Cardiac Resynchronization Therapy

Dyssynchronous contraction, as a reflection of intra-and interventricular conduction delays between chambers of the heart, is common in advanced HF patients. Dyssyn-chrony contributes to diminished cardiac function and unfavorable myocardial energetics through altered filling times, valvular dysfunction, and wall motion defects. Cardiac resynchronization therapy (CRT) with biventricular pacing devices improves cardiac function, quality of life, and mortality in patients with NYHA FC III or IV HF, evidence of intraventricular conduction delay (QRS greater than 120 msec), depressed LV function (LVBF less than 35%), and on an optimal pharmacologic regimen. A recent study also showed that the addition of an ICD to CRT with biventricular pacing further reduced hospitalizations and mortality.61

Intra-aortic Balloon Counterpulsation

Intra-aortic balloon counterpulsation (IABC) or intra-aortic balloon pumps (IABPs) are one of the most widely used mechanical circulatory assistance devices for patients with cardiac failure who do not respond to standard therapies. An IABP is placed percutaneously into the femoral artery and advanced to the high descending thoracic aorta. Once in position, the balloon is programmed to inflate during diastole and deflate during systole. Two main beneficial mechanisms are: (a) inflation during diastole increases aortic pressure and perfusion of the coronary arteries, and (b) deflation just prior to the aortic valve opening reduces arterial impedence (afterload). As such, IABC increases myocardial oxygen supply and decreases oxygen demand. This device has many indications including cardiogenic shock, high-risk unstable angina in conjunction with percutaneous interventions, pre-operative stabilization of high-risk patients prior to surgery, and patients who cannot be weaned from cardiopulmonary bypass. Possible complications include infection, bleeding, thrombosis, limb ischemia, and device malfunction. The device is typically useful for short-term therapy due to the invasiveness of the device, the need for limb immobilization, and the requirement for anticoagulation.

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