1. Revascularizaton of Ischemic DCM Percutaneous Revascularization and Hemodynamic Support Matthew R. Wolff, M.D. University of Wisconsin Disclosures: Cordis / Johnson and Johnson Abbott

2. Patient E.T. 84 y.o. retired game warden 6 month history of progressive dyspnea (~15 feet), orthopnea, PND No angina Echo: dilated cardiomyopathy EF = 20% Moderate CRF Cr = 2.0 mg/dl Occluded left internal carotid artery

7. Percutaneous LVAD (TandemHeart TM ) Logistic Euroscore 36.8 %

8. Percutaneous LVAD insertion (TandemHeart TM ) 21 Fr. Left atrial inflow cannulae 15 or 17 Fr. Femoral arterial outflow catheter 4 – 4.5 L/min flow

14. AHA Heart Disease and Stroke Statistics – 2005 Update Prevalence of Congestive Heart Failure by Age (NHANES 1999 – 2004)

15. Hemodynamic Support for High-Risk PCI Pressors and intravenous inotropes IABP  Reduced afterload  Increased diastolic perfusion pressure  Increased forward flow - MODEST Percutaneous Left Ventricular Assist

17. TandemHeart Support for Elective PCI in High-Risk Ischemic DCM at UW (11/21 cases from 2004-6) Preoperative Characteristics Age (yrs)73 ± 14 Unprotected LMCA5/11 EF (%)24 ± 8 Logistic Euroscore (30 d mortality, %) 32 ± 19

18. TandemHeart Support for Elective PCI in High-Risk Ischemic DCM Procedural Outcome Procedural Time (min)170 ± 37 Time to Pump (min)45 ± 6 Preclose/Hemostasis in Lab11/11 Mean Flow (L/min)3.1 ± 0.2 Vessels Treated2.3 ±1.2 Stents Deployed3.8 ± 1.7

19. TandemHeart Support for Elective PCI in High-Risk Ischemic DCM Hospital Course 30 day Survival10/11 Vascular Complications (Transfusion) 1/11 Other Complications (Atrial Lead Dislodged) 1/11

20. TandemHeart Support for Elective PCI in High-Risk Ischemic DCM Mean Follow up 20 ± 11 Months Survival (%)73 (deaths at 3, 4, 4 months) EF (%)44 ± 7

21. TandemHeart Support for Elective PCI in High- Risk Ischemic DCM ( 7 Survivors with ≥ 12 month F/U)

22. Indications for pLVAD High-risk PCI Cardiogenic shock  AMI  Decompensated chronic heart failure Post-op CABG RV support  RV infarct  Post-op CABG  Bi-ventricular failure with LVAD

23. Impella Recover LP 2.5 System NOT FOR SALE IN THE UNITED STATES *Caution: Investigational Device, limited by Federal law to Investigational Use 12 Fr Distal 2.5 L/min flow

24. Who to Revascularize? Myocardial Viability Clinical– angina MRI PET Thallium Dobutamine Echo

25. Tarakji, K. G. et al. Circulation 2006;113:230-237 Propensity-matched patients undergoing PET viability testing (306/765) at the Cleveland Clinic

26. Tarakji, K. G. et al. Circulation 2006;113:230-237 Association between predicted 3-year mortality and the amount of compromised viable myocardium (ischemic and hibernating) determined by PET/FDG study according to performance of early intervention among propensity-matched patients

27. Copyright ©2001 American College of Cardiology Foundation. Restrictions may apply. Berger, P. B. et al. J Am Coll Cardiol 2001;38:1440-1449 How to revascularize? BARI Survival curves of patients with three-vessel disease and reduced ventricular function undergoing percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) in the Bypass Angioplasty Revascularization Investigation

28. Copyright ©2001 American College of Cardiology Foundation. Restrictions may apply. Morrison, D. A. et al. J Am Coll Cardiol 2001;38:143-149 AWESOME Kaplan-Meier survival