life, hemodynamic function, and hospitalizations. A device that combined CRT with an implantable cardioverter-defibrillator (ICD) improved survival in addition to functional status. CRT is currently indicated only in NYHA class ni-IV patients receiving optimal medical therapy (ACE inhibitors, diuretics, -blockers, and digoxin) and... 

Device programming Failure to achieve adequate biventricular capture... 

Braun MU, Rauwolf T, Zerm T, Schulze M, Schnabel A, Strasser RH. Long term biventricular resynchronisation therapy in advanced heart failure effect on neurohormones. Heart 2005 91 601-5. 

Duray GZ, Israel CW, Pajitnev D, Hohnloser SH. Upgrading to biventricular pacing/defibrillation systems in right ventricular paced congestive heart failure patients prospective assessment of procedural parameters and response rate. Europace 2008 10 48-52. 

Sogaard P, Egeblad H, Pedersen AK, et al. Sequential versus simultaneous biventricular resynchronization for severe heart failure evaluation by tissue Doppler imaging. Circulation 2002 106 2078-84. 

Boriani G, Muller CP, Seidl KH, et al. Randomized comparison of simultaneous biventricular stimulation versus optimized interventricular delay in cardiac resynchronization therapy. The Resynchronization for the HemodYnamic Treatment for Heart Failure Management II implantable cardioverter defibrillator (RHYTHM IIICD) study. Am Heart J 2006 151 1050-8. 

Auricchio A, Klein H, Tockman B, et al. Transvenous biventricular pacing for heart failure can the obstacles be overcome Am J Cardiol 1999 83(5B) 136D-42D. 

Coronary venous lead connectors were initially developed to accommodate patients with heart failure who were previously implanted for other reasons and were considered eligible for an upgrade to biventricular pacing. For these patients, the ventricular output of the PM generator was divided via a Y connector from one bipolar output to two separate outputs - one for the previously implanted RV lead and the other for the new left ventricular (LV) lead. 

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