May-Thurner syndrome: A vascular abnormality encountered during electrophysiologic study

In the course of clinical practice the electrophysiologist may encounter a variety of vascular abnormalities which are important to recognize, as they may impact upon the health and welfare of the patient. We describe a case of iliac vein compression (May-Thurner) syndrome and review its etiology, diagnosis, significance, and treatment.     

米力农改善心脏手术后心力衰竭所致低心排血量综合征患者的肾功能

目的评价正性肌力药米力农在治疗体外循环(CPB)心脏手术后心力衰竭所致低心排血量综合征时对患者肾脏的影响。方法选取2018年1月至2020年6月间在我院心胸外科治疗的CPB心脏手术患者,在患者心脏停跳后30 min(基线期)和60 min(治疗后)进行肾脏和全身血流动力学检测。CPB术后30 min发生低心排血量综合征患者接受米力农治疗,根据患者CPB心脏手术后是否应用米力农,将患者分为米力农组(n=59)和对照组(n=82)。比较两组患者血流动力学指标和肾血流动力学指标基线期值、治疗后值、治疗后较基线期变化值。比较治疗后两组患者预后指标及并发症发生率。结果治疗后米力农组患者心脏指数变化值[(0.55±0.26) L/(min·m²) vs.(-0.35±0.28) L/(min·m²),t=19.394,P <0.001]、心搏容量指数变化值(t=8.776,P <0.001)、氧释放系数变化值(t=8.143,P <0.001)、混合静脉血氧饱和度变化值(t=9.935,P <0.001)与对照组比较显著提高,周身血管阻力指数变化值(t=10.574,P <0.001)、肺血管阻力指数变化值(t=10.654,P <0.001)与对照组比较显著降低。治疗后米力农组患者肾血流量变化值[(117.30±153.82) m L/min vs.(-63.73±157.64) m L/min,t=6.795,P <0.001]、肾脏供氧量变化值(t=4.248,P <0.001)与对照组比较显著提高,肾小球滤过分数变化值(t=6.382,P <0.001)、肾血管阻力变化值[(-0.06±0.05) mm Hg/(m L·min) vs.(0.03±0.06) mm Hg/(m L·min),t=9.407,P <0.001]和肾氧摄取率变化值(t=7.625,P <0.001)与对照组比较显著降低。结论米力农在心脏手术后早期用于治疗急性心力衰竭所致低心排血量综合征,可以增加患者心输出量和肾血流量,扩张肾血管。米力农可以改善患者易感肾脏的氧合作用,但不会引起肾小球滤过率的显著变化。     

髂静脉受压综合征病因及影像学进展

髂静脉受压综合征是常见的临床综合征之一,诊断标准尚未统一。目前影像学检查在髂静脉综合征的诊断中具有重要价值,主要包括彩色多普勒超声、CT、MRI和血管造影等。本文针对髂静脉受压综合征的病因学及影像学研究进展进行综述。     

Acute deep venous thrombosis induced by May-Thurner syndrome after spondylolisthesis surgery: A case report and review of literature

BACKGROUNDDeep venous thrombosis (DVT) is a serious complication of lumbar spine surgery. Current guidelines recommend pharmacomechanical prophylaxis for patients at high risk of DVT after spine surgery. May-Thurner syndrome (MTS), a venous anatomical variation that may require invasive intervention, is an often overlooked cause of DVT. To date, no case reports of symptomatic MTS caused by isthmic spondylolisthesis or subsequent acute DVT after posterior lumbar surgery have been published.CASE SUMMARYWe here present a case of a patient who developed acute DVT 4 h after spondylolisthesis surgery, and MTS was only considered after surgery, during a review of a gynecological enhanced computed tomography image taken before the procedure.CONCLUSIONIn conclusion, clinicians should consider MTS in the presence of a dangerous triad: spondylolisthesis, elevated D-dimer levels, and sonographically indicated unilateral deep vein dilation. Consultation with a vascular surgeon is also essential to MTS management.     

Postcardiac surgery low cardiac output syndrome: dopexamine or dopamine?

