Left Ventricular Failure: A Complete Clinical Guide

Left Ventricular Failure: A Complete Clinical Guide

Question. Describe clinical features, investigation, and treatment of left ventricular failure.
Or
Write short note on left ventricular failure.

Answer.

Left ventricular failure is defied as failure to maintain an effctive ventricular output for a given pulomonary venous or left atrial pressure or can do so only at the expense of an elevated left atrial filing pressure.

Left Ventricular Failure: A Complete Clinical Guide

Causes left ventricular failure.

1. Left ventricular outflw obstruction:

1. Systemic hypertension
2. Aortic valvular stenosis
3. Idiopathic hypertrophic subaortic stenosis
4. Coarctation of aorta

2. Left ventricular inflw obstruction:

1. Mitral stenosis
2. Left atrial myxoma
3. Endomyocardial firosis with stif left ventricle

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3. Left ventricular volume overload:

1. Mitral valve prolapsed
2. Mitral regurgitation
3. Aortic regurgitation (rheumatic and non­rheumatic)
4. Ventricular septal defect
5. Patent ductus arteriosus
6. High output states
7. Papillary muscle dysfunction

4. Reduced left ventricular contractility:

1. Cardiomyopathy predominantly involving left
   ventricle
2. Anterior wall myocardial infarction
3. Left ventricle endocarditis

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Clinical Features left ventricular failure.

1. Progressive dyspnea is the earliest sign of left heart failure.
2. Presence of orthopnea due to increase in venous return during recumbent position.
3. Attcks of breathlessness which occur at night and awaken the patient, i.e. paroxysmal nocturnal dyspnea.
4. In severe heart failure there is a periodic respiration in which periods of hyperpnea alternate with apnea, i.e.
   Cheyne­Stokes respiration.
5. Presence of dry cough which is disturbing.
6. Presence of oliguria and nocturia.
7. Presence of tachypnea because of stif congested lungs and there is also presence of tachycardia because of hypoxia created due to pulmonary congestion.
8. Presence of fatigue and weakness.
9. Cerebral symptoms are present, i.e. altered mental state, diffilty in concentration, memory impairment, headache, insomnia and anxiety

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Physical Findings left ventricular failure.

1. Extremities can be cold or pale.
2. There is presence of tachycardia and rapid pulse rate.
3. Presence of profuse sweating
4. Presence of tachypnea, i.e. increased respiratory rate
5. There is low pulse volume or pulsus alternans can be present.
6. Presence of central cyanosis.
7. Third heart sound can be heard.
8. There is presence of basal pulmonary rales or crackles.
9. Presence of an expiratory wheezing.
10. Presence of oliguria.
11. Hydrothorax or pleural effsion is present.
12. Presence of anxiety and depression.
13. Urine can be ofhigh specifi gravity and shows proteinuria.
14. Presence of massive cardiomegaly.

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Investigations left ventricular failure.

1. Electrocardiogram:

1. Presence of left ventricular hypertrophy and left atrial hypertrophy in patients having aortic valvular diseases as well as mitral regurgitation.
2. Presence of ST­T changes in patients having disease of myocardium.

2. Chest X-ray:

1. Presence of enlargement of cardiac shadow.
2. Presence of pulmonary venous congestion which extends from hilum to periphery.
3. There is presence of Kerley’s lines because of interstitial edema.

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3. Echocardiogram:

1. Increase in the left ventricular dimensions
2. Left ventricular end diastolic pressure or volume of both can be high
3. Increase in the cardiac output and stroke volume
4. There is reduction in ejection fractions

4. Other tests:

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Treatment left ventricular failure.

1. First aim of treatment is to fid and remove the precipitating cause, i.e. arrhythmia or an intercurrent infection.
2. Patient should be kept in sitting position, with legs hanging alongside of the bed, i.e. upright posture should be maintained.
3. Diet: Salt­free diet is given till left ventricular failure improves and later on restricted salt diet is given.
4. Sedatives: Morphine should be given in doses of 5 to 10 mg along with an anti­emetic, i.e. metoclopramide 10 mg IV and repeat the drug as soon as desired.
5. Oxygen: About 60% of oxygen is given by facemask under positive pressure. It should be given as 6 to 8 lts / min through Wolfe’s botte.
6. Loop diuretics: Furosemide 40–100 mg IV should be given.
7. IV sodium nitroprusside 20–30 µg/min or IV nitroglycerine should be given in patients whose systolic blood pressure is more than 100 mm of Hg.
8. Digitalis: If digoxin is not used previously, the three fourth of full dose, i.e. 0.5 to 1 mg is given as IV dose.
9. Bronchodilators: At times, aminophylline or theophylline in dose of 250 to 500mg IV decreases bronchoconstriction.
10. In cases of severe left ventricular failure, inotropes can be given.
11. If all the above measures failed, then rotating tourniquet should be applied to extrimities.
12. Intra-aortic balloon counterepulsation: It is used in acute left ventricular failure during cardiac procedures or cardiac repairs