The failing heart; Update in surgical treatment Gunnar Myrdal MD. PhD, Reykjavik University Hospital. ICELAND

SOLVD, NEJM 1991, 325:293 and 1992, 327:685 CONSENSUS, NEJM 1987, 316: NYHA class predicts prognosis, but before modern therapy, not reproducible, and subjective

Heart failure 5.7 mil. People in US 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 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 Absolut Hemodynamic 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 indications Impaired LV function Previous history of class III-IV HF Peak VO2 >15 ml/kg/min

Contraindications for THX Absolut age; >70yr severe disease, life exp. <2yr Systemic dieases; SLE or Sarcoidosis cancer (exc. Skin) AIDS Fixed PAH (PVR>5 Woods)

Contraindications for THX Relativ 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 1966 BCM-Rice pump Kantrowitz Cardiovad in NY 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 pump Only one moving part Small 350g, 125 cc volume 80% smaller than HeartMate ® XVE Flow capacity: 3 to 10 lpm HeartMate 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!

Acute Cardiogenic Shock Surgical CABG Valve Replacement Failed Transplant Implantable LVAD LVA Repair Post-Infarct VSD Inotropes (I.A.B.P.) Optional Within 30 min. of 1 st Attempt to wean from CPB within 1 Hour. 1 st attempt to wean of CPB Short-term VAD Medical Acute MI Acute Viral Myocarditis Acute Postpartum Coronary Dissection Intractable Ventricular Arrhythmia Trauma Massive Pulmonary Embolus Low output with 2 high dose of inotropes Low output with 2 or 3 high dose of inotropes & IABP If RV fails after LVAD insertion as demonstrated by elevated CVP and poor LVAD flow despite optimazation of inotropes If LV fails after RVAD insertion as demonstrated by elevated PAP and poor RVAD flow despite optimization of inotropes Bi-Ventricular Support If severe biventricular failure with elevated PAP and CVP R-Ventricular Support If LV and RV are distended and hypokinetic with elevated PAP and CVP L-Ventricular Support Impella BVSConcept If isolated RV is distended and hypokinetic with elevated PAP and CVP

”Destination therapy”

REMATCH- studien Rose 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