Objective: To compare the efficacy and safety of dopexamine with dopamine in the treatment of low cardiac output syndrome after cardiac surgery. Design: This was a multicentre, double-blind, randomised, parallel-group study conducted in intensive care units at centres in Holland and Belgium. Patients were randomised to receive dopexamine (up to 2.0 μg/kg per min) or dopamine (up to 6.0 μg/kg per min) for 6 h after low cardiac output syndrome was confirmed. Results: 70 patients were enrolled (35/group) and there was no significant difference in the operative procedures or haemodynamics at entry into the study. Clinical efficacy, defined as a cardiac index > 2.5 l/min per m² with urine production > 0.5 ml/kg per h and stable haemodynamics for two consecutive readings 1 h apart, was achieved by 90 and 87 % of patients in the dopexamine and dopamine groups, respectively. However, more patients maintained clinical efficacy over the 6-h period in the dopexamine group, which was statistically significant at 1–2 h and approached significance at all other time points. Safety was assessed by comparing the adverse events and concomitant medication. Fewer patients on dopexamine had cardiac events compared with dopamine-treated patients (25 vs 38 events), although there was no difference in the pattern of rhythm disturbance. Fewer patients in the dopexamine group required concomitant vasodilating drugs (18 vs 30). Conclusion: Taking the proportion of patients achieving clinical efficacy, the time to achieve it and the maintenance of it along with the adverse event profile, dopexamine was shown to be an effective and safe drug to use in the management of low cardiac output syndrome after coronary artery bypass graft surgery and may be superior to dopamine. Received: 19 November 1996 Accepted: 8 July 1997     

心力衰竭患者血浆心钠素水平与左心功能关系的临床研究

目的:探讨血浆心钠素(ANP)水平与心力衰竭患者临床心功能变化之间的关系.方法:采用特异性放免法测定心衰患者血浆ANP水平,同时采用NYHA心功能分级和超声心动图检查评定患者左心功能.结果:随心功能恶化,血浆ANP水平呈上升趋势.各级心功间差异均有显著性意义(P＜0.05).经抗心衰药物综合治疗后,ANP水平降低(P＜0.01).ANP水平与左心室射血分数(LVEF)、左心室短轴缩短率(ΔD%)呈负相关;与左室收缩末内径(LVSd)、左室舒张末内径(LVDd)呈正相关.结论:心钠素在心力衰竭的进展中,其血中浓度与心衰程度密切相关,可用于监测心衰程度.     

Transpulmonary cardiac output measurement in a rat model of cardiac arrest and CPR: Impact of vascular access

Objective

The present study investigated the impact of the vascular access site for cardiac output (CO) measurement by thermodilution on survival and neurohistopathological injury in a rat model of cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). Secondary the influence of the vascular access site on cardiac output measurements was examined.

Methods

Rats underwent asphyxial CA and CPR. Thermocouple probes were either placed via the femoral artery into the bifurcation of abdominal aorta/iliac artery (Femoral) or via the carotid artery into the aortic arch (Carotid). CPR was initiated after 9 min CA. Local cerebral blood flow (lCBF) and CO were assessed for 120 min after restoration of spontaneous circulation. Neurohistopathological injury was determined using Fluoro-Jade B staining.

Results

Survival was reduced in the Carotid group compared to the Femoral group (p < 0.01). Fluoro-Jade B staining in the hippocampus showed no difference between CA groups. CO measurements were comparable between femoral and carotid artery access sites. lCBF revealed a delayed hyperperfusion in the Carotid group only.

Conclusions

The present study demonstrates the influence of the vascular access site for placing thermocouple probes for CO measurement on animal survival after CA/CPR. CO did not differ between the two access sites with consequential different detection sites. Use of the femoral access for CO measurement is recommended for long-term survival after CA/CPR.     

左心室辅助装置在心脏术后低心排综合征的临床应用

心脏术后低心排综合征是心脏手术常见并发症,发生率为0.2%～6%,严重影响手术预后,其中部分患者需要左心室辅助装置(left ventricular assist device,LVAD)支持治疗。LVAD是循环支持的一种机械辅助方式,在严重低心排综合征治疗中,〗通过维持和增加循环量,保障和改善器官组织灌注并减轻左心负荷,为减轻心肌水肿,恢复心肌正常代谢和心脏功能赢得有效时间。果断及时使用LVAD是抢救成功的关键。仔细操作、合理抗凝、合理调整辅助流量等是降低并发症的重要措施。     

