Mechanical circulatory support

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Assisted Circulation MEDICAL MEDICAL  Drugs  EECP MECHANICAL  IABP ( Introaortic balloon pump)  VAD (Ventricular assist device)

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Presentation transcript:

Mechanical circulatory support Hitoshi Hirose, MD Associate Professor of Surgery Thomas Jefferson University Nothing to disclose

Cardiogenic shock

Pharmacological therapy Volume Inotropes Pressors Still cardiogenic shock..

IABP

IABP Reduces afterload Increase diastolic coronary perfusion pressure Modest increase coronary blood flow Excellent safety profile Easy to use Stabilize pts with Cardiogenic shock, provides HD support for pts undergoing PCI 10k

IABP shock II trial 2012 NEJM Back ground of study IABP has been used almost half century. USA: despite of class 1B ACC/AHA – only 35% of cardiogenic shock pt had IABP support. Europe: despite of class 1C ESC– only 25% of cardiogenic shock pt had IABP support. Why? No RCT, reviews and meta-analysis weak.

IABP-Shock-II Trial Largest RCT ever in cardiogenic shock

IABP does not reduce mortality Randomized multicenter trial in cardiogenic shock patients complicating myocardial infarction undergoing early revascularization, IABP support did not reduce 30 days mortality or one year mortality.

Impella

Impella 2.5 Percutaneously placed mini rotary pump. Inserted from femoral artery. Inlet at LV, outlet at ascending Ao. Precise positioning. No RV support. Not good for arrhythmia. Support only 2.5 Lpm. 50k

Impella 5.0 Centrally placed mini rotary pump. Inserted from Asn Ao or Fem cut down. Inlet at LV, outlet at ascending Ao. Support up to 5 Lpm. No RV support. Not good for arrhythmia. Need open sternum. 65k

Tandem Heart

Tandem heart Inlet at LA via atrial septum Outlet at iliac artery. Requires catheterization technique. Can be placed in OR (bet LA & Ao, bet RA and PA) Support LV only unless placed in OR bet RA/PA. Allow up to 4 Lpm. 65k

HMII LVAD

Implantable VAD Destination therapy or bridge to transplant. Patient can go home with implantable VAD. No other device can go home with it. 100k

Other implantable LVADs Jarvik 2000 HearWare HVAD HMIII

HMII Long-term outcomes Kirklin J. K. et al.; J Thorac Cardiovasc Surg 2012;144:584-603

HMII improved survival for DT Molina EJ et al. Semin Thrac Surg 2013;25:56-63

Timing of VAD implant High mortality rate after VAD in INTERMACS 1 (crash burn). VAD/TAH are not Emergent procedure. Unknown Liver Kidney Neuro Profiles Definition INTERMACS 1 “Crash and burn” INTERMACS 2 “Sliding on inotropes” INTERMACS 3 “Dependent stability” INTERMACS 4 “Frequent flyer” INTERMACS 5 “Housebound” INTERMACS 6 “Walking wounded” INTERMACS 7 “Placeholder”

Implantable LVAD with external RVAD RVAD support after LVAD CetriMag, Rotaflow RVAD (bet RA & PA). No oxygenation or resp support. RVAD increase the risk after LVAD. Try to avoid requirement of RVAD at the time of the LVAD placement. 12k

Syncardia TAH

Total artificial heart Destination therapy or bridge to transplant. Patient can go home with TAH. Biventricular support. No respiratory support. 500k

ECMO

ECMO device 20k

ECMO is life saving tool and Buy a time to make decision Optimize and stabilize end-organ function. Liver, Kidney, Lung, Brain Pripheral cannulation (avoid sternotomy). Decompress the Right side heart. Improve congestion of the liver, kidney. Easy to support a few weeks even a month.

VA ECMO

VV ECMO

VA vs. VV Any difference?

Yes there is a large difference VA provide full cardiac and resp support. Including cardiac stand-still, arrythymia (VT/VF) VV require normal RV/LV to circulate. Good for non-cardiac resp failure Switching from VA to VV, or VV to VA is not simple. Plan before placing on ECMO.