Short Term Assist Devices Vinay Badhwar, MD Associate Professor of Surgery Department of Cardiothoracic Surgery Chief of Cardiac Surgery UPMC Presbyterian University of Pittsburgh
UPMC
Disclosures Nothing to disclose
10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013
Objectives •
Indications and Pitfalls
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Device Options
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Outcomes 10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013
Categories of Therapy • Bridge to Recovery • Bridge to Decision • Bridge to Transplant • Bridge to Destination
10th Gulf Heart Association, 24th Saudi Heart Association February 13, 2013
Definition of Post-Cardiotomy Failure (Practical Definition) • Cardiac Index < 2.0 L/min/m2 • Systolic BP < 90 mm Hg • LVEDP or PCWP > 25 • In conjunction with IABP support and max Inotropic support • Increased SVRI 10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Post-Cardiotomy Failure • Requiring an IABP: seen in 1 to 10 % • Survival = 45 to 60%
• Requiring an LVAD: seen in 0.1 to 0.8% • Weanability = 40% to 70% • Survival = 20% to 50%
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Major Causes of Heart Failure Following Cardiac Surgery • Inadequate myocardial protection • Incomplete revascularization • Coronary or LIMA spasm • Coronary embolism (air) Translates to ischemia and peri-operative myocardial infarction
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Goals for Ventricular Support • Maintain fluid balance • Decrease LV afterload • Decrease RV afterload • Maintain contractility • Maintain sinus rhythm 10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Mechanical Support • Partial • IABP
• Complete • VAD
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
IABP • Complications • • • • •
Limb ischemia Thromobembolic complications Hemolysis and thrombocytopenia Acute aortic dissection Balloon rupture
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Physiologic Principles of an LVAD A) Decrease LV afterload and LV wall tension B) Decrease LV preload A) + B) = Decreased LV pressure
= Decreased myocardial oxygen consumption C) Augment myocardial perfusion
D) Maintain physiologically adequate systemic perfusion
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Risk Factors to Evaluate Prior to LVAD • Unsuccessful surgery (unless Tx cand.) • Preop or intra-op myocardial infarct • Biventricular failure • Previous MI or CHF • Age • Coagulopathy risk • Pre-implant multi-organ failure 10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Factors Influencing Outcome for Acute Post-Cardiotomy Support • • • • •
Pre-implant multi-organ failure Degree of LV decompression Promptness of implant Degree of completed myocardial infarction Pre-operative LV function
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Timeline for Decision Making for Acute Post-Cardiotomy Failure Support Initial attempt to wean
20 min
Failed
10-20 min IABP and/or Inotropic Agents
Failed
LVAD
J Heart Lung Transplant 2013;32:157-87
LV Apex vs Left Atrial Cannulation â&#x20AC;˘ Left Atrial cannulation leaves LV with areas of
stagnant flow. â&#x20AC;˘ Data with Thoratec using atrial cannulation especially in face of acute MI shows higher TE rate. Mean flow: LA cannula = 4.4 L/min/M2 LV cannula = 5.5 L/min/M2
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Length of Support In general RV recovers within 48 hrs to 5d • The LV will usually recover within 5 to 10 days but could take several weeks. • Given more long-term devices some LV’s may recover after months. •
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Logistical issues influencing outcome • The LV is rarely effected in an isolated fashion • Weaning support before recovery of associated endorgan failure is rarely successful • Success of weaning will depend upon successful revascularization of viable myocardium • Isolated RV failure is also rare.
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
A point about supporting the patient with an RV infarct • It is dangerous to assume the LV is normal • Conduction system abnormalities are common • Bradycardia can lead to sudden and fatal pulmonary edema • Permanent epicardial pacing leads should be placed
• A safer alternative is to use biventricular support 10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
A Decade of Short-Term Outcomes in Post–Cardiac Surgery Ventricular Assist Device Implantation Data From the Society of Thoracic Surgeons’ National Cardiac Database Adrian F. Hernandez, MD; Joshua D. Grab, MS; James S. Gammie, MD; Sean M. Circulation. 2007;116:606-612.) O’Brien, PhD; Bradley G. Hammill, MA; Joseph G. Rogers, MD; Margarita T. Camacho, MD; Mercedes K. Dullum, MD; T. Bruce Ferguson, MD; Eric D. Peterson, MD, MPH Between January 1995 and December 2004, 5735 VADS were implanted in 601 STS NCD centers. Overall, the percentage of cardiac surgical procedures requiring VAD insertion support was 0.3% of all cardiac operations
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
J Card Surg 2010;25:442-454
ECMO
Weanability = 49% Survival = 34%
Weanability = 52% Survival = 30%
Weanability = 55% Survival = 43%
Tandem Heart
Percutaneous RVAD
Percutaneous
10th Gulf Heart Association, 24th Saudi Heart Association LVAD 15, 2013 February
Cannulation for Extracorporeal Support Exit sites â&#x20AC;&#x201C; excise tissue Attempt to tunnel cannula/tubing Plan for perm VAD if possible
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Abiomed AB VAD
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Thoratec PVAD Cannulation
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Ideal Orientation of Cannuale For Thoratec BiVAD PVAD
Aortic Outflow Graft
Right Atrial Inflow Graft
Pulmonary Artery Outflow Graft
LV Inflow Graft
IMPELLA Left heart support pump
Right heart support pump
Impella 2.5
Impella LD and RD
Weanability = 56% Survival = 37%
OUTCOMES
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Higher Mortality with RV failure post LVAD
Kormos et al. J Thorac Cardiovasc Surg 2010;139:1316-24
RVAD+LVAD= Worse Outcomes
The Journal of Heart and Lung Transplantation 2012; 31:117-126
Time to Implant Impacts the Outcome
Sooner is better
Time to percutaneous right ventricular support device (pRSVD) implantation between survivors and non-survivors. Kapur at all, The Journal of Heart and Lung Transplantation 2011, 30
Impella RP: Novel Percutaneous Device •
3D catheter-based percutaneous VAD (22 Fr pump mounted on a 11 Fr catheter)
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Treatment: RV dysfunction
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Flow: > 4 L/min
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Duration of support: up to 14 days
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Pump Inflow: Inferior Vena Cava (IVC)
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Pump Outflow: Pulmonary Artery (PA)
Impella RP is not approved by FDA
Impella RP Improved Hemodynamics in Acute Heart Failure Model
Acute Right Heart Failure Porcine Model (RCA occlusion)
Arterial Pressures During Acute Right Heart Failure
Impella RP Insertion Technique • Impella RP insertion performed in the operating theatre under general anesthetics with fluoroscopic and trans-esophageal echocardiogrphic (TEE) guidance • Device is inserted using Seldinger technique via femoral vein • A guidewire is advanced into the pulmonary artery with the aide of a balloon-tip pulmonary arterial catheter • The Impella RP is introduced into the venous system through either a peel away sheath • Device placement and position is confirmed by fluoroscopy and TEE prior to the commencement of support
Impella RP is not approved by FDA 10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013
Impella Placement Outlet into main PA
Inlet at the IVC/Right atrial junction
Preliminary Clinical Experience With Impella RP Improvement in Hemodynamics After Initiation of Support
â&#x2020;&#x201C;50%
CVP pre RP implant
CVP post RP initiation
Summary • Post Cardiotomy Failure is not common but is a morbid diagnosis • Multifaceted approach for treatment is focused upon afterload reduction of the LV and protection of the RV • Early utilization of Mechanical Circulatory Support is critical for myocardial salvage
10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013