直接法多层螺旋CT髂静脉成像诊断髂静脉压迫综合征

目的 探讨MSCT静脉成像(MSCTV)对髂静脉压迫综合征(IVCS)的诊断价值。 方法 对28例临床怀疑IVCS的患者先后行下肢深静脉顺行造影及直接法髂静脉MSCTV检查,评价两种方法对髂静脉的显示能力;以DSA或手术结果为"金标准",计算并比较两种检查方法诊断IVCS的敏感度及特异度。 结果 28例中,经直接法髂静脉MSCTV检查,髂静脉显示清晰26例,显示不清2例;经下肢深静脉顺行造影检查,髂静脉显示清晰19例,显示不清9例;差异有统计学意义(χ²=5.543,P=0.019)。直接法髂静脉MSCTV对IVCS的诊断敏感度及特异度分别为95.65%(22/23)、80.00%(4/5),下肢深静脉顺行造影的诊断敏感度及特异度分别为65.22%(15/23)、80.00%(4/5),敏感度差异有统计学意义(P=0.022)。 结论 直接法髂静脉MSCTV诊断IVCS具有较高敏感度,有助于检出IVCS。     

82例心力衰竭患者应用利尿剂的护理

利尿剂是心力衰竭患者临床治疗中的常用药物,但利尿剂在治疗的同时,常伴有一些不良反应,而心力衰竭患者又需长期反复应用利尿剂,如观察、处理不及时,会影响治疗效果,导致疾病的恶化。本文82例心力衰竭患者应用利尿剂期间,通过全面的评估、个体化的健康宣教、严密的观察和有效的护理干预,确保了患者的用药安全和用药效果,达到了治疗目的。本组除3例因多脏器衰竭死亡外,其余病例均无不良反应,好转出院。     

IV milrinone for cardiac output increase and maintenance: comparison in nonhyperdynamic SIRS/sepsis and congestive heart failure

Objective: To characterize the effect of the phosphodiesterase inhibitor (PDEI) milrinone in adult patients with a non-hyperdynamic condition during the course of the systemic inflammatory response syndrome (SIRS) or sepsis when compared with patients with congestive heart failure (CHF). PDEIs are potent inhibitors of cytokine production and expression. We hypothesized that there might be an outstanding beneficial effect of PDEIs in the setting of SIRS/sepsis. Design: Prospective, open labeled, protocol-driven pilot study. Patients: Nine patients with a non-hyperdynamic hemodynamic condition during SIRS/sepsis (group 1) and seven patients with CHF (group 2) requiring inotropic support. All patients were having heart disease. All patients had a combination of various catecholamines at the time of inclusion in the study and had received fluid resuscitation to an extent that left ventricular stroke work index (LVSWI) did not increase further. Intervention: Milrinone infusion at a rate of 0.5 μg/kg per min in addition to preexisting catecholamine therapy. Measurements and results: Measurements of cardiac index (CI; thermodilution) and calculation of vascular resistance and LVSWI was done every 8 h for at least 40 h during milrinone infusion. CI and LVSWI significantly increased in both groups (p < 0.001 and p = 0.006, respectively). There were no significant differences between groups in these parameters (p > 0.11 and p > 0.13, respectively). The LVSWI increase occurred while there was a decrease in pulmonary capillary wedge pressure, suggesting a true and comparable improvement in cardiac function relatively independent of loading conditions. Preexisting catecholamines had to be increased in both groups (NS). Milrinone had to be discontinued in one patient due to hypotension. Conclusion: Milrinone administration is feasible in selected patients with a non-hyperdynamic condition during SIRS/sepsis and with preexisting heart disease. Under the conditions of this study, milrinone was no better in terms of CI and LVSWI maintenance in septic cardiac dysfunction when compared with CHF. These results do not necessarily extend to other cohorts with no preexisting heart disease. Received: 23 November 1998 Final revision received: 23 February 1999 Accepted: 6 April 1999     

Cardiac output and cardiac index measured with cardiovascular magnetic resonance in healthy subjects,elite athletes and patients with congestive heart failure

Background

Cardiovascular Magnetic Resonance (CMR) enables non-invasive quantification of cardiac output (CO) and thereby cardiac index (CI, CO indexed to body surface area). The aim of this study was to establish if CI decreases with age and compare the values to CI for athletes and for patients with congestive heart failure (CHF).

Methods

CI was measured in 144 healthy volunteers (39 ± 16 years, range 21–81 years, 68 females), in 60 athletes (29 ± 6 years, 30 females) and in 157 CHF patients with ejection fraction (EF) below 40% (60 ± 13 years, 33 females). CI was calculated using aortic flow by velocity-encoded CMR and is presented as mean ± SD. Flow was validated in vitro using a flow phantom and in 25 subjects with aorta and pulmonary flow measurements.

