Dr. Maurizio Cecconi
I had the pleasure of chairing this session with Prof Piotr Ponikowski. Prof. Ponikowsi welcomed the audience, anticipating how the multidisciplinary background of the faculty – from cardiology to intensive care medicine to nephrology to cardiac surgery- would have created a great background for an interactive session. Dr David Newby from Edinburgh started by presenting the use of non invasive ventilation (NIV) both in acute cardiogenic pulmonary edema (ACPE) and in chronic heart failure. Dr Newby elegantly explained that NIV is a very effective way of relieving symptoms for patients distressed by ACPE. Its application is associated with faster improvement in oxygen saturation, respiratory rate, heart rate and acid-base balance when compared to standard facemasks. However, the current literature does not show any survival benefit. Still a therapy that makes the most distressed patients feel better quicker is an important part of the management of ACPE. Regarding which modality is better, continuous positive airway pressure (CPAP) seems to be the modality of choice. In the context of chronic heart failure, NIV has been investigated in patients with sleep disorders. In these patients, as in the context of ACPE, NIV can improve symptoms (if related to obstruction). However there is no long term survival benefit associated with its use. Dr Michael Joannidis, from the University of Innsbruck presented the latest evidence in the field of renal replacement therapy (RRT). Heart disease and acute kidney injury (AKI) are often associated. AKI affects up to 22% of patients in intensive care units (ICUs). 42% of these patients have either an associated cardiovascular problem or are post cardiac surgery patients. The heart-kidney interaction can have different presentations as explained by the recent definitions of cardio-renal syndrome. RRT role in patients with AKI and cardiac problems has several rationales: it can decrease venous return in overloaded patients, it can clear urea and toxins and it can have an impact in the immunomodulation of the disease. Dr Joannidis explained that RRT can be achieved in many ways. If the reason to start RRT is to remove fluid, then ultrafiltration alone can be adequate. Data suggest this modality is better than diuretics alone. When clearance becomes important, however, then ultrafiltration is not sufficient and many modalities, from intermittent dialysis to continuous veno-venous hemofiltration (CVVH), to cite a few, have been investigated. RRT can be performed intermittently or continuously. Some data suggest a possible benefit of continuous RRT in patients with heart failure. The overall agreement is that rates of about 20-30 ml/kg in 24 hours are sufficient and higher doses do not offer other benefits. Regarding RRT and anticoagulation, recently citrate anticoagulation has gained popularity with respect to heparin infusions, being more effective in prolonging filter survival and well tolerated by patients. Dr Alain Combes from Paris continued with an elegant presentation about intra-aortic balloon pump (IABP) and short-term ventricular assist devices (VADs). IABP is still a class I recommendation in acute myocardial infarction (AMI) and cardiogenic shock (CS), however recent evidence suggests that this may have to be revised soon. While previous data showed a morality benefit for IABP in AMI with CS (when most of the data was pre PCI), more recent data does not actually support this anymore. IABP is not the only way to support the heart during CS. A new option is represented by ventricular assist devices (VAD). Some of these devices seem promising, especially the ones that can deliver higher flows (up to 5 L/min). Dr Combes also suggested that Extra corporeal membrane oxygenation (ECMO) is becoming a first line alternative to IABP in CS. More details about all possible forms of ECMO were given by Dr Antonios Pitsis from Thessaloniki. Dr Pitsis presented a whistle stop tour of technology, explaining that, based on the principal indication of support needed (i.e. cardiac or respiratory), then different options can be considered. If ECMO is started for cardiac support then the choice should fall on a Venous – Arterial System, if the choice is for respiratory support then a venous venous ECMO may be the first choice. These technologies are not without complications, nevertheless recent worldwide experiences, as in the case of the H1N1 pandemic, show that in expert hands, they can save lives. I particularly enjoyed this session. I was honoured to represent the European Society of Intensive Care Medicine in this joint session with the European Society of Cardiology. Intensive Care Medicine and Cardiology represent a winning partnership for our patients and I hope to see more joint sessions at our congresses in the future.
Device therapy in cardiovascular failure
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