CPC YEAR 5 MEDICINE

HEART FAILURE

LECTURER: DR NORZIAN
DATE: 14/4/2017

Chew Han Jia

Ngu Sie Tein
Gan Wan Sin
Nurul Huda
Syamira Aqilah
Case Presentation

Heart Failure
 Patients Data
Name: Yen Kiow
Age: 69 years old
Sex: Male
Race: Chinese
Marital status: Single
Address: Setapak
Occupation: Lorry driver
Date of admission: 4/4/2017
Date of clerking: 5/4/2017
Ward: Ward 6E Hospital Serdang
 History

Chief Complaint:

Mr Yen Kiow, a 69 year-old Chinese

gentleman, with underlying diabetes
mellitus, hypertension and
hypercholestrolemia, u/l ischemic
heart disease with CABG done on
2012, presented with central chest
pain for 2 days prior to admission.
History of Presenting Illness:
2 days ago:
He had episode of chest pain where:
Central
Sudden in onset
Pressing in nature
Not radiating
Occur at rest
Pain score 10/10

Initially, the chest pain was relieved by sublingual GTN.

During the day of admission, he developed another episode
of chest pain which was not relieved upon taking 2 tablets
of GTN. Thus, he seek treatment immediately in HSG.

He did not have palpitation, profuse sweating, nausea,

vomiting and dizziness.
He was just recently discharged from HKL 2 weeks ago
due to decompensated heart failure.

2 weeks ago:
He had shortness of breath and reduced effort
tolerance. Previously he only had slight limitation of
physical activity and he was comfortable at rest, which
his NYHA functional classification was class II. But now
he had SOB at rest, could only climb one flight of stairs
and walk for 50 metres before he developed SOB
which his NYHA was class IV.
He also had paroxysmal nocturnal dyspnoea as he
woke up every night gasping for air. It disturbed his
sleep quality.
He had orthopnea as well. He frequently slept by
sitting on a chair. He could not lie flat due to SOB.
 He had bilateral lower limb swelling first
noticed at his foot and progressively
worsened up to knee level. There were no
pain, redness, itchiness and ulcer noted.
He did not have abdominal distension,
scrotal swelling and facial puffiness.
He was admitted for 5 days and
discharged with medication. After
discharge, his symptoms resolved
partially. However, it worsened 2 days
prior to current admission.
This current admission was his 4th admission due to heart problem.

First hospital admission:

2011 (6 years ago) :

He had first episode of chest pain in 2011. He was admitted to
Hospital Selayang for 2 days. He was then referred to Hospital
Serdang for angiogram. It was done electively after few months
and the result revealed severe 2 vessel disease.

Echocardiogram was done. It showed 27% of left ventricular

ejection fraction and thickened left ventricle.

Cardiac MRI was done, showing overall left ventricle function

impaired and calculated ejection fraction was 26.3%, impaired LV
function and minimal scarring of myocardium.

He was planned for CABG on 6/6/2011. However, due to fully

occupied bed and patient continue smoking, CABG was
postponed twice.
2nd hospital admission for CABG in 2012

20/2/2012 (5 years ago) :

CABG x3 with left internal mammary artery (LIMA)
was done. Transesophageal echocardiography
(TOE) showed akinetic at anteroseptal region, thin
wall, globally hypokinetic and ejection fraction of
35%. The procedure was uneventful.
Echocardiogram was done on day 4 post op. It
showed poor LV function and EF 37%. No
pericardial effusion was seen.
He was discharged on day 6 post op with
medication. (aspirin, digoxin, carvedilol, gliclazide,
metformin and ranitidine)
 Post CABG, he attended follow up once in 3
months for 1 year in HSG. He was then
discharged and referred to nearest KK.
The last echocargiogram done was on
22/2/2013. It showed good LV function with
EF 54%. Normal valve morphology was seen.
He remained asymptomatic after CABG for
past 5 years. He was compliance to his
medications and follow up.
However, he was not compliance to his fluid
restriction of 800ml per day within these few
years. He was told to restrict fluid after CABG
in 2012.
Systemic Review:

Respiratory system: No cough, hemoptysis,

wheezing
Gastrointestinal system: No abdominal pain,
hematemesis, diarrhea, constipation, per rectal
bleeding
Genitourinary system: No dysuria, nocturia,
hematuria, incontinence, frequency, frothy urine
Musculoskeletal system: No bone pain, muscle
pain, no joint pain
Neurological system: No loss of consciousness,
seizure, weakness of limbs
Past Medical History:

