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MECHANICAL CIRCULATORY SUPPORTS IN ADVANCED
HEART FAILURE
Dr SHALINI GARG SR II DM CARDIOLOGY
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100
75
50
25
0I II III IV
1
10
NYHA CLASS
Ann
ual S
urvi
val R
ate
Hos
pita
lizat
ions
/ ye
ar
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Deceased
Adapted from Bristow, MR Management of Heart Failure, Heart Disease: A Textbook of Cardiovascular Medicine, 6th edition, ed. Braunwald et al.
Class III
25% of HF Patients
Frequent hospitalizations
Worsening symptoms despite drug therapy
Significant opportunity for new therapies
Survival RateHospitalizations
Natural History of Heart Failure
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Stages of Heart Failure
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Addressing Heart Failure in 2013
Katz AM Heart Failure
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INTERMACS SCOREInteragency Registry for Mechanically Assisted Circulatory Support
Long-Term LVADIdeal candidates are INTERMACS classes 3-4
Short-Term LVADCandidates are INTERMACS classes 1-2
Not a LVAD CandidateINTERMACS 1 or those with multisystem organ failure
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INTERMACS Level Pre-Implantfor 1092 Primary LVAD (June 2006–March 2009)
1 Critical cardiogenic shock
2 Progressive decline
3 Stable but inotrope dependent
4 Recurrent advanced HF
5 Exertion intolerant
6 Exertion limited
7 Advanced NYHA III
Kirklins et al INTERMACS 2. JHLT 2010
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Short term Device options
Bridge to recoveryBridge to decision
IABP
ECMO
Tandem Heart
Impella
AbioMed 5000Centrimag
Circulation 112 (3): 438
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Intraaortic Balloon Pump (IABP)
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Basic principles of counterpulsation
Counterpulsation is a term that describes balloon inflation in
diastole and deflation in early systole. Balloon inflation causes
‘volume displacement’ of blood within the aorta, both
proximally and distally. This leads to a potential increase in
coronary blood flow and potential improvements in systemic
perfusion by augmentation of the intrinsic ‘Windkessel effect’,
whereby potential energy stored in the aortic root during
systole is converted to kinetic energy with the elastic recoil of
the aortic root.
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IABP inflates with aortic valve closure:Provides pressurized pulse of blood against closed aortic valve, increasing coronary perfusion
IABP deflates immediately prior to aortic valve opening:Reduces LV afterload
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IABP: Physiology
• Inflation at aortic valve closure:• Increases aortic diastolic blood pressure• Increases diastolic coronary perfusion• Net neutral effect on cerebral perfusion• Increases C.O./“runoff” to subdiaphragmatic organs
• Deflation prior to systole:• Reduces impedance to LV ejection (afterload)• Reduces myocardial oxygen consumption
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IABP: Physiology
• 2 main beneficial effects:
– 1) Augmented coronary perfusion
– 2) Reduced LV afterload/Increased CO
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IABP: Physiology
• 2 main beneficial effects:1) Augmented coronary perfusion
• Only in normal coronary arteries• No augmentation beyond severe stenoses pre PCI• Augmentation beyond severe stenoses post PCI
2) Reduced LV afterload/Increased CO
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IABP: Physiology
• 2 main beneficial effects:
– 1) Augmented coronary perfusion
– 2) Reduced LV afterload/Increased CO• Most important of 2 main effects when severe coronary
stenoses present
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Hemodynamic Effects of IABP Aorta ↓systolic pressure, ↑diastolic pressure
Left ventricle ↓systolic pressure, ↓end-diastolic pressure, ↓volume, ↓wall tension
Heart ↓afterload, ↓preload, ↑cardiac output
Blood flow ↑→ coronary blood flow
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IABP: Indications• Cardiogenic shock: Post cardiotomy, Ass. with acute MI, Mechanical complications of MI• In ass. with CABG Pre op : Pt with severe LV dysfunction Pt with intractable ischemic arrythmias Post op: Post Cardiotomy cardiogenic shock• In ass. With non surgical revascularization.
