Sunday, 24 November 2013

Pleural disease – Pleural effusion Treatments Caused by Congestive heart failure

The pleura is a thin tissue covered by a layer of cells (mesothelial cells) that surrounds the lungs and lines the inside of the chest wall.
B. Pleural effusion
It is a condition of collection of fluid within the pleural cavity as a result of heart failure, bleeding (hemothorax), infections, excessive or decreased fluid volume, etc.
B.6. Treatments
B.6.1. Treatments in conventional medicine perspective
Treatments in conventional medicine perspective are depending to the underlined causes of the diseases with an aim to produce enough oxygen to the lung for the body to function.
B.6.1.1. Congestive heart failure
Congestive heart failure is a condition of which the heart can’t pump enough blood to the body’s needs.
1. Nonsurgical treatment
1.1. Medication
The renin-angiotensin-aldosterone system is a well-established therapeutic target in the treatment of heart failure (HF). Substantial advances have been made with existing agents-angiotensin-converting enzyme (ACE) inhibitors, angiotensin II-receptor blockers (ARBs), and mineralocorticoid-receptor antagonists (MRAs)-and new data continue to emerge. According to teh study by the Medical Research Institute, University of Dundee, ARBs have been shown to be a beneficial alternative to ACE inhibitors in HFrEF, but their value when added to ACE inhibitors has been questioned. Upstream, direct renin blockade with aliskiren is being pursued in two large trials of HF, despite the premature halting of a third study. A substantial, unmet need remains in patients who have HF with preserved ejection fraction (HFpEF)(70).
2. Surgical treatments
2.1. Implantation of medical devices
a. Ventricular assist device (VAD).
Ventricular assist devices (VADs) have become an established therapeutic option for patients with end-stage heart failure. There is a reprot of six cases of VAD patients with clinical presentation of heart failure at different times after implantation and describe the mechanisms involved(71)
b. Cardiac resynchronization therapy (CRT) device (biventricular cardiac pacemaker).
In the study to elucidate the role of nuclear medicine imaging in the selection of candidates for cardiac resynchronization therapy (CRT) and in the evaluation of CRT effectiveness of a total of 28 patients (19 male and 9 female) with dilated cardiomyopathy (DCM) and heart failure (HF), found that all patients after CRT were divided into three groups. The first group included 10 patients with LVEF increased by more than 10 % (hyperresponders), the 2nd group included 11 patients with an increase in EF of more than 5 % but less than 10 % (responders) and third group consisted of 7 males whose LVEF remained unchanged or worsened compared with pre-operative values (nonresponders). Prior to CRT, no statistically significant differences were found between groups in hemodynamic parameters (EF, EDV, ESV, SV), intra- and interventricular dyssynchrony, as well as in the midsize of perfusion defects. Following long-term CRT, we found increase in LVEF and decrease in average size of perfusion defects in groups of hyperresponders and responders (p < 0.05). Results of SPECT with 123I-BMIPP, performed prior to CRT, showed that nonresponders had more pronounced disturbance of myocardial metabolism compared with the group of hyperresponders (20 vs. 14.7 %, p < 0.05)(72).
c. Internal cardiac defibrillator (ICD)
The Kalmar County Hospita, presented a case report and a selective review of pertinent literature retrieved by a PubMed search, including two up-to-date consensus documents. One-third to two-thirds of all ICD patients receive defibrillation therapy in the final days of their lives. Patients and their physicians rarely discuss deactivating the ICD. Automatic defibrillation therapy in a terminally ill patient with an ICD is painful and distressing, serves no medical purpose, and should be avoided. This issue should be discussed with ICD patients and their families. Institutions caring for terminally ill patients, as well as cardiology units where ICD patients are treated, should develop ethically and legally well-founded protocols for dealing with the question of ICD deactivation(73).
d. Rotary blood pumps
Rotary blood pumps are increasingly recognized as mainstream therapy for severely symptomatic heart failure. Carefully targeted refinements in patient selection and postoperative care have substantially reduced the adverse event burden. The Oxford University Hospitals Trust, John Radcliffe Hospital, suggested that It should focus on the choice between pump versus palliative care for the thousands of patients of all age groups who are judged ineligible for transplantation. Comprehensive healthcare systems must consider contemporary evidence and provide the most symptomatic of heart failure patients with effective care(74).
2.2. Surgical treatments
a. Heart valve repair or replacement.
The aim of the surgery is to relieve symptoms and improve quality of life of patients with congestive heart failure. In the study to o describe the pathophysiology of functional tricuspid regurgitation, summarize the current reports favoring a more aggressive approach toward tricuspid valve surgery, and discuss the emerging role of tricuspid valve annuloplasty with left ventricular assist device (LVAD) implantation, found that the presence of significant tricuspid regurgitation, whether in the context of mitral valve disease or heart failure, should no longer be treated with 'surgical abstention'. Whether the surgical correction of tricuspid regurgitation in left heart disease can definitively improve clinical outcomes should be addressed by prospective clinical trials(75). Other in the study to evaluate the long-term (5-year) safety and efficacy of mitral valve surgery with and without the CorCap cardiac support device (Acorn Cardiovascular, St Paul, Minn) in patients with dilated cardiomyopathy and New York Heart Association class II-IV heart failure, indicated that the data provide evidence supporting mitral valve repair in combination with the Acorn CorCap device for patients with nonischemic heart failure with severe left ventricular dysfunction who have been medically optimized yet remain symptomatic with significant mitral regurgitation(76).
b. Coronary bypass surgery
According to the study by the University of California, in the study to quantify the effects of a novel implantable hydrogel (Algisyl-LVR™) treatment in combination with coronary artery bypass grafting (i.e. Algisyl-LVR™+CABG) on both LV function and wall stress in heart failure patients. The data supportedthe novel concept that Algisyl-LVR™+CABG treatment leads to decreased myofiber stress, restored LV geometry and improved function(77)..
c. Heart transplant
Only for patients with severe congestive heart failure and other treatments have failed. According to the Ohio State University, Columbus, Avoidance of the clinical syndrome of acute right-sided heart failure after heart transplantation is, unfortunately, not possible. Clinical experience and the literature certainly suggest that a significant factor in the successful management of right ventricular (RV) failure is recipient selection. Moreover, threshold hemodynamic values beyond which RV failure is certain to occur and heart transplantation is contraindicated do not exist.Only through careful preoperative planning can this life-threatening condition be managed in the postoperative period(78).
d. Myectomy
Patient with blockage that occurs in hypertrophic cardiomyopathy may meed myectomy, if all medication have failed. There is a report of a 38-year-old woman of Hypertrophic Obstructive Cardiomyopathy, HOCM complicated with lung edema and cardiac arrest due to acute left heart failure. Intraventricular pressure gradient showed 125 mmHg in previous study, and echocardiogram demonstrated evidences suggestive of terminal-staged HOCM. After unsuccessful attempts of intravenous propranolol administration, emergency myectomy of left ventricular outflow tract was carried out. Postoperative course was uneventful, and intraventricular pressure gradient was relieved. The patient is now asymptomatic without medication after 1 years of operation. This case suggests that emergency myectomy may be a choice to relieve refractory congestive heart failure in patient with HOCM(79).
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