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

3. Inclusion criteria of Mechanical Circulatory Support Cardiogenic shock criteria Cardiogenic shock criteria Maximal inotropic support Maximal inotropic support IABP IABP

4. Exclusion criteria of Mechanical Circulatory Support BUN > 100 mg/dl BUN > 100 mg/dl Cr > 5 mg/dl Cr > 5 mg/dl Chronic lung disease Chronic lung disease Chronic liver disease Chronic liver disease Metastatic cancer Metastatic cancer Sepsis Sepsis Neurological deficit Neurological deficit Post cardiotomy cardiogenic shock Post cardiotomy cardiogenic shock Age > 65 yr ( if bridge to transplant ) Age > 65 yr ( if bridge to transplant )

5. Definition of cardiogenic shock Cardiac output index < 2 lit/min/m 2 Cardiac output index < 2 lit/min/m 2 Systolic blood pressure < 90 mmHg Systolic blood pressure < 90 mmHg Left or right atrial pressure > 20 mmHg Left or right atrial pressure > 20 mmHg Urine output < 20 cc/hr Urine output < 20 cc/hr Systemic vascular resistance > 2100 dynes-sec.cm -5 Systemic vascular resistance > 2100 dynes-sec.cm -5

6. Indication of IABP Cardiogenic shock Cardiogenic shock Postcardiotomy Postcardiotomy Associated with acute myocardial infarction Associated with acute myocardial infarction Mechanical complications of myocardial infarction Mechanical complications of myocardial infarction Mitral regurgitation Mitral regurgitation Ventricular septal defect Ventricular septal defect In association with coronary artery bypass surgery In association with coronary artery bypass surgery Preoperative insertion Preoperative insertion Patients with severe left ventricular dysfunction Patients with severe left ventricular dysfunction Patients with intractable ischemic arrhythmias Patients with intractable ischemic arrhythmias Postoperative insertion Postoperative insertion postcardiotomy cardiogenic shock postcardiotomy cardiogenic shock

7. Indication of IABP (continue) In association with nonsurgical revascularization In association with nonsurgical revascularization Hemodynamically unstable infarct patients Hemodynamically unstable infarct patients High-risk coronary angioplasty High-risk coronary angioplasty Patients with severe left ventricular dysfunction Patients with severe left ventricular dysfunction Complex coronary artery disease Complex coronary artery disease Stabilization of cardiac transplant recipient before insertion of ventricular assist device Stabilization of cardiac transplant recipient before insertion of ventricular assist device Postinfarction angina Postinfarction angina Ventricular arrhythmias related to ischemia Ventricular arrhythmias related to ischemia

8. Contraindication of the use of IABP Absolute: Absolute: Aortic valve insufficiency Aortic valve insufficiency Aortic dissection Aortic dissection Relative: Relative: Femoral arterial insertion Femoral arterial insertion Abdominal aortic aneurysm Abdominal aortic aneurysm Severe calcific aortoilliac or femoral arterial disease Severe calcific aortoilliac or femoral arterial disease Percutaneous insertion Percutaneous insertion Recent ipsilateral groin inceision Recent ipsilateral groin inceision Morbid obesity Morbid obesity

9. Complication of IABP Minor Minor Bleeding at the insertion site Bleeding at the insertion site Superficial wound infection Superficial wound infection Lymphocele Lymphocele Peritoneal perforation Peritoneal perforation Major Major Limb ischemia requiring thrombectomy, revascularization, or Limb ischemia requiring thrombectomy, revascularization, or amputation amputation Aortic dissection Aortic dissection Aortoiliac laceration Aortoiliac laceration Femoral artery pseudoaneurysm Femoral artery pseudoaneurysm Retroperitoneal hemorrhage Retroperitoneal hemorrhage Renal ischemia from mal position Renal ischemia from mal position Myocardial ischemia from poor timing of balloon augmentation Myocardial ischemia from poor timing of balloon augmentation Deep wound infection requiring operative debridement Deep wound infection requiring operative debridement

10. Medication of VAD Intended useTherapeutic GoalDevises Bridge to recoveryTemporary supportIABP Centrifugal pump ECMO Abiomed HeartMate Novacor Bridge to bridgeStabilization to LVAD/BiVAD Abiomed Centrifugal pump ECMO Bridge to transplantationSupport to transplantation HeartMate Novacor Thoratec BiVAD Abiocor/TAH Axial flow pump DestinationPermanent supportHeartMate Novacor Abiocor/TAH LionHeart

