Preoperative screening for LVAD an TAH implantation P. Leprince Institut de cardiologie Chirurgie Cardiovasculaire Groupe Hospitalier Pitié-Salpétrière Paris, France Pascal.leprince@aphp.fr

Disclosure St Jude (Abott): Heartmate II Medtronic: HVAD, ECMO Jarvik 2000 Syncardia

Pre operative assessment Assess Illness severity Patient selection Optimize the sickest patients Define risk factor for surgery Right ventricle assessment Other organic and functional considerations Select appropriate device

Illness assessment for operative risk

Low: < 1.58 Mid: 1.58-2,58 High: > 1.58

3 centers 101 patients Intermacs 1 (28) Intermacs 2-3 (49) AJ Boyle et al. JHLT 2011, 30: 402

Intermacs 2016 report

BTB: HVAD 2012-2014 La Pitié 38 patients, 33 males 51± 12.5 y 12(31%) bridge to LVAD with peripheral ECMO 29 (76%) implanted on ECMO (vs CPB +valvular surgery) 7 (18%) peripheral ECMO + HVAD 17 (45%) percutaneous ECMO RVAD + HVAD  63 % RVAD support 71% hospital discharge

No ECMO ECMO pre N=26 N=12 No support ECMO Pc RVAD No support ECMO 31% N=5 19% N=13 50% N=6 50% N=2 16% N=4 33% 87% 60% 54% 83% 100% 75%

Infection screening and control

Right ventricular function Echocardiography TAPSE S wave Strain Septal function LV/RV ratio

In case of RV dysfunction Patient optimisation: inotropes, diuresis, CVVHD Biventricular or TAH support LVAD with temporary RVAD

Percutaneous temporary RVAD

Temporary percutaneous ECMO RVAD

Percutaneous temporary ECMO RVAD   N = 27 RVAD Timing (j) 2,1 ± 5,4 Duration (j) 12,9 ± 7,6 Devenir Death under RVAD 10 (37,0%) Weaning from RVAD 17 (63,0%) Transplantation 3 (11,1%) 6 months death 14 (51,8%) 50% 67% John n=12 14 d 21% 53% Bad-O n=45 21 j 64% Dang n=14 13 d

Other considerations Pulmonary function Neurologic function +++Carotide art. assessment Valvular disease +++ aortic valve Arrhytmias Psychologic and psychiatric conditions Social conditions

Which device for which patient? Center experience with multiple devices RV Function? Heart transplant candidate or DT patient? Body size: output vs space Surgical technic: sternotomy vs thoracotomy redo patient CPB vs ECMO vs off pump? Hemorrhagic risk

Requirement for biventricular support Syncardia Carmat Double LVAD LVAD + temporary RVAD TAH with BiHVAD La Pitié

Which device for which patient? Center experience with multiple devices RV Function? Heart transplant candidate or DT patient? Body size: output vs space Surgical technic: sternotomy vs thoracotomy redo patient CPB vs ECMO vs off pump? Hemorrhagic risk

Which device for which patient? Center experience with multiple devices RV Function? Heart transplant candidate or DT patient? Body size: output vs space Surgical technic: sternotomy vs thoracotomy redo patient CPB vs ECMO vs off pump? Hemorrhagic risk

Biventricular Destination BTT HMIII LVAD

Спасибо Большое