The failing heart;

Update in surgical treatment

Gunnar Myrdal MD. PhD, Reykjavik University Hospital. ICELAND

SOLVD, NEJM 1991, 325:293 and 1992, 327:685CONSENSUS, NEJM 1987, 316:1429www.uptodate.com

NYHA class predicts prognosis, but before modern therapy, not reproducible, and subjective

Heart failure

5.7 mil. People in US

300.000 die / year = 300 mil.300 per one million per year die

Heart failure

Coronary disease primary causes

Advances in medical therapy improve survival in moderate and severe heart failure

Prognosis for end-stage heart failure remains poor

Heart failure

The greatest survival benifit to day in patients with end-stage heart failure is seen with cardiac transplantation

Shumway, Stanford 1950-60 CPB

Kidney transplant 1957

Barnard 1967, first human cardiac transplant, survived 18 days ...............the very next year 102 attempts with poor outcome

Cyclosporin A, 1976

Cardiac Transplantations

Despite great medical improvement in this field the number of cardiac transplants performed worldwide has plateaued......... Primarly due to lack of donor organ supply..............

Indications for THX

AbsolutHemodynamic compromise sec. to HF

Refractory cardiogenic shock

Dependenc on IV inotropic support

Peak VO2 <10 ml/kg/min

Severly limiting non-revasc. IHD affecting daily live

Recurrent symptomatic VT refractory to therapy

Indications for THX

Infufficient indicationsImpaired LV function

Previous history of class III-IV HF

Peak VO2 >15 ml/kg/min

Contraindications for THX

Absolutage; >70yr

severe disease, life exp. <2yr

Systemic dieases; SLE or Sarcoidosis

cancer (exc. Skin)

AIDS

Fixed PAH (PVR>5 Woods)

Contraindications for THXRelativ

age; >65yr

Periferal arrtery disease/ carotid/AAA

Hypertensio

BMI>35 or <20

Infektions, CMV, HIV, Hepatit B

DM and nefro/neuro/retinopati

sign. irreversible organ failure

Kreatinin Clerance <25 ml/min

2X incr. Bilirubin/ASAT etc

Pulmonary diseas; obstr/restrict.

Coagulations

GI bleeding

Drug/tobacco/alcohol

SOCIAL

Survival for cardiac transplants

Heart failure

Supply of donor hearts is limited

Transplantation not indicated because of age and other comorbidity

Heart failure

......therefore a considerable interest in alternative forms of cardiac replacement therapy.

....however, cardiac transplantation still remains the gold standard of cardiac replacement therapy.

Development of cardiopulmonary bypass tech. 1950´s

Dr Demikow 1950´s in Russia

DeBakey 1966 in humans

LVAD approval in 1990´s by FDA as a bridge to transplant

Extracoporeal Continuous Membrane Oxygenation= ECMO

Texas Heart Institute by DeBakey 1966BCM-Rice pump

Kantrowitz Cardiovad in NY 1971.

Pulsative LVAD 1976 as Pierce-Donachy

later Heartmade (Thoratec), FDA approved as bridging device to THX

2002 HM XVE approved as a destination therapy

Although high incidence of device failure

Smaller pumps; continous flow pumps in developements since 1988-first human trials ten years later.

Smaller size

Fewer moving parts

HM II FDA approval 2005 as a bridge to transplantation.........

... and 20th of january 2010 pre-market approval as a destination therapy

Allows HM II to be used in patients with NYHA Class IIIB and IV... Who have received optimal medical therapy 45 of last 60d, not candidates for transplantation.

Axial flow blood pumpOnly one moving partSmall

350g, 125 cc volume80% smaller than HeartMate® XVE

Flow capacity: 3 to 10 lpmHeartMate XVE style inflow and outflow cannulae

- ”bridge to transplantation”

- ”bridge to recovery”

- ”destination therapy”

- ”Bridge to decision”

Acute Heart Failure

In Acute Settings, Cardiac Function is RECOVERABLE

• Acute Myocardial Infarction

• Post-Cardiotomy Shock

• Myocarditis

• Acute Cardiomyopathy, …

Causes of Post MI Shock

”

- ”bridge to recovery”

Mechanical Circulatory Support

Improves Recovery Outcomes in

Profound Cardiogenic Shock Post

Acute Myocardial Infarction:

A US Retrospective Study including 26 US Centers

Future Paradigm

Less invasive technology for early

support

Future Paradigm

Earlier Support with

Impella Technology

Earlier Support with

Impella Technology:

Bridge to recovery

or

Gain time for decision

Impella® recover system

•Acute Myocardial Infarction

• Post-Cardiotomy Shock

• Myocarditis

• Acute Cardiomyopathy, …

In Acute Settings, Cardiac Function is RECOVERABLE

Year 2006

Male 32yr

Biventricular failure

Creatinin 300, anuri, bilirubin 120

EF 10%, PVR >3, CVP 25, MAP 40

IDCM with acut myocarditis

Bridged to long-term LVAD with Impella LD 5.0

Surgery Bridge to recovery

Goal: To maintain the circulation and allow time for recovery, we need a range of potent hemodynamic support devices that can be put in promptly by cardiologists in the cath lab, and then transition to potent longer-term surgical devices, to protect end-organs and allow time for myocardial recovery

Days – 1 week:

• New minimally invasive technologies (~ Impella 5.0)

• VAD ~BVS 5000 (5+L/m)

Hours to few days support:

• IABP

• New Technologies ~Impella

Cardiology High-Risk PCI, AMI

Cardiac Surgery

Bridge to Decision

Weeks – Months

• VAD, HMII

~AB 5000 (5+L/m)

Future!

”Destination therapy”

REMATCH- studienREMATCH- studien

Rose et. al., New England Journal of Medicine, 2001Rose et. al., New England Journal of Medicine, 2001

Slaughter. M; NEJM 2009

To take home!

Small devices to use in CS

Good results with new devices for long term use

Require cooperation and teamwork beetween cardiologist, ICU doctors and surgeons

Not a one man show!!

Select patients with care