0. 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
CP Connolly,HM CW

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

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

3. 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)

4. 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.

5. 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.

6. 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

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

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

9. Mechanics of Circulatory Support Oxygen Demand and PVA

10. Mechanics of Circulatory Support Cardiac Contractility and Oxygen Demand

11. 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).

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

13. Impella
Infusion Pump
Impella Console
Power Supply

14. IMPELLA 2.5 System

15. IMPELLA 2.5 SysteIMPELLA 2.5 System

16. Braun Vista Purge System
IMPELLA 2.5 System
Braun Vista Purge System

17. TandemHeart Left

18. The Tandem Heart

19. 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

20. 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: (2012)

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

22. 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: (2012)

23. CP Connolly,HM CW