He had diabetes mellitus, hypertension and

hypercholestrolemia for 8 years. He was diagnosed
when he visited private clinic for medical check up.
He did not monitor his blood glucose and blood
pressure at home. He went for follow up in KK every
6 months. He was unsure about the range of his
blood glucose and blood pressure. He was
compliance to follow up and medications.
He did not develop complications such as
hypoglycemic episode, stroke, blurry vision,
numbness of limbs and renal problem . He did not
have hospital admission due to diabetes mellitus and
hypertension.
Past Surgical History:

There was no significant past surgical history.

Drug and Allergy History:

Currently he was on aspirin 150mg OD, clopidogrel

75mg OD, simvastatin 20mg ON, bisoprolol
3.75mg OD, trimetazidine 20mg TDS, frusemide
40mg OD, GTN PRN, omeprazole 20mg, isosorbite
dinitrate 10mgTDS, perindopril 2mg OD and
insulatard 20U ON.
He did not have allergy to any medications and
food. He did not take tradisional medication.
Family History:
His parents passed away many years
ago due to unknown causes. His
mother had diabetes mellitus. Both
of them did not have heart problem.
He has 5 siblings and he is the
second child. All his siblings are
healthy.
There was no family history of
cardiac problem, premature cardiac
death and malignancy.
Social History:

He is single and currently stays alone in a flat at first

floor in Setapak with no facility of lift. He had
difficulty in climbing stairs recently due to shortness
of breath. He needed to rest for few minutes after
one flight of stairs.
He worked as lorry driver for 30 years. However he
could not work since 2 weeks ago due to his heart
problem.
He was a smoker for 40 years and he smoked 3
cigarettes per day (6 pack years). He did not take
alcohol.
He did not have financial problem. He did not
exercise frequently.
Summary:

Mr Yen Kiow, a 69 year-old Chinese gentleman,

with underlying diabetes mellitus, hypertension
and hypercholestrolemia for 8 years, underlying
ischemic heart disease with CABG done on
2012, presented with chest pain for 2 days,
associated with worsening PND, orthopnea and
lower limb swelling. His current NYHA functional
classification was class IV. He did not
compliance to fluid restriction. Otherwise, he
did not have abdominal distension, facial
puffiness, yellowish discoloration and urinary
symptoms.
 Physical Examination
General Inspection
Patient was lying comfortably on bed. He
was not in respiratory distress and not in
pain. He did not look pale and jaundice. He
did not appear cachexic.
Vital signs
Blood pressure 138/90 mmHg (Hypertension)
Respiratory rate 19 breaths per min
Heart rate 65 beats per minute
Temperature 37C
SpO2 99%
Peripheral examination
The palms were warm and not in pallor. There
were no clubbing, peripheral cyanosis and
capillary refill time was less than 2 seconds.
There were no signs of infective endocarditis
such as Osler nodes, Janeway lesion and splinter
hemorrhage.
There were no signs of chronic liver disease
such as leuconychia, Depuytrens contracture
and palmar erythema.
The pulse was 65 beats per minute with regular
rhythm and good volume. No radial-radial delay
and radial femoral were noted. There was no
collapsing pulse.
 On eyes examination, there were no
jaundice and no pallor.
Oral hygiene was good with no
central cyanosis.
On lower limbs examination, a scar
was noted on the medial side of right
leg. It was non tender and well
healed. Bilateral lower limbs pitting
edema was noted up to knee level.
No redness, ulcer or discharge were
noted.
Cardiovascular examination
There was no raised jugular venous pressure.
On chest inspection, a sternostomy scar was
noted measuring 13cm. It was well healed
and no keloid formation.
No chest deformity, visible pulsation and
dilated vein were noted.
The apex beat was displaced which was at
left 6th intercostal space in anterior axillary
line.
There were no parasternal heave and thrills
palpable.
 On auscultation, first and second heart
sound were heard over mitral, tricuspid,
pulmonary and aortic area. There were no
murmur and added sound heard.
Bibasal crepitations were heard.
No sacral edema was noted.
Respiratory examination:
There were no signs of pleural effusion such
as stony dullness, reduced breath sound and
reduced vocal resonance.
Abdominal examination:
There was no hepatomegaly noted. Shifting
dullness was negative.
Summary
Yen Kiow, a 69 year-old Chinese
gentleman, with underlying diabetes
mellitus, hypertension and
hypercholestrolemia for 8 years,
CABG done on 2012, presented with
chest pain for 2 days, associated
with worsening PND, orthopnea and
bilateral lower limb swelling. On
examination, the apex beat was
displaced and bibasal crepitations
were heard.
 Provisional Diagnosis