– Hemodynamically unstable infarct patients– High risk PCI : severe LV dysfunction, complex CAD
• Stabilization of Cardiac Transplant recipient before insertion of VAD• Post Infarction Angina • Ventricular Arrythmias related to Ischemia
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IABP: ContraindicationsContraindications FOR IABP
Absolute Relative
Aortic regurgitation Uncontrolled sepsis
Aortic dissection Abdominal aortic aneurysm
Chronic end-stage heart disease with no anticipation of recovery
Tachyarrhythmias
Severe peripheral vascular disease
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Technique of insertion and operation
The IABP device has two major components: (i) a double-lumen 8.0–9.5 French catheter with a 25–50 ml
balloon attached at its distal end(ii) a console with a pump to drive the balloon. The balloon is made of polyethylene and is inflated with gas
driven by the pump. Helium is often used because its low density facilitates rapid transfer of gas from console to the balloon. It is also easily absorbed into the blood stream in case of rupture of the balloon
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The appropriate balloon size is selected on the basis of pt’s height
PATIENT’S HEIGHT BALLOON VOLUME
< 152 cms 25 cc
152 – 163 cms 34 cc
164 – 183 cms 40 cc
> 183 cms 50 cc
The diameter of the balloon, when fully expanded should not exceed 80–90% of the diameter of the patient’s descending thoracic aorta.
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• Once vascular access is obtained, the balloon catheter is
inserted and advanced, usually under fluoroscopic guidance,
into the descending thoracic aorta, with its tip ~ 2 to 3 cm distal
to the origin of the left subclavian artery (at the level of the
carina).
• Intraoperatively, balloon placement can be ascertained using
transoesophageal echocardiography.
• The outer lumen of the catheter is used for delivery of gas to
the balloon and the inner lumen can be used for monitoring
systemic arterial pressure.
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• The console is programmed to identify a trigger for balloon
inflation and deflation. The most commonly used triggers are
the ECG waveform and the systemic arterial pressure waveform.
• The balloon inflates with the onset of diastole, which
corresponds with the middle of the T-wave. The balloon deflates
at the onset of LV systole and this corresponds to the peak of the
R-wave.
• Poor ECG quality, electrical interference, and cardiac
arrhythmias can result in erratic balloon inflation.
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When intra-aortic balloon pumping is begun, the assist
interval is set on 1:2 (the IAB inflates and deflates every
other systole). This is done so that landmarks can be
identified and the effects of inflation and deflation can be
compared to the baseline hemodynamic status. Later on the
Assist ratio can be changed to 1:1.
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PDP/AUG should be higher than the PSP/SYS unless:
• Balloon is positioned too low
• severe cases of hypo volemia
• balloon is too small for patient’s aorta
• low SVR
• improper timing
• catheter partially kinked, in sheath, not unwrapped
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Criteria for Assessment of Effective IAB Therapy on the Arterial Pressure Waveform1 ) Inflation occurs at the dicrotic notch.
2) Inflation slope is parallel to the systolic upstroke and is a straight line.
3) Peak Diastolic augmentation should be greater than the unassisted systolic peak.
4) An end-diastolic dip in pressure is created with balloon deflation.
5) Two assisted pressures (systolic and diastolic) should be lower than the unassisted pressures .
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Timing is set and changed using two separate controls that
move the timing markers to the left and right. The inflate
control is moved to the left to adjust the inflate time to occur
earlier and to the right to occur later. The deflate control
operates in a similar manner: moved to the left for earlier
deflation, to the right for later deflation.
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LATE DEFLATIONWaveform characteristics• assisted aortic end-diastolic pressure may be equal to the unassisted aortic end-diastolic pressure; •rate of increase of assisted systole is prolonged •diastolic augmentation may appear widened.
