Mechanics of Percutaneous Circulatory Support Issam D. Moussa, MD Professor of Medicine Mayo Clinic College of Medicine Chair, Division of Cardiovascular Medicine Mayo Clinic Jacksonville, Florida CP1088236 Connolly,HM CW 11-13-2002

Conflict of Interest Baxter Research Grant Medtronic Research Grant Terumo Research Grant

Percutaneous Circulatory Support Which patients Goals of circulatory support What devices Mechanics of circulatory support

Percutaneous Circulatory Support Which Patients? Patients undergoing high-risk PCI (Elective) Patients with acute myocardial infarction with or without cardiogenic shock, to reduce infarct size and support end-organ perfusion (Emergent) Patients with acute decompensated heart failure, due to acute coronary syndrome, myocarditis or exacerbation of a chronic heart failure state (Urgent)

Percutaneous Circulatory Support Goals – Elective Setting Allow the cardiovascular system to withstand transient insults during PCI and resume normal function post procedure. Increase myocardial ischemic threshold to allow time for procedural complications to resolve.

Percutaneous Circulatory Support Goals – Urgent and Emergent Settings Unload the heart, take over the work – partially or totally – to minimize ischemic damage Maintain a stable hemodynamic state of systemic pressure and perfusion without the need for vasopressors and inotropes.

Percutaneous Circulatory Support Ideal Hemodynamic Impact Hemodynamic support Maintain blood pressure Maintain cardiac output Maintain pulmonary venous pressure Myocardial protection Increase oxygen supply (coronary blood flow) Reduce oxygen demand (HR & PVA) Cardiac Power Output (Watts) CPO= (MAP x CO) / 451 Maintain End-Organ Perfusion

Percutaneous Circulatory Support Mechanics of Circulatory Support Basics of Cardiac Work Load

Mechanics of Circulatory Support Pressure-Volume Area = Cardiac Work Load

Mechanics of Circulatory Support Oxygen Demand and PVA

Mechanics of Circulatory Support Cardiac Contractility and Oxygen Demand

Percutaneous Circulatory Support What Devices? Intra aortic balloon pump (IABP) Left atrial-to-arterial pumping (e.g., TandemHeart, Cardiac Assist) Intracorporeal transvalvular ventricular-to-aortic pumping (e.g., Impella, Abiomed).

IABP Inflation Diastole Deflation Systole Augmentation of diastolic pressure Increase coronary perfusion Increase myocardial oxygen supply Decrease cardiac work Decrease afterload Increase cardiac output

Impella Infusion Pump Impella Console Power Supply

IMPELLA 2.5 System

IMPELLA 2.5 SysteIMPELLA 2.5 System

Braun Vista Purge System IMPELLA 2.5 System Braun Vista Purge System

TandemHeart Left

The Tandem Heart

The TandemHeart The pump Low prime volume (10cc) centrifugal pump driven by a three phase, brushless, DC servomotor Delivers flows up to: 5.0 liters per minute with percutaneous cannulation 8.0 liters per minute with surgical cannulation Pulls oxygenated blood from the left atrium and returns it to the systemic arterial circulation Integrated pump & motor is fully sterilized and small in size, enabling placement close to the patient in the sterile field

Percutaneous Circulatory Support Devices Mechanism Hemodynamic Impact IABP Pressure Augmentation Increased diastolic, decreased systolic aortic pressure, decreased PCWP, no active flow Tandem Heart LA -------- Aorta Indirectly unloads LV by decompressing LA, Up to 4 L/Min flow (retrograde) Impella LV----------Aorta Directly unloads LV, up to 2.5 L/Min flow (antegrade) Burkoff D et al. CCI 80:816-829 (2012)

Device Comparison Using Circulatory Simulation Burkoff D et al. CCI 80:816-829 (2012)

Percutaneous Circulatory Support Devices Systemic Support (CPO) Myocardial Protection (Increase O2 Supply) (Reduce O2 Demand) Inotropes ++ - - - IABP + Tandem Heart +++ - / + Impella 2.5 Impella 5.0 Burkoff D et al. CCI 80:816-829 (2012)

CP1088236 Connolly,HM CW 11-13-2002