Decompensated heart failure secondary to

myocardial infarction
Points for:
Presented with chest pain for 2 days
Associated with worsening failure symptoms such
as PND, orthopnea and ankle swelling
Risk factors such as diabetes mellitus,
hypertension and hypercholestrolemia for 8 years
Chronic smoker
Apex beat was displaced
Bibasal crepitation was heard
Bilateral lower limbs edema was noted
 Differential Diagnosis
1. Decompensated heart failure secondary to non
compliance to fluid restriction
Points for:
. Presented with worsening failure symptoms
. He was not compliance to fluid restriction as he
drank more than 800ml everyday
.Risk factors such as diabetes mellitus,
hypertension and hypercholestrolemia for 8 years
.Chronic smoker
.Apex beat was displaced
.Bibasal crepitation was heard
.Bilateral lower limbs edema was noted
2. Chronic kidney disease with fluid overload
Points for:
Presented with bilateral lower limb swelling
Risk factors such as diabetes mellitus and
hypertension
Points against:
No urinary symptoms such as frothy urine,
nocturia and polyuria
No previous diagnosed kidney disease
On physical examination, he did not
appear sallow looking, no anemic, and no
scars on abdomen.
3. Chronic liver disease
Points for:
Presented with bilateral lower limbs
swelling
Points against:
No high risk behaviour such as alcohol
abuse and IVDU
No signs of chronic liver disease such as
leuconychia, Depuytren contracture and
palmar erythema
No jaundice, ascites, hepatomegaly and
splenomegaly
 Investigations
1. Creatinine Kinase 4/4/2017
Result: 130U/L (30-200)
Impression: Normal

2. Troponin T 4/4/2017
Result: 26.000ng/L (0.000-14.000)
Impression: High
3. Full Blood Count 4/4/2017
- To look for anemia which might be cause of
heart failure
Parameter Result Normal Range Impression
Red blood cell 5.08 x 10^12/L 4.50-5.50 N
Hemoglobin 14.5g/dL 13.0-18.0 N
Hematocrit 44.8% 40.0-54.0 N
MCV 88.2fl 76.0-96.0 N
MCH 28.5pg 27.0-32.0 N
MCHC 32.4g/dL 30.0-50.0 N
RCDW 13%
Platelet 179 x 10^9/L 150-400 N
MPV 10.90fL
White blood cell 9.2 x 10^9/L 4.00-11.0 N
Neutrophil % 62% 40-75 N
Absolute 5.71 x 10^9/L 2.00-7.50 N
neutrophil
Parameter Result Normal Range Impression
Lymphocyte % 26% 20-45 N
Absolute 2.40 x 10^9/L 1.50-4.00 N
lymphocyte
Monocyte % 10% 2-10 N
Absolute 0.740 x 10^9/L 0.200-0.800 N
Monocyte
Eosinophil % 1% 1-6 N
Absolute 0.110 x 10^9/L 0.040-0.400 N
eosinophil
Basophil % 1% N
Absolute 0.070 x 10^9/L 0.020-0.100 N
Basophil
Impression: No anemia was noted. All results
were normal.
4. Renal Profile 4/4/2017
- To rule out chronic kidney disease causing
bilateral leg swelling

Parameter Results Normal Impression

Range

Urea 8.8mmol/L 3.2-9.2 N

Sodium 139mmol/L 136-145 N

Potassium 3.7mmol/L 3.5-5.1 N

Chloride 106mmol/L 98-107 N

Creatinine 82umol/L 62-115 N

Impression: Normal kidney

function.
5. Liver Function Test 4/4/2017

Paramete Result Normal Impressio

r range n
Total 60g/L 64-83 Low
Protein
Albumin 33g/L 35-50 Low
Bilirubin 19.6umol/L 3.4-20.5 N
ALT 37U/L N
ALP 71U/L 40-150 N
AST 34U/L 5-34 N

Impression: Hypoalbuminemia
6. Coagulation Profile 5/4/2017
- To do for preparation of angiogram