Physiological effects• afterload reduction is essentially absent• increased MVO2 consumption because of the left ventricle ejecting against a greater resistance and a prolonged isovolumetric contraction phase•IAB may impede LV ejection and increase the afterload
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1. Inflation -- Just Prior to the Dicrotic Notch (DN) If > 40ms before—EARLY INFLATION If dicrotic notch exposed—LATE INFLATION2. Deflation:-- BAEDP < PAEDPBAEDP = Balloon Aortic End Diastolic PressurePAEDP = Patient Aortic End Diastolic Pressure If BAEDP is higher—LATE DEFLATION may be occuring3. Deflation:Assisted Systole (APSP/ASYS) < Peak Systole (PSP/SYS)SYS/PSP = Peak Systolic PressureASYS/APSP = Assisted Peak Systolic PressureIf both pressures are equal—EARLY DEFLATION can be suspected
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BALLOON PRESSURE WAVEFORM During a cycle of inflation/deflation, helium is rapidly moved in and
out of the balloon. The environment within the balloon and the surrounding forces that affect balloon behavior all contribute to a predictable pattern of gas flow and pressure. The gas pressure characteristics are converted into a waveform. This transduced waveform can tell us much about the interaction of the balloon within the patient’s aorta.
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• Initial under fill of the intra-aortic balloon• Leak• Auto-fill failure• Balloon disconnected
Auto-vent failure Possible vacuum malfunctionKinked Line
Kinked catheter.
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Weaning from the Intra-Aortic Balloon Pump
There are two methods of weaning which may be used independently or in conjunction with one another. Weaning can be accomplished by decreasing the frequency and/or volume of balloon inflation. Weaning by decreasing the frequency is accomplished by decreasing the frequency of assistance from one balloon inflation per cardiac cycle to 1:2, 1:3, 1:4, and 1:8. Weaning can also be accomplished by decreasing the volume delivered to the balloon. Do not reduce the volume delivered to the balloon less than 2/3 the capacity of the balloon, i.e. a 40cc balloon should not have the volume reduced to less than 28cc.
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IABP: ComplicationsComplications associated with IABP
Transient loss of peripheral pulse
Limb ischaemia
Thromboembolism
Compartment syndrome
Aortic dissection
Local vascular injury—false aneurysm, haematoma, bleeding from the wound
Infection
Balloon rupture (can cause gas embolus)
Balloon entrapment
Haematological changes, for example thrombocytopenia, haemolysis
Malpositioning causing cerebral or renal compromise
Cardiac tamponade
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IABP: ComplicationsRisk Factors
• Odds Ratios for Major complications with IABP therapy:
– PVD: 2.0– Female Gender: 1.7– Small BSA: 1.5– Advanced age: 1.3
(Little Old Ladies!!!)
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Ventricular Assist Device (VAD)
Long-Term LVADImplanted surgically with the intention of
support for months to years
Short-Term LVADUtilized for urgent/
emergent support over the course of days to
weeks
A mechanical circulatory device used to partially or completely replace the function of
either the left ventricle (LVAD); the right ventricle (RVAD); or both ventricles (BiVAD)
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Ventricular Assist Devices
• There are several many different VADs. All VADs have the following four parts:– An inflow cannula which takes
blood from the ventricular to the pump
– A pump – An outflow cannula that takes the
pumped blood to the ascending aorta
– A power source for the pump
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• They are powered by external power sources that connect to the implanted pump via a percutaneous lead (driveline) that exits the body on the right abdomen.
• Pump output flow can be pulsatile or nonpulsatile.
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Components of a Ventricular Assist Device
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Classification of Ventricular Assist Devices On the basis of period of use: a) Temporary, b) Permanent
On the basis of impaired ventricle: a) LVAD, b) RVAD, c) Bi-VAD
On the basis of Pumping mechanism: a) Pulsatile b) Non pulsatile
On the basis of suspension of rotors: a) Bearing suspension b) Electromagnetic or Hydrodynamic suspension.
