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Mechanical Therapies for Heart Failure
2020 Annual Chattanooga Cardiovascular SymposiumAlan Simeone, MD, FACS
Nothing to Disclose
What’s on the Agenda?
Acute Systolic Heart Failure
• Intra-aortic Balloon Pump
• Impella
• Extra Corporeal Membrane
Oxygenation (ECMO)
Chronic End-stage Systolic Heart Failure
• Key Concepts• Implantable Devices• Bridge vs Destination
• LV Failure • Implantable LVAD
• Bi-Ventricular Failure• Bi-VAD• Total Artificial Heart
Cardiogenic Shock
First Step is RecognitionArterial Access > Acid/Base, Lactate
Venous Access > PA Catheter
Additional Data
Cardiac Power Output
(MAP x CO)/451
Pulmonary Artery Pulsatility Index
(sPAP – dPAP )/CVP
Intra Aortic Balloon Pump
First used in 1967
Counterpulsation device most commonly inserted via femoral artery
7 to 9F catheter, 30, 40 or 50 cc Helium driven balloon
Inflates in Diastole, deflates prior to Systole
Timing by ECG or Arterial pressure tracing
Increases Diastolic Coronary Perfusion Pressure
Decreases LV Afterload
IABP Waveform
IABP
• Falling out of Favor in Cardiogenic Shock after Acute Myocardial Infarction
• Difficult to study – small numbers, many variables
• Newer percutaneous devices offer more quantifiable levels of support
• IABP remains very beneficial in the End-Stage chronic heart failure population
• Specifically, those failing on Inotropic support who are potential Transplant or Implantable Device Candidates
• Also useful as a temporary adjunct to medical therapy in Acutely Decompensated Chronic Heart Failure
• Remains useful in Post-Cardiotomy Shock
Impella
Miniature Axial Flow Pump mounted on a Catheter
Impella
• Impella 2.5• About 2.5 L/min, Femoral, 14F Sheath
• Impella CP• About 4 L/min, Femoral, 14F Sheath
• Impella 5.0• About 5 L/min, Cut-down, 23F Sheath
• Impella LD• About 5 L/min, Open Chest Asc. Aorta
• Impella 5.5• About 6 L/min, Cut-down, 23F Sheath
• Impella RP• About 4 L/min, Femoral VEIN, 23F Sheath
Impella Pros and Cons
• A True Mechanical Blood Pump
• Provides Forward Flow
• Can Decompress the LV• Reduces LVEDP
• - LA and Pulmonary Venous Pressure
• Reduce Wall Tension and O2 Demand
• Can Be a Percutaneous Option
• Expensive – Impella 2.5 20k to 23k
• Relatively large sheaths
• Malpositioning not unusual
• Hemolysis
• Short-term
• Good Evidence Still Sparse
Veno-Arterial Extra Corporeal Membrane OxygenationV-A ECMO
• Portable, Miniaturized Cardiopulmonary Bypass
• Venous Drainage Cannula
• Circuit Tubing
• Centrifugal Pump
• Oxygenator
• Arterial Return Cannula
V-A ECMOAdvantages
• Full Support of Perfusion – Flows depend on Cannula size assuming constant preload and afterload
• Support for Pulmonary Dysfunction
• Permits Recovery of Organ Function and Diuresis
• Hardware and Circuit can be inexpensive
• Can be instituted Quickly
Disadvantages• Bleeding
• Clotting
• Bleeding and Clotting
• Inflammatory Response
• Perfusion at the expense of LV Unloading
• Limb Malperfusion
• Limited Duration
• Personnel and Expertise required
• Exit Strategy essential
V-A ECMO
• Outcomes Depend on Patient Characteristics• Age
• Presence of Acute complications of Low Pressure/Low Flow
• Chronic Disease Burden
• Etiology and potential for recovery
• Downtime prior to initiation of support
• Suitability for more durable method of support
• An Excellent bridge to Durable Mechanical Support or Transplant in Patients with Decompensated End-Stage Heart Failure
How bad can living with end-
stage heart failure be?
It can’t be worse than a
VAD!Right?
Classification - Heart Failure
New York Heart Association (NYHA) Heart Failure Symptom Classification System
• I: No symptom limitation with ordinary physical activity
• II: Ordinary physical activity somewhat limited by dyspnea (e.g., long-distance walking, climbing two flights of stairs)
• III: Exercise limited by dyspnea with moderate workload (e.g., short-distance walking, climbing one flight of stairs)
• IV: Dyspnea at rest or with very little exertion
American College of Cardiology-American Heart Association Classification of Chronic Heart Failure
• A: High risk for developing heart failure: Hypertension, diabetes mellitus, CAD, family history of cardiomyopathy
• B: Asymptomatic heart failure: Previous MI, LV dysfunction, valvular heart disease
• C: Symptomatic heart failure: Structural heart disease, dyspnea and fatigue, impaired exercise tolerance
• D: Refractory end-stage heart failure: Marked symptoms at rest despite maximal medical therapy
550,000 Americans Hospitalized yearly despite best medical therapy
When Hospitalization Required
• 30 to 50% re-admitted within the first 6 months
One Year Mortality
Class II: 10 - 15%
Class III: 15 – 25%
Class IV: 30 – 50%
Inotrope-Dependent Advanced Heart Failure:
70 – 90% one-year mortality
• Transplant Effective but limited, prior to early 80’s was discarded
• Devices for Mechanical Support have existed since the early 1960’s
• Emphasis shifted from heart replacement to Ventricular Assistance• TAH has lingered – Current SynCardia TAH began life as the Jarvik-7
• Progress has seen transition from bulky, pulsatile mechanical pumps with complex moving parts to small, continuous-flow devices
• Compared to Medical Therapy, LVADs have significantly improved survival, Quality of Life and Functional Status since the landmark study in 2001.
Durable Mechanical Support Devices
HeartMate II HeartMate 3
• HeartMate II• Axial Flow
• Continuous Flow
• Mechanical Bearings
• Driveline
• External Battery Power
• Bridge to Transplant
• Destination Therapy
• HeartMate 3• Centrifugal Flow
• Continuous Flow, Pulsatility from algorithmic speed changes
• No Mechanical Bearings –Magnetically Levitated
• Modular Driveline
• External Battery Power
• Bridge to transplant
• Destination Therapy
• Two Year Survival 82%
• Any Stroke 9%
• Pump Thrombosis 1%
n engl j med 380;17 nejm.org April 25, 2019
LVAD - Not Perfect
• Require Anticoagulation• Bleeding
• Thrombosis
• Acquired von Willebrand’s syndrome
• Infection – Driveline is the Achilles Heel
• Aortic Regurgitation
• The Right Ventricle
Biventricular Failure
• Most Common Cause of RV Failure is LV Failure
• RV can usually recover with temporary medical and mechanical support• Centrimag RVAD
• Impella RP
Total Artificial Heart
• SynCardia TAH approved as a Bridge to Transplant
• A descendant of the Jarvik 7
• Pneumatically Driven, 4 valves• Intractable Arrhythmia
• Restrictive Cardiomyopathy
• ?Cardiac Tumor
• Mechanical Complication of MI
• Heart Failure in Adult Congenital
Biventricular Failure
• Magnitude of the problem dependent on potential for Transplant
• In a patient who is not a candidate for transplant >
• No good options for long-term support
• BiVAD implantable VADs have been used
• The RV VAD requires modification
The Future?
• Bivacor
• Investigational
• Centrifugal total artificial heart with a single magnetically levitated double-sided impeller
Thank You
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