Parameter Result Normal Impressio

range n
PT 11.3 9-12 N
APTT 39.9 25-40 N
INR 1.19
APTT ratio 2.4

Impression: Normal coagulation

profile
7. Fasting blood glucose 4/4/2017
Result: 8.01mmol/L (<7.0)
Impression: High

8. ECG 4/4/2017

9. Chest X Ray 4/4/2017

10. Echocardiogram 22/2/13
Good LV Function with EF 54% by M-Mode
RWMA Present
Mid Anterior Septal Wall Seen Hypokinetia
Normal Valve Morphology by CFM
No PE Seen
No LV Clot / No Thrombosis Seen
 TIMI risk score
Age 65
3 CAD risk factors
Known CAD
ASA in past 7 days
At least 2 angina episode in past 24 hrs
Raised serum cardiac biomarkers
ST deviation in ECG

TIMI risk score 5 : High risk

 Final Diagnosis
Decompensated heart failure
secondary to NSTEMI with TIMI risk
score 5
 Management
Acute management :
Secure the ABC
Oxygen supplement
IV morphine 2mg with IV anti-emetics
Anti-platelet : Crushed aspirin 300mg and clopidogrel
300mg
S/c fundaparinox 2.5mg OD
IV lasix 40mg BD
Continuous monitoring of ECG and cardiac enzymes.
Strict i/o charting and daily weight
ROF 800mls/day
 Femoral Coronary Angiogram and Graft
Study was done on 2nd day of admission
(5/4/2017)
RFA 6FS JR 4 JL4

LMS: smooth
LAD: CTO prox LAD
LCx: CTO prox LCx
RCA: mid RCA 95%

SVG to OM patent
SVG to PDA stump
LIMA to LAD patent

Impressions: 3VD with successful adhoc PCI

to RCA.
 Discharge on day 3 of admission and
given TCA for echocardiogram after 6
months.
He was asked to continue his old
medication. Dual anti-platelet
therapy was continued for one year.
THEORY:
HEART FAILURE
Heart Failure Definition

HF as a complex clinical syndrome that

results from structural or functional
impairment of ventricular filling or
ejection of blood, which in turn leads to
the cardinal clinical symptoms of
dyspnea and fatigue and signs of HF,
namely edema and rales.

Source: American College of Cardiology Foundation

(ACCF)/
American Heart Association (AHA) guidelines
 Epidemiology
Prevalence:
Overall: 3-20 per 1000 population.

>65 years: 100 per 1000 population.

HF is an important cause of hospitalization

6% - 10% of all acute medical admissions in Malaysia.

It is also an important cause of hospital re-admissions.

About 25% of patients with HF are readmitted within

30 days for acute decompensation.

Source: CPG Management of Heart Failure 3rd

Ed (2014)
 Etiologies of Heart
Failure
Depressed Ejection Fraction
(<40%) Nonischemic dilated cardiomyopathy

Coronary artery disease Familial/genetic

Myocardial infarctiona disorders
Myocardial ischemiaa Infiltrative disordersa
Chronic pressure overload Toxic/drug-induced damage
Hypertension Metabolic disordera
Obstructive valvular disease
Chronic volume overload
Viral
Chagas disease
Regurgitant valvular disease
Disorders of rate and rhythm
Intracardiac (left-to-right)
shunting Chronic
Extracardiac shunting bradyarrhythmias
Chronic lung disease Chronic
Cor pulmonale
tachyarrhythmias
Pulmonary vascular disorders
Preserved Ejection Fraction
(>4050%)
High-Output States
Pathologic hypertrophy
Metabolic disorders
Primary (hypertrophic
cardiomyopathies) Thyrotoxicosis
Secondary (hypertension) Nutritional disorders (beriberi)
Aging Pregnancy
Restrictive cardiomyopathy
Excessive blood flow requirements

Infiltrative disorders Systemic

(amyloidosis, sarcoidosis)
Storage diseases
arteriovenous
(hemochromatosis) shunting
Fibrosis Chronic anemia
Endomyocardial disorders
Causes of acute decompensation in
chronic heart failure