11. Comparison between different VADs DevisesQuality of lifeShort –term survival (days per week) Long-term survival (months) IABP Centrifugal pump ECMO Abiomed HeartMate Novacor + +++ ++ + +++ 0 +++ Abiomed Centrifugal pump ECMO ++++++ ++ + 000000 HeartMate Novacor Thoratec BiVAD Abiocor/TAH Axial flow pump +++ ++ +++ ++ + ++ +++ ++ + ++ HeartMate Novacor Abiocor/TAH LionHeart +++ Undocumented  +++

12. LVAD Screening score VariableRelative riskweight Mechanical ventilation5.34 Postcardiotomy3.32 Prior LVAD3.32 Central venous pressure >16 mm Hg2.11 Prothrombin time >16 sec2.11 Excluded by multivariable analysis: Prior RVAD Coronary artery disease Acute myocardial infarction Urine output <30 ml/hr Reoperative surgery 3.2 2.0 1.7 1.2

13. Hemodynamic status during mechanical of ventricular assistance CVP (mmHg)LAP (mmHg)Systolic Aop (mmHg) CI (L/min/m 2 ) dx 15-20<15>90>2Satisfactory pumping <15 <90<2Hypovolemia 15-20>20<90<2Inlet cannula obstraction >20<15<90<2RV falure

14. Device selection depends on: Availability Availability Physicians experiences Physicians experiences

15. FDA approved several VADs 1. Abiomed biventricular system (BVS) 5000i for postcardiotomy and post MI cardiogenic shock 2. The thoratic poracorporeal device, Novacor and HeartMate for bridge to transplantation. 3. The HeartMate for destination therapy 4. Implantable device as LionHeart, Jarvik, HeartMate II, DeBakey and Cor-Aide.

16. Short term devices Extracorporeal centrifugal pump Extracorporeal centrifugal pump Extracorporeal membrane oxygenation (ECMO) Extracorporeal membrane oxygenation (ECMO) ABIOMED BVS 5000i ABIOMED BVS 5000i

17. The Dbiomed biventricular system (BVS) 5000i

18. Long term device Pulsatile devices Pulsatile devices HeartMate LVAD (Implantable) HeartMate LVAD (Implantable) Novacor (Implantable) Novacor (Implantable) Thoratic Thoratic Total artificial heart Total artificial heart Cardiowest Cardiowest Abiocor Abiocor Axial flow pumps Axial flow pumps Micromed debakey VAD Micromed debakey VAD HeartMate II HeartMate II Jarvik 2000 Jarvik 2000 Totally implantable pulsatile devices Totally implantable pulsatile devices LionHeart LVD 200 LionHeart LVD 200 Novacor II Novacor II

19. HeartMate

20. Novacor

21. Thoratec paracorporeal VAD

22. Abiocor

23. MicroMed DeBakey

24. Jarvik 2000

25. LionHeart

26. Major Complication ComplicationDefinition BleedingBlood loss resulting in at least one of the following: 1. Transfusion of >6 units of RBC in 24 h 2. Reoperation 3. Death 4. Any other intervention for a hemorrhage Cerebrovascular accident Any central nervous deficit that is sudden in onset and persists for more than 24 h. Deficit must be confirmed as having an embolic origin by conventional diagnostic methods (eg, CT-scan) or can be demonstrated to result from an infarct (at autopsy) InfectionAny confirmed infection All infections should be categorized as: exit site, pump pocket, systemic/septiaemia, other (eg, respiratory) Right sided heart failure Cardiac Index 6 h in the absence of device failure, anatomic restrictions, left-sided dysfunction or hypovolemia (CVP >18 mmHg), requiring intervention Liver failureBilirubin >5 mg/dL

27. Complications during mechanical circulatory support Novacor (n=95) HeartMate (n=58) LionHeart (n=9) Thoratec IVAD (n=3) Cerebrovascular accident 30.1%9.3%44.4%- Bleeding24.7%35.2%66.7%100% Pocket infection7.3%10.2%-- Driveline infection 20%25.3%-- Hemolysis-1.9%22.2%- Liver failure14.5%11.1%44.4%1/3 Right heart failure 24.5%25.9%14.3%- Gastrointestinal complications 19.3%9.3%44.4%- Arrhythmias3.15%1.7%--