SHA24/043001

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

10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013

Abiomed AB VAD

10th Gulf Heart Association, 24th Saudi Heart Association February 15, 2013

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