Acute myocardial infarction/myocardial ischemia

Arrhythmias (e.g. atrial fibrillation)
Uncontrolled Blood Pressure
Infections (e.g. pneumonia)
Non-compliance to medications
Excessive fluid and salt intake
Anemia
Development of renal failure
Adverse effects of drug therapy (e.gNSAIDs)
Pathophysiology
Starlings Law:
Ventricular
performance is
related to the
degree of
myocardial
stretching.
(preload CO)
 Compensatory mechanisms
(To maintain CO-to maintain arterial pressure &
perfusion of vital organs):

myocardial contractility activation of

neurohumoralsystem
cardiac workload
+RAAS release
Cell stretching cathecolamines
vasoconstriction, (AD + NorAD)
Cardiac hypertrophy sodium and water
cardiac dilatation retention
HR

blood volume CO
& blood pressure
 Left Ventricular
Remodelling
Changes in LV
mass

volume

shape

composition of the heart

that occur after cardiac injury and/or abnormal hemodynamic loading conditions.
Complications
In advanced heart failure, the following may occur:

Renal failure - poor renal perfusion due to low cardiac output

Hypokalaemia - result of treatment with potassium-losing

diuretics or hyperaldosteronism

Hyperkalaemia - may be due to the effects of drugs which

promote renal resorption of potassium, in particular the
combination of ACE inhibitors (or angiotensin receptor blockers)
and mineralocorticoid receptor antagonists.

Hyponatraemia - a feature of severe heart failure , caused by

diuretic therapy, inappropriate water retention
 Impaired liver function - hepatic venous congestion and
poor arterial perfusion

Thromboembolism
Deep vein thrombosis and pulmonary embolism may occur due to
the effects of a low cardiac output and enforced immobility.
Systemic emboli occur in patients with atrial fibrillation or flutter,
or with intracardiac thrombus complicating conditions such as
mitral stenosis, MI or left ventricular aneurysm.

Atrial and ventricular arrhythmias - related to electrolyte

changes (e.g. hypokalaemia, hypomagnesaemia), the
underlying cardiac disease, and the pro-arrhythmic effects of
sympathetic activation.
Symptoms of heart
failure
Shortness of breath
Leg swelling
Reduce effort tolerance
Orthopnea
Paroxysmal nocturnal dyspnoea
Nocturnal cough (+/- pink frothy
sputum)
Signs of heart failure

Tachycardia
Narrow pulse pressure <30
Raise jugular venous pressure
Ankle oedema
Pulmonary crackles
Displaced apex beat
Presence of 3rd heart sound
Peripheral oedema
Ascites
Hepatomegaly
Types of heart failure

Left sided vs right sided

Reduced ejection fraction vs
preserved ejection fraction
Acute heart failure vs Chronic
heart failure
###Congestive
cardiac failure
- If patient has both
right and left
ventricular failure
 Heart failure with preserved
Heart failure with

ejection fraction

reduced ejection
fraction Normal systolic
function (LVEF 50%)
40%
with diastolic
dysfunction ------>
- The cardiac output is
impair in the left
reduced due to
depressed myocardial
ventricular filling due
contractility to decreased
relaxation (early
- Therefore, there will
be hemodynamic
diastole) or reduced
alteration and compliance (early to
structural changes late diastole) -------->
within the myocardium elevated the filling
and vessels pressure
Pathophysiology classification of HF

I Heart failure with reduced ejection fraction 40%

II Heart failure with preserved ejection fraction 41-
49%
(borderline)
III Heart failure with preserved ejection fraction 50%
 Acute heart failure Chronic heart failure

Rapid onset of
Chronic states
when patient has
symptoms and
stable symptoms
signs of heart
failure due to
Acute
acute precipitating
factors may cause
deterioration of
acute cardiac
cardiac function
decompression
New York Heart Association Functional Classification