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Krishnamani, R. et al. (2010) Emerging ventricular assist devices for long-term cardiac support
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2009.222
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Pulsatile Devices• Ventricle-like pumping sac device.
– Blood enters via the inflow cannula and fills a flexible pumping chamber.
– Electric motor or pneumatic (air) pressure collapses the chamber and forces blood into systemic circulation via the outflow cannula.
• Can be LVAD, RVAD, or BiVAD• First-generation devices (in use since early 1980s)• Patients will have a palpable pulse and a measurable blood pressure.
Both are generated from the VAD output flow.• Pulsatile VADs emulated the real contraction phenomenon of
ventricles while Advanced VADs use continuous flow mechanisms
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FEATURES• is a short-term uni- or
biventricular support system .
• comprised of two 100 mL polyurethane blood sacs.
• the inlet and outlet portions of which are guarded by polyurethane valves
The Abiomed BVS 5000i
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
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HeartMate XVE
• Has a titanium-alloy external housing, with inflow and outflow conduits that use porcine xenograft valves.
• Internal blood-contacting surface is made of textured titanium that results in the development of a pseudo-neointima on which thrombus formation is greatly reduced, thereby decreasing the need for anticoagulation.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
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Non-Pulsatile Devices• Continuous-flow devices
Impeller (spinning turbine-like rotor blade) propels blood continuously forward into systemic circulation.
Axial flow: blood leaves the pump in the same direction as it enters (boat motor propeller).
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Key features of nonpulsatile VAD
• Most implanted devices are LVADs only.
• Are quite and cannot be heard outside of the patient’s body. Assess VAD status by auscultation over the apex of the LV. The VAD should have a continuous, smooth humming sound.
• The Patient may have a weak, irregular, or non-palpable pulse
• The Patient may have a narrow pulse pressure and may not be measurable with automated blood pressure monitors. This is due to the continuous forward outflow from the VAD.
• The Mean Arterial Pressure is the key in monitoring hemodynamics. Ideal range is 65-90 mmHg.
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Heartware HVAD
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Patient Selection: Who benefits from a VAD
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Recommendations in pt with severe Heart Failure ineligible for transplant
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Mechanical Circulatory Support
VADRECOVE
RY
CANDIDACY
DESTINATION THERAPY
TRANSPLANT
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Mechanical Circulatory SupportINDICATION NOMENCLATURE DEFINITION
Bridge to transplantation Patient is listed for heart transplantation
Bridge to candidacy
Patient initially deemed ineligible for heart transplantation because of comorbidity (cardiorenal syndrome or pulmonary hypertension), which improves during mechanical support
Bridge to recoveryPatient with a potentially reversible cause of cardiac decompensation (acute myocarditis, postcardiotomy syndrome, peripartum cardiomyopathy)
Bridge to decision Patient in whom the potential for transplantation or recovery is yet unclear
Destination therapy Patient in whom recovery or transplantation is not feasible
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Indications for Use:Pulsatile vs. Continuous Flow
• Pulsatile Devices– PVAD– IVAD– Heartmate XVE
LVAD• Continuous Flow
– Heartmate II LVAD
– Heartware HVAD
FDA Approved Devices for Bridge to Transplant
PVAD/IVADHeartmate XVE LVADHeartmate II LVADHeartware HVAD
FDA Approved Device for Destination Therapy
Heartmate XVE LVADHeartmate II LVAD
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• Score of 0-8 is low risk and predict 3 months survival of 87.5% while greater than 19 is very high risk with survival of 13.7%
• This Risk Score is not validated for Cont. flow device implanted for destination therapy
RISK FACTORS FOR 3 MONTHS MORTALITY AFTER VAD IMPLANT
RISK FACTORS SCORE
Platelet Count < 148 X 103 per uL 7
Serum Albumin < 3.3 g/dL 5
INR > 1.1 4
Vasodilator treatment 4
Mean PAP < 25mm Hg 3
SGPT > 45 units/ml 2
HCT < 34% 2
BUN > 51U/dL 2
No IV Inotropes 2
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Anti Coagulation is must
• Optimal INR for cont. flow device is 1.5 to 2.5• Higher degree of anti coagulation is required in AF, prior
thromboembolic events , known LA or LV thrombi and if there is low assist device flow rate < 3 l/min.
