Heart failure therapy based on interventricular mechanics and cardio-vascular communications

Abstract

The heart should not be divided in right and left, whether in health nor in disease. However, the morphological and functional differences between the right and left ventricle should be known and the impact of the ventricle's position considered. Further, the parameters beyond heart rate, contractility, pre- and afterload guaranteeing a sufficient systemic cardiac output have to be integrated in therapeutic measures; preferentially the influence of interventricular mechanics. Despite of recent developments of specific drug therapies, heart failure is associated with a high rate of morbidity and mortality in children. During the progression of heart failure, pulmonary vascular disease is the consequence or the reason for further failing. Clinical symptoms are associated with congestion and low cardiac output at rest or exercise. Improved understanding of the pathophysiological mechanisms particularly of ventricular failure has resulted in the development of innovative therapies that target atrial/ventricular/arterial interactions. Recent advances in interventional and surgical approaches provide promising new strategies to deal with right and left ventricular deterioration. These techniques may delay listing for heart and (heart-) lung transplantation or even make redundant in individual cases. The beneficial effects of these ventricular interaction strategies are mainly based on the mechanics of the interventricular septum and improvement of systolic and diastolic ventricular performance.

Keywords: Pediatric heart failure; Potts-shunt; dilative cardiomyopathy; pulmonary banding; pulmonary hypertension (PH).

Figure 1

Echocardiography in four chamber view is shown of an infant with dilated cardiomyopathy prior to creation of a restrictive atrial communication (upper part); seen is a dilated left ventricle and left atrium, the left atrial congestion is further recognizable by the shifted atrial septum to the right; the right ventricle is even slightly dilated corresponding with a postcapillary induced pulmonary hypertension. The lower part demonstrates a restrictive atrial communication by color Doppler.

Figure 2

Artificial valved Potts shunt. (A) A surgically performed reverse Potts shunt, which was valved by utilizing a Melody^®-valve; (B) shows the Melody^® ensemble caught by a snare from the arterial side supporting placement of the valve within the Potts-shunt from femoral vein access through an additional re-valved tricuspid valve.