Class Description 1 year

mortality
Class I No limitation. Ordinary physical activity does 5-10%
not cause fatigue, dyspnoea or palpitation
Class II Slight limitation of physical activity. Such 10-15%
patient comfortable at rest. Ordinary
physical activity results in fatigue,
palpitation, dyspnoea or angina
Class III Marked limitation of physical activity. 15-20%
Although patients are comfortable at rest,
less than ordinary activity will lead to the
symptoms
Class IV Inability to carry on any physical activity w/o 20-50%
discomfort. Symptoms of CCF is present at
rest. With any physical activity, increased
discomfort is experienced
INVESTIGATION
 Basic
investigations
12 lead ECG
-identify heart rate, rhythm,
QRS morphology, evidence of
ischemia, LVH and arrhythmias.
Chest radiograph
-identify pulmonary congestion,
cardiac size and shape, and
other underlying lung
pathology.
Blood tests
-FBC, renal function, liver
function, serum glucose, and
lipid profile
Urinalysis
-proteinuria, glycosuria.
Other
investigations
Echocardiography
-LV chamber size, volumes, and
systolic function
-LV wall thickness, scarring
-valvular structure and function
-congenital cardiac defects
Natriuretic peptides( BNP)- useful in
2 situations:
-emergency setting, useful rule
out test for patient with acute
dyspnea. If <100pg/ml unlikely AHF.
- high level supports the diagnosis
of AHF & very high correlate with
the severity of HF and adverse
outcomes
 Additional Ix when
indicated
Blood tests:
-serum cardiac markers(troponins,CK,CKMB)
-TFT, CRP

Tests for myocardial ischemia and/or viability:

-treadmill exercise test
-stress echocardiography

Invasive tests:
-coronary angiography
-cardiac catheterization
-endomyocardial biopsy
CHEST X-RAY
Mnemoni
c: ABCDE
bilateral perihilar
or partial bat-
wing appearance
of the alveolar
filling process,
which in this
case is confined
entirely to the
mid lung zones
 marked
interlobular septal
thickening with
septal lines
(Kerley B lines)
and reticular
opacities in the
lung periphery.
This is a typical
chest x-ray of a
patient in
severe CHF.
Note the
cardiomegaly,
alveolar edema,
and haziness of
vascular
margins.

Prominent
upper lobe
vessels on X-
ray chest
(CXR) PA
view
suggests
pulmonary
venous
Prominen
t upper
lobe
blood
vessels
Pleural
effusion
Left
pleural
effusio
n
MANAGEMENT
Acute Heart Failure
Principles of Mx:
Rapid recognition of the condition

Identification and stabilization of life

threatening hemodynamics
Identification and treatment of the

underlying cause and precipitating/

aggravating factors
Relief of clinical symptoms and signs
ACUTE HEART FAILURE
Assess ABCD

Sit patient upright

Give oxygen (high flow mask,

CPAP 5-10mmHg) aim SpO2 >
95%

Monitor blood pressure

SBP >100 SBP <100

mmHg mmHg
 SBP >100 SBP <100
mmHg mmHg

IV Noradrenaline: 0.02
1mcg/kg/min (1st line)
IV GTN 2-5mg IV Adrenaline: 0.05-
IV Frusemide 40-100mg 0.1mcg/kg/min
IV Morphine sulphate 1-3 mg Dopamine: 5 15mcg/kg/min
bolus (repeated up to max or
Dobutamine: 2
10mg) + Maxolon 10 mg
20mcg/kg/min
*Until desire SBP achieved
(SBP>100 mmHg)
Send urgent investigations
concomitantly:

ECG
Imaging: Chest X-ray
Blood ix: FBC, RP, BUSE, ABG,
haemoglobin, urea, creatinine, cardiac
enzymes
Echocardiography
**If there is improvement in patient
condition, continue the oral mediations.
Source:
Management of
heart failure, 3rd
 CHRONIC HEART
FAILURE 2. PHARMACOLOGICAL
1. NON
MANAGEMENT
PHARMACOLOGICAL
a) Diuretics
MEASURES
b) Angiotensin Converting
These include the Enzyme Inhibitors (ACE-I)
following: c) -Blockers
a) Education d) Mineralocorticoid
Receptor Antagonists
b) Diet & Nutrition (MRA)
c) Lifestyle e) Angiotensin II Receptor
Blockers (ARB)
d) Exercise
f) Ivabradine
e) Sleep Disorders g) Digoxin
f) Social Support h) Anti-Coagulation Therapy
Cont.
3. Device Therapy in
HF 4. Surgery for HF

Cardiac Resynchronization Therapy Revascularization Procedures

(CRT) Valve Surgery
Implantable Cardioverter Defibrillator LV Reduction Surgery
(ICD) LV Assist Devices
Combined Biventricular Pacing with
ICD Capabilities

5. HEART
TRANSPLANTATION
References
1. Management of Heart Failure, 3rd Edition
CPG 2014.
2. Sarawak Handbook of Emergencies, 3rd
Edition.
3. Harrisons Principles of Internal
Medicine, 19th Ed.
4. Davidsons Principle and Practice of
Medicine, 22nd Ed