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Contraindications
– End-stage lung, liver, or renal disease– Metastatic disease – Medical non-adherence or active drug
addiction– Active infectious disease– Inability to tolerate systemic anticoagulation
(recent CVA, GI bleed, etc.,)– Moderate to severe RV dysfunction for some
LVADs
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• RV dysfunction is an important source of morbidity and mortality after LVAD insertion.
• Predictors of post implant RVF are CVP/PCWP > 0.63, BUN > 39 mg/dL, and preop mechanical ventilatory support.
• RV failure is reversible with inotropes or PDEI. • If RV function does not improve and LVAD flow still
suboptimal (<2.4 L/min/m2 ) with CVP > 16 mm Hg then RVAD insertion is necessary which can be short term or long term.
• Recent data demonstrates that early planned institution of RV support can mitigate the potential adverse consequences of RV dysfunction after LVAD placement.
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Basic VAD Management ALL VADs are:
Preload-dependent EKG-independent Afterload-sensitive Anticoagulated Prone to:
• infection• bleeding• thrombosis/stroke• mechanical malfunction
Key differences depend on pulsatile vs. non-pulsatile device
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Variations of Short-Term VADs
• Impella 2.5 and 5.0• Tandem Heart• CentriMag• ECMO (V-A)
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Impella 2.5 and 5.0• Utilized for LV support only; not
appropriate to use with RV failure• Impella 2.5 can be inserted through
the femoral artery during a standard catheterization procedure; provides up to 2.5 L of flow
• Impella 5.0 inserted via femoral or axillary artery cut down; provides up to 5L of flow
• The catheter is advanced through the ascending aorta into the left ventricle
• Pulls blood from an inlet near the tip of the catheter and expels blood into the ascending aorta
• FDA approved for support of up to 6 hours
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Effect of IABP and Impella 2.5 device on important hemodynamic parameters
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
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Algorithm for device selection.
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TandemHeart pVAD• Used for LV support; not
appropriate in RV failure• Cannulas are inserted
percutaneously through the femoral vein and advanced across the intraatrial septum into the left atrium
• The pump withdraws oxygenated blood from the left atrium and returns it to the femoral arteries via arterial cannulas
• Provides up to 5L/min of flow
• Can be used for up to 14 days
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CentriMag
• Can be used for LV and/or RV support
• Cannula are typically inserted via a midline sternotomy
• Capable of delivering flows up to 9.9 L/min
• Can be used for up to 30 days
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ECMO (VA)
• Used for patients with a combination of acute cardiac and respiratory failure
• A cannula takes deoxygenated blood from a central vein or the right atrium, pumps it past the oxygenator, and then returns the oxygenated blood, under pressure, to the arterial side of the circulation
• Can be used for days to weeks
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TOTAL ARTIFICIAL HEART
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
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Artificial Heart
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Effects of Chronic Hemodynamic Unloading with Ventricular Assist Devices
Structural• Regression of myocyte hypertrophy.• Reduction in neurohormonal activation• Normalization in expression of contractile proteins .• Enhanced electron transport chain respiratory function• Decreased apoptosis and cellular stress markers
Functional Provide mechanical circulatory support to restore the circulation of blood flow to the
body.• Decreases preload• Decreases cardiac workload• Increases systemic circulation & tissue perfusion• Decreases neurohormonal response
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•Thank you