Results

There was a slight decrease of CI with age in healthy subjects (8 ml/min/m² per year, r² = 0.07, p = 0.001). CI in males (3.2 ± 0.5 l/min/m²) and females (3.1 ± 0.4 l/min/m²) did not differ (p = 0.64). The mean ± SD of CI in healthy subjects in the age range of 20–29 was 3.3 ± 0.4 l/min/m², in 30–39 years 3.3 ± 0.5 l/min/m², in 40–49 years 3.1 ± 0.5 l/min/m², 50–59 years 3.0 ± 0.4 l/min/m² and >60 years 3.0 ± 0.4 l/min/m². There was no difference in CI between athletes and age-controlled healthy subjects but HR was lower and indexed SV higher in athletes. CI in CHF patients (2.3 ± 0.6 l/min/m²) was lower compared to the healthy population (p < 0.001). There was a weak correlation between CI and EF in CHF patients (r² = 0.07, p < 0.001) but CI did not differ between patients with NYHA-classes I-II compared to III-IV (n = 97, p = 0.16) or patients with or without hospitalization in the previous year (n = 100, p = 0.72). In vitro phantom validation showed low bias (−0.8 ± 19.8 ml/s) and in vivo validation in 25 subjects also showed low bias (0.26 ± 0.61 l/min, QP/QS 1.04 ± 0.09) between pulmonary and aortic flow.

Conclusions

CI decreases in healthy subjects with age but does not differ between males and females. We found no difference in CI between athletes and healthy subjects at rest but CI was lower in patients with congestive heart failure. The presented values can be used as reference values for flow velocity mapping CMR.     

Hypereosinophilic syndrome: endomyocardial biopsy versus echocardiography to diagnose cardiac involvement

Objective: To compare echocardiograms and endomyocardial biopsies to diagnose cardiac involvement in hypereosinophilic syndrome.

Methods: We examined the agreement between echocardiography and endomyocardial biopsies to detect cardiac involvement in hypereosinophilic syndrome by reviewing cases identified as hypereosinophilia or hypereosinophilic syndrome in Mayo Clinic databases from January 1978 through June 2009. Single-organ cases of eosinophilia such as eosinophilic fasciitis and eosinophilic gastroenteritis were excluded. We recorded echocardiogram and endomyocardial biopsy results including biopsy staining for eosinophil granule major basic protein (if performed). Clinical and laboratory features documented included presenting symptom(s), maximum total eosinophil count, dose of prednisone (if any) and eosinophil count at the time of endomyocardial biopsy, cardiac enzymes, serum tryptase level, electrocardiogram result, the result of testing for the FIP1L1-PDGFRA fusion gene, complications associated with the biopsy procedures and available follow-up information.

Results: From a total of 387 patients’ records screened 288 met the criteria for hypereosinophilic syndrome and of these 240 had echocardiograms. Among these patients there were 138 normal echocardiograms, 67 had echocardiograms without findings of hypereosinophilic syndrome but with one or more other abnormalities, and 35 had echocardiograms with findings consistent with hypereosinophilic syndrome. Twenty-five patients from this group of 35 patients had both echocardiogram and endomyocardial biopsy. In 15 patients there was agreement between both endomyocardial biopsy and echocardiography as to the presence (n = seven) or absence (n = eight) for findings of cardiac involvement. In 10 of 25 patients test results diverged: 3 patients with positive echocardiographic changes did not have confirmatory findings by endomyocardial biopsy and seven patients with positive biopsy findings had echocardiograms without findings of hypereosinophilic syndrome.

Conclusions: Echocardiograms and endomyocardial biopsies agree for presence or absence of cardiac involvement 60% of the time. Endomyocardial biopsy detected cardiac involvement in 7 patients in whom the echocardiogram was negative for findings of hypereosinophilic syndrome.     

Early detection (9+6 weeks) of cardiac failure in a fetus diagnosed as Turner syndrome by 2D transvaginal ultrasound‐guided coelocentesis

A 28‐year‐old woman was diagnosed by transvaginal ultrasound at 9+6 weeks with early fetal cardiac failure (hydrothorax and bradycardia). Doppler analysis of ductus venosus showed a negative A‐wave pattern. The follow‐up sonogram obtained at 11+6 weeks documented a missed abortion. A transvaginal ultrasound‐guided coelocentesis was performed under local cervical anesthesia before uterine suction and 8 mL of clear extracoelomic fluid were successfully aspirated. Cytogenetic analysis demonstrated a 45,X karyotype. Ultrasound and Doppler waveform analysis of ductus venosus allowed early diagnosis of fetal cardiac failure. Coelocentesis may be the method of choice for early fetal karyotyping and may be used in the future to induce immunologic tolerance. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2009.     

