When Right Ventricular Failure may become a VAD Failure Dept. of Cardiothoracic Surgery Medical University of Vienna G. M. Wieselthaler

G.M.Wieselthaler, Univ. of Vienna 04/ VAD is established therapy for terminal heart failure -- 85% of implanted pumps are LVADs -- natural right ventricular function is the trigger for the LVAD -- evaluation of right ventricular function in end-stage HF patients is difficult -- severe tricuspid insufficiency complicates evaluation process -- acute right heart failure after LVAD highest peri-operative mortality Right Ventricular Failure and VAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 Evaluation methods for native right ventricular function: -- echocardiography -- ECG gated MRI -- vaso-active right heart catheterization Right Ventricular Failure and VAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 Echocardiography: Pre LVADPre LVAD Post LVAD Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 Echocardiography: Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 Echocardiography: Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 Echocardiography: Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 Echocardiography: Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 Echocardiography: Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 Echocardiography: Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 MRI: Z. F. 61 a, idiopath. CMP Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 MRI: W.K., 56 a, isch. CMP + PH Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 MRI: W. K., 56 a, isch. CMP + PH Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 Evaluation of Right Ventricular Function Hemodynamic Testing before LVAD Implantation in 4 Patients BaselineNitro Bolus After Simdax 2 hours HR (b/min)76 ± 1172 ± 1180 ± 12 MAP (mmHg)81 ± 2579 ± 2179 ± 23 PAP (mmHg)45 ± 735 ± 639 ± 5 PCWP (mmHg)31 ± 617 ± 616 ± 1 CVP (mmHg)17 ± 47 ± 210 ± 3 CO (L/min)3,4 ± 0,74,3 ± 1,14,2 ± 1 SvO2 (%)41 ± 1265 ± 355 ± 8 Wood U4,4 ± 1,24,5 ± 0,85,5 ± 1,5

G.M.Wieselthaler, Univ. of Vienna 04/2009 Patient 2: K. R. m, 66 a, 172 cm/92kg  Dg: isch CM since 2002, St.p. anterior wall infarct, St.p. AICD 5/2005 art. Hypertonie, COPD art. Hypertonie, COPD  repeted Levosimendan-infusions  Tx: Blopress 16 mg 1/2, Concor 5mg 1/2, Lasix 40 mg 1-1, Spirobene,Restex, Seretide, Berodual, Marcoumar  Lab: Crea 2.0 mg/dl, Bili 2.0 mg/dl,  Lab preop: Crea 1,15 mg/dl, Bili 1,95 mg/dl  Right heart catheter vom :  mPAP 52, PCWP 28, CO 5.2, Wood U 4,6  Echo: highly reduced LVF EF 10%, EED 8.7 cm Evaluation of Right Ventricular Function

G.M.Wieselthaler, Univ. of Vienna 04/2009 Evaluation of Right Ventricular Function Baselin Nach Perlingani t Bolus i.v. Nach 3 Stunden PGE 2 Nach Anästhesie Einleitung Postoperativ 15 Stunden postoperativ HR MAP mPAP CVP PCWP CO3,95,14,34,55,44,9 SvO PVR TPG Wood U 5,43,72,84,93,53,2 Pro BNP

G.M.Wieselthaler, Univ. of Vienna 04/2009 Evaluation of Right Ventricular Function General exclusion criteria for VAD implantation: absolute contraindications: - BUN > 100 mg / l or s-creatinine > 5,0 mg/dl - BUN > 100 mg / l or s-creatinine > 5,0 mg/dl - total bilirubin > 5 mg/ dl - total bilirubin > 5 mg/ dl - active infection - active infection - anamnestic coagulopathy - anamnestic coagulopathy - tumor anamnesis (bridge to transplant) - tumor anamnesis (bridge to transplant) - cerebrovascular disease - cerebrovascular disease - aortic disease - aortic disease relative contraindications: - parenchymatous lung disease (Sarcoidosis) - parenchymatous lung disease (Sarcoidosis) - fixed pulmonary hypertension - fixed pulmonary hypertension - mechanical heart valve - mechanical heart valve - heparin intolerance (HIT) - heparin intolerance (HIT)

