1. Contemporary Approaches to Acute Mechanical Circulatory Support
Navin K. Kapur, MD, FACC, FSCAI, FAHA
Associate Professor, Department of Medicine Interventional Cardiology & Advanced Heart Failure Programs
Executive Director, The Cardiovascular Center for Research & Innovation

2. Relevant Disclosures
Research Funding: Abiomed, Maquet, Cardiac Assist, Abbott, Boston Scientific Speaker/Consulting Honoraria: Abiomed, Maquet, Cardiac Assist, Abbott

3. The Field of MCS: Robust with Innovation
IVADs
HVAD
Impella CP
TH-RV AD CP RP
Impella 5.
TH + 5.0
Bi-Pellas
Tufts Interventional Heart Failure Program

4. 2007: A Major Inflection Point in CV Medicine
Seyfarth: ISAR-SHOCK
(Impella 2.5 vs IABP)
Burkhoff : TH vs IABP Thiele : TH vs IABP (Cardiogenic Shock)
Stretch and Bonde JACC 2014

5. Hemodynamic Efficacy Without Clear Clinical Benefit in Small RCTs Comparing Acute MCS Options
Thiele and de Waha et al EHJ 2017

6. The Spectrum of Acute MCS Devices in 2017
Left Ventricle
Right Ventricle

7. Distinct Hemodynamic Profiles of Acute MCS
IABP ( Pressure + Volume) VA-ECMO ( Pressure +
Volume)
Tandem ( Pressure + Volume) Impella ( Pressure + Volume)
Annamalai et al JHLT 2016 Esposito et al ASAIO 2016 Kapur et al. ASAIO 2016

8. Detroit Cardiogenic Shock Initiative
The Hemodynamic Support Equation for Acute MCS From Arithmetic to Calculus
Hemodynamic Problem
Recovery
Hemo-Metabolic Problem
Time in Cardiogenic Shock
Death
Bridge to Recovery
Detroit Cardiogenic Shock Initiative
Rx: Hemodynamic Support
Circulatory and Ventricular
It’s Too Late for AMCS Impress Trial
Rx: Multi-organ Support
Unloading, Ventilator, CVVHD
Kapur and Esposito Curr Cardio Risk 2016 & F

9. Matching Patients and AMCS Pumps The Tufts Cardiogenic Shock Algorithm
Kapur & Esposito. F1000 Reviews 2017

10. Matching Patients and AMCS Pumps The Tufts Cardiogenic Shock Algorithm
Kapur & Esposito. Curr Cardiol. 2016

11. Hemodynamic Formulas to Assess RV Function
Cardiac Filling Pressures
RA / PCWP
>0.63 (RVF after LVAD) [14]
>0.86 (RVF in Acute MI)[31]
PA Pulsatility Index
(PASP-PADP) / RA
<1.85 (RVF after LVAD) [42]
<1.0 (RVF in Acute MI) [41]
Pulmonary Vascular
Resistance
mPA-PCWP / CO
>3.6 (RVF after LVAD) [16]
Trans-pulmonary Gradient
mPA-PCWP
Undetermined [36]
Diastolic Pulmonary
Gradient
PAD - PCWP
Undetermined [36, 37]
RV Stroke Work
(mPAP-RA) x SV x
<15 (RVF after LVAD) [16]
<10 (RVF after Acute MI) [40]
RV Stroke Work Index
(mPA-RA)/ SV Index
< (RVF after LVAD) [14,42]
Pulmonary Artery
Compliance
SV / (PASP-PADP)
<2.5 (RVF in Chronic Heart Failure) [39]
Elastance
PASP/ SV
Undetermined [38]
Right atrial (RA); Pulmonary artery (PA); PA systolic pressure (PASP); PA diastolic pressure (PADP); mean PA
pressure (mPAP); Pulmonary capillary wedge pressure (PCWP); Right ventricular failure (RVF); Left ventricular assist device (LVAD); Myocardial infarction (MI); Stroke volume (SV)
Kapur, Esposito, and Burkhoff et al Circulation 2017

12. From Pulsatile Load to PA Pulsatility
RAP = 22
RAP = 15
RAP = 7
Kiernan and Kapur. JIC 2009

13. Hemodynamic Signatures of RV Failure
The Pulmonary Artery Pulsatility Index (PAPi)
PA Pulse Pressure (Systolic – Diastolic)
PAPi
CVP (RA Pressure)
Korabathina & Kapur CCI 2012

14. Not All RV AMCS Devices are Created Equal
Kapur NK et al Circulation 2017

15. TandemHeart in Right Ventricular Failure
pRVAD = LPM sRVAD = LPM
Early RV Support =
Reduced In-hospital Mortality
Kapur NK et al. JACC Heart Failure 2013
Kapur NK et al. JHLT 2012

16. Percutaneous Support for RV Failure
Impella RP Implant RECOVER RIGHT TRIAL
Size 22 Fr pump on an 11 Fr catheter Flows > 4 L/min
Anderson MA et al JHLT 2015

17. Anderson MA et al. JHLT 2015

18. Direct RV Bypass: Impella RP for Acute RVF
Kapur, Esposito and Burkhoff et al Circulation 2017

19. Indirect RV Bypass: VA-ECMO for Acute RVF
Kapur, Esposito and Burkhoff et al Circulation 2017

20. Shock Profiles and Outcomes with Impella & VA-ECMO
BiV Support for BiV Congestion
100%
90%
80%
In-Hospital Mortality
60%
70%
60%
50%
40%
25%
30%
20%
10% 0%
LV Impella Alone
BiPella
Biventricular Congestion is Common in CGS
Univentricular Support For Univentricular Failure
Esposito & Kapur et al Under Review 2017

21. Impella 5.0 LVAD Activation Hemodynamics
5.0 Alone
CVP 28
CVP 24
LV AO

22. Impella 5.0 + RP Activation Hemodynamics
Bi-Pella
CVP 22
CVP 34
LV AO

23. LV Suction with Impella CP or 5.0 due to RV Failure

24. BiPella Supported Shock PCI : LM Culotte + LAD + LCx
Gorgeous Result Heroic Accomplishment Nice Job
Patient DIED. Don’t Ignore the Door to Support Time.

25. Clinical Success with Acute MCS: Less about the tools, More about how and when you use them
Kapur and Davila Eur H J 2017

26. Conclusions Acute MCS devices have distinct hemodynamic effects
Early hemodynamic support may limit conversion of hemodynamic shock (reversible) to hemo-metabolic shock (irreversible).
Defining hemodynamic status may improve optimal acute MCS device selection
Early identification of RVF and early use of RV AMCS improves outcomes. Don’t hang your hat on a number.
Look for hemodynamic signs of Bi-V failure when managing cardiogenic shock
Kapur et al Circulation 2017

27. Thank you To Learn More about Acute MCS & Hemodynamics
To Learn More about Acute MCS & Hemodynamics
December Berlin, Germany
Interventional Heart Failure
August 24-25, 2017: Barcelona, Spain