Nurse-determined assessment of cardiac output. Comparing a non-invasive cardiac output device and pulmonary artery catheter: A prospective observational study

Background

The accurate measurement of Cardiac output (CO) is vital in guiding the treatment of critically ill patients. Invasive or minimally invasive measurement of CO is not without inherent risks to the patient. Skilled Intensive Care Unit (ICU) nursing staff are in an ideal position to assess changes in CO following therapeutic measures. The USCOM (Ultrasonic Cardiac Output Monitor) device is a non-invasive CO monitor whose clinical utility and ease of use requires testing.

Objectives

To compare cardiac output measurement using a non-invasive ultrasonic device (USCOM) operated by a non-echocardiograhically trained ICU Registered Nurse (RN), with the conventional pulmonary artery catheter (PAC) using both thermodilution and Fick methods.

Design

Prospective observational study.

Setting and participants

Between April 2006 and March 2007, we evaluated 30 spontaneously breathing patients requiring PAC for assessment of heart failure and/or pulmonary hypertension at a tertiary level cardiothoracic hospital.

Methods

SCOM CO was compared with thermodilution measurements via PAC and CO estimated using a modified Fick equation. This catheter was inserted by a medical officer, and all USCOM measurements by a senior ICU nurse. Mean values, bias and precision, and mean percentage difference between measures were determined to compare methods. The Intra-Class Correlation statistic was also used to assess agreement. The USCOM time to measure was recorded to assess the learning curve for USCOM use performed by an ICU RN and a line of best fit demonstrated to describe the operator learning curve.

Results

In 24 of 30 (80%) patients studied, CO measures were obtained. In 6 of 30 (20%) patients, an adequate USCOM signal was not achieved. The mean difference (±standard deviation) between USCOM and PAC, USCOM and Fick, and Fick and PAC CO were small, −0.34 ± 0.52 L/min, −0.33 ± 0.90 L/min and −0.25 ± 0.63 L/min respectively across a range of outputs from 2.6 L/min to 7.2 L/min. The percent limits of agreement (LOA) for all measures were −34.6% to 17.8% for USCOM and PAC, −49.8% to 34.1% for USCOM and Fick and −36.4% to 23.7% for PAC and Fick. Signal acquisition time reduced on average by 0.6 min per measure to less than 10 min at the end of the study.

Conclusions

In 80% of our cohort, USCOM, PAC and Fick measures of CO all showed clinically acceptable agreement and the learning curve for operation of the non-invasive USCOM device by an ICU RN was found to be satisfactorily short. Further work is required in patients receiving positive pressure ventilation.     

Strategies for the diagnosis and treatment of the iliac vein compression syndrome

AimTo evaluate the diagnosis and treatment strategies for the iliac vein compression syndrome (IVCS) and the factors that affect the treatment outcome.MethodsIn total, 69 patients with IVCS were enrolled in the study. The patients underwent computed tomography (CT) venography before treatment. CT observations included assessment of the iliac venous channel sagittal diameter (IVCD) before the lower lumbar vertebra, causes of oppression, thrombus density, and embolization range. The patients with IVCS were divided into the simple IVCS (sIVCS, n = 22), lumbar degeneration-related type IVCS (dIVCS, n = 33), and IVCS of other causes (oIVCS, n = 14) including lumbar fracture, hematoma of infection, and abscess wraping around and compressing the iliac vein, groups. The treatment methods included target venous catheter-directed thrombolysis (CDT), a mechanical breaking and sucking treatment for the thrombi, followed by balloon dilatation and iliac vein stent implantation. The factors that may possibly affect the treatment outcomes included IVCS type, duration of disease, thrombus hardness, embolization length, and treatment regimen. Logistic regression was used to analyze the factors that affected the therapeutic efficacy.ResultsAt the first stage, CDT was only effective in 15 cases (5 dIVCSs and 10 oIVCSs) and was ineffective in the remaining 54 cases, which required further mechanical breaking and sucking of the thrombi and intravenous balloon dilatation. In the second stage, combination of thrombi breaking and suction and balloon dilatation was preliminarily effective in 26 cases (6 sIVCSs, 16 dIVCSs and 4 oIVCSs), but during follow-up from 1 to 6 months, treatment was considered futile for 9 recurrent cases (3 sIVCSs and 6 dIVCSs). So, 28 cases of preliminary ineffective treatment and 9 relapse in the second stage were arranged to the third stage of treatment by iliac vein stent implantation. All 37 cases were treated effectively and achieved a satisfactory iliac vein patency, and were followed-up for 24 months without recurrence. Logistic regression analysis showed that IVCS type (β = 4.14; Wald test, P < 0.01), duration of illness (β = -5.33; Wald test, P = 0.02), thrombus density (β = -6.46; Wald test, P = 0.01), embolization length (β = 2.74; Wald test, P = 0.03), and treatment regimens (β = 11.92; Wald test, P = 0.01) all had a significant effect on the treatment outcomes.ConclusionThe selection of a suitable intervention treatment regimen for different types of IVCS may aid in improving the curative effect.     

