Cardio-hepatic Syndrome Organ Dysfunction In Acute Heart Failure

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Organ dysfunction in acute heart failure:Cardio-hepatic syndromeAlexandre MebazaaDepartment of Anesthesia & Critical CareUniversity Hospitals Saint Louis – Lariboisière, Paris, FranceUniversity Paris 7; INSERM – UMR 942

Conflict of interest Speaker’s bureau Alere, Edwards,Thermofischer Consultant for Bayer, Cardiorentis, Novartis,Orion, Vifor Pharma

Online, free accessShort version: HFA/EUSEM/SAEM Eur Heart Journal 2015; Long version: Eur J Heart Failure 2015

‘Clinical scenario 2’ in the CCU:dyspnoea SBP 110-150 mmHgDecompensated chronicheart failure Dyspnoea develops graduallyGradual increase in body weightSystemic oedemaMinimal pulmonary oedemaIt is a systemic illness: Possible renal dysfunctionAnaemiaLow albumin levelsIncreased pulmonary congestionSystemic congestion

Acute heart failure right & left ventricular failure:results of meta-analysisLVfailureRAP - right atrial pressurePCWP - pulmonary capillary wedge pressureIshihara S et al (submitted for publication)

“Butterfly” pattern on chest X-rayMonnier-Cholley L Chest X-ray in Acute Heart Failure in Mebazaa A et al (Eds) Acute Heart Failure (2009) Springer Science & Business Media

Acute heart failure right & left ventricular failure:results of meta-analysisRV failureRAP - right atrial pressurePCWP - pulmonary capillary wedge pressureIshihara S et al (submitted for publication)

Cardiorenal SyndromeType IAcute setting‘abrupt worseningof cardiac function(e.g. from ADHF)eading to acutekidney injury’?Ronco52:1527-39Ronco Cetet al.al. JJACCAm Coll2008,Card 2008,52:1527-39

CVP (p 0.01)SBPWorsening Renal Function (%)Effects of CVP, CI, SBP and PcwP on worseningrenal function In Acute Heart Failure patientsCIPCWPMullens et al. JACC 2009, 53:589-596

Association between baseline creatinine leveland invasive haemodynamics in AHF: results of a meta-analysisp 0.30p 0.006p 0.58p 0.007Ishihara S et al (submitted for publication)

Gheorghiade et al. Eur J Heart F 2010

Abstract of the review« The main reason for hospitalization for acute heart failure isCONGESTION, rather than low cardiac output ».Gheorghiade et al. Eur J Heart F 2010

Several interactions have beendescribed in acute heart failure- Cardio-renal syndromes- Cardio-liver syndrome(s) ?

EFICALaboratory Tests on AdmissionZannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

EFICARisk Factors of 4-week MortalityZannad F, Mebazaa A, et al. Eur J Heart Fail. 2006

DANGERMechanical ventilation canworsen liver congestion 38 y.o. man, dilated cardiomyopathy referred to the emergency room forshortness of breath predominant right heart failure major hepatic cytolysis (AST: 10000 IU/l;ALT: 5000); lactate: 5.4 mmol/L; PT 35% Renal failureGatecel et al. Anesthesiology, 1995, 82:588

Mechanical ventilation can worsen liver congestionGatecel et al. Anesthesiology, 1995, 82:588

Mechanical ventilation can worsen liver congestionGatecel et al. Anesthesiology, 1995, 82:588

ArterialpressureNormalIntra-tissular pressure 0Outflow pressureMAP Tissular pressureStableCHFMAP Tissular pressureAHFEffect of HeartFailureon OrganCongestion

high PAPvolume loadingPARAPARVFTRRVLiver/KidneyCONGESTION

Liver dysfunction in AHF:Clinical characteristicsAlk bnormal(37%)Nikolaou et al Eur Heart Journal 2013

6-month mortality as a function of livercytolysisNikolaou et al Eur Heart Journal 2013

6-month mortality as a function ofcholestatisNikolaou et al Eur Heart Journal 2013

AHF-induced liver congestion(increased BNP)Normalliver lobule bile ductcompression(increased AP) bile ductcompression(increased AP) and cytolysis(increased transaminanses)Nikolaou et al Eur Heart Journal 2013

AHF-induced liver congestion(increased BNP)Normalliver lobule bile ductcompression(increased AP) bile ductcompression(increased AP) and cytolysis(increased transaminanses)Nikolaou et al Eur Heart Journal 2013

Factors associated withelevated alkaline phosphataseNikolaou et al Eur Heart Journal 2013

ALARM-HF: IV treatment at admissioninotropesMebazaa et al Intensive Care Medicine 2011

Whole cohortDiureticsLevosimendan0.0In-hospital mortalityEpinephrineVasodilatators05101520Days2530

Online, free accessHFA/EUSEM/SAEM Eur Heart Journal 2015

What to do in the first 30-60 min (1)HFA/EUSEM/SAEM Eur Heart Journal 2015

What to do in the first 30-60 min (1)SEVERITY SCOREHFA/EUSEM/SAEM Eur Heart Journal 2015

Next 120 minHFA/EUSEM/SAEM Eur Heart Journal 2015

Admission/ dischargeHFA/EUSEM/SAEM Eur Heart Journal 2015

Main messages (1) Congestion is the main disease in acute heart failure Novel therapies, such as novel vasodilators, aim atreducing congestion « time is muscle «

Main messages (2) There are evidence for a cardio-liver syndrome inAHF Cholestasis is associated with signs of congestion Hepatolysis is associated with decreased blood flow

In summary There are evidence for a cardio-liversyndrome in AHF Cholestasis is associated with signs ofcongestion Hepatolysis is associated with decreasedblood flow

Cardio-hepatic syndrome Alexandre Mebazaa Department of Anesthesia & Critical Care University Hospitals Saint Louis - Lariboisière, Paris, France University Paris 7; INSERM - UMR 942. Conflict of interest Speaker's bureau Alere, Edwards, Thermofischer

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