G.M.Wieselthaler, Univ. of Vienna 04/ in press Mechanical Circulatory Support

G.M.Wieselthaler, Univ. of Vienna 04/2009 fixed pulmonary hypertension and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 fixed pulmonary hypertension and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/ Patients for LVAD Implantation After Inductio n After CPB OR Endpostop 6 hours postop 12 hours postop 24 hours postop HR (b/min)69 ± ± ± ± ± ± ± 14 MAP (mmHg)68 ± 668 ± 765 ± 772 ± 576 ± 472 ± 568 ± 2 mPAP (mmHg)37 ± 427 ± 527 ± 4 25 ± 523 ± 328 ± 7 PCWP (mmHg)24 ± 711 ± 410 ± 214 ± 58 ± 0,811 ± 311 ± 2 CVP (mmHg)17 ± 510 ± 311 ± 310 ± 211 ± 112 ± 311 ± 3 CO (L/min)3,7 ± 15,7 ± 0,75,6 ± 0,74,7 ± 0,75,4± 0,55,6 ± 0,14,8 ± 0,3 SvO2 (%)58 ± 1470 ± 368 ± 4 66 ± 464 ± 866 ± 5 Wood U3,6 ± 1,23 ± 1,23,1 ± 0,92,9 ± 0,93,2 ± 1,12,9 ± 0,33,3 ± 1,5 fixed pulmonary hypertension and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 After Induction After CPBOP Endpostop 6 hours postop 12 hours postop 24 hours postop Dobutamin (µg/kg/min) 3,11211,411,26,87,17,5 Levosimendan (µg/kg/min) 0,2 Norepinephrine (µg/kg/min) 0,070,140,220,260,030,050,04 Nitric Oxide (ppm)10 10 Patients for LVAD Implantation 1 Patient additionally had Milrinone intraoperatively, 3 Patients postoperatively 2 Patients needed Nitroglycerin postoperatively, 1 Patient was switched from to Nitro to Urapidil fixed pulmonary hypertension and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/ patients Heart Mate 39% RHF 14 Patiens RVAD Right Heart Failure and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 Right Heart Failure and LVAD 245 patients 9% RVAD (23 patients)

G.M.Wieselthaler, Univ. of Vienna 04/ Patients Heart Mate LVAD In 11 RVAD Right Heart Failure and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 Adverse Event DuraHeart (n=33) 18 pt-yrs (mean:197 days) HM VE 1 (n=280) 86 pt-yrs (mean:112 days) HM II 2 (n=133) 62 pt-yrs (mean:168 days) Bleeding requiring surgery Driveline/pocket infection Stroke0.280* Non-stroke neurologic * RHF requiring RVAD Device thrombosis 0NA0.03 Pump mechanical failure Hemolysis Frazier OH, et al. J Thoracic Cardiovasc Surg 2001;122: Miller LW, et al. NEJM 2007;357: Comparison of Adverse Event Rates (per pt-yr) DuraHeart vs. HM VE vs. HM II As of June 15, 2007 *Event rate after implementing less intensive anticoagulation (n=22, 13 pt-yrs)

G.M.Wieselthaler, Univ. of Vienna 04/2009 HeartWare HVAD multi-institutional trial Complication Patients Events Event Rate n n per pt yr Infections (exit site) Bleeding (requiring re-operation) Respiratory Dysfunction Renal Dysfunction Right Heart Failure At 180 days adverse events in first 23 implants: G.M.Wieselthaler et al, JHLT 2009 submitted

G.M.Wieselthaler, Univ. of Vienna 04/2009 Continuous unloading of left ventricle can cause shift of thined, free lateral ventricular wall and results in reduced pump-flows & can provoke suction Right Heart Failure and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 thin & flexing interventricular septum in a patient with dilative CMP Right Heart Failure and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/ in a patient with a thin & flexing interventricular septum -- leads to shift of interventricular septum to the left side & increased TI with consecutive right ventricular failure consecutive right ventricular failure Right Heart Failure and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 Right Heart Failure and LVAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 Right Heart Failure and LVAD LVAD vs. BiVAD: -- extended infarct areas (RCA) -- consider BiVAD -- patients with malignant arrythmias benefit from BiVAD -- patients in prolonged cardiogenic shock always BiVAD -- Patients with two- or multi-organ failure always BiVAD

G.M.Wieselthaler, Univ. of Vienna 04/2009 Right Heart Failure and LVAD Conclusion: -- evaluation of native right ventricular function is very difficult and still challenging -- preservation of right ventricular function in medical heart failure therapy should be the main target -- as soon as native right ventricular function starts to decrease refer patient for surgical evaluation (transplant // bridge to transplant) = vaso-active RHC !! -- try to avoid last option “BiVAD” -- quality of life on a LVAD is ten times better than on a BiVAD