左西孟旦在心脏术后心肾综合征患者中的应用

目的：探讨左西孟旦在心脏术后心肾综合征（CRS）患者中的临床疗效,寻找由心功能不全导致肾功能不全的新治疗方法。方法统计143例心脏术后早期心肾综合征患者,其中 A 组68例未使用左西孟旦,B 组75例患者术后早期使用左西孟旦,对比2组术后第1、2、3日血管活性正性肌力药物评分（VIS）,脑钠肽前体（proBNP）、肾小球滤过率（eGFR）、尿量、主动脉球囊反搏（IABP）和持续肾替代治疗（CRRT）使用情况及 ICU 停留时间。结果2组在术前心功能、手术体循时间无明显差异（P ＞0．05）,术后第1 日 B 组 VIS 即小于 A 组且有差异（P ＜0．05）;第2日 B 组proBNP 浓度小于 A 组（P ＜0．05）;第 3日 B 组 eGFR 及尿量均高于 A 组（P ＜0．05）;CRRT 使用患者比例 B 组小于 A 组（P ＜0．05）,IABP 使用率无差异。结论左西孟旦在心脏术后心肾综合征患者中的应用可减少儿茶酚胺类药物的使用量,改善心功能,增加尿量,有助于肾功能恢复。     

连续性静脉-静脉血液滤过治疗心脏病术后急性肾功能衰竭的护理

目的:观察连续性静脉-静脉血液滤过(CVVH)治疗心脏病术后急性肾功能衰竭(ARF)的效果,减少护理并发症,提高治疗的安全性和有效性。方法:对53例心脏病术后并发重症ARF患者进行CVVH治疗,观察治疗前后患者MAP,CVP,BUN,Scr,K+等的变化,观察治疗过程中护理并发症发生情况。结果:53例患者经过CVVH治疗后32例存活,15例死亡,6例放弃治疗。存活患者经过CVVH治疗后CVP,Scr,BUN,K+,MAP升高。结论:连续性静脉-静脉血液滤过治疗ARF对于缓解患者临床症状和改善预后是一个有效的治疗手段,治疗过程中科学的护理计划,严密的护理监测和管理是使患者安全及治疗有效的保证。     

Cardiac resynchronization therapy and automatic implantable cardiac defibrillators in the treatment of heart failure: a review article

PURPOSE: To review the use of cardiac resynchronization therapy (CRT) and automatic implantable cardiac defibrillators (AICDs) in heart failure (HF) patients. DATA SOURCES: Selected scientific literature. CONCLUSIONS: New developments in device therapy for HF patients are helping to decrease morbidity and mortality in this challenging patient population. CRT improves left ventricular (LV) ejection fraction, quality of life, 6-min walk distances, and New York Heart Association scores in select patients. AICDs can prevent sudden cardiac death in those who have LV dysfunction and are at risk for ventricular arrhythmias. Cardiac devices are now becoming a standard of care for those with HF who meet certain criteria. IMPLICATIONS FOR PRACTICE: Despite advances in medical therapy for treating LV dysfunction, newly diagnosed patients face a 50% mortality rate in 5 years. The natural history of HF leads to continual deterioration of function unless adverse cardiac remodeling is reversed. Until recently, the only means for improving symptoms and cardiac function has been through the optimization of standard medicines that are indicated for LV dysfunction, such as angiotensin-converting enzyme inhibitors and beta-blockers. However, not all patients benefit from medical management alone. Cardiac devices may now be considered when significant symptoms persist after standard medicines are optimized. When practitioners use a multiple-modality approach, careful patient selection based on the inclusion criteria used in the trials outlined in this article will likely lead to improved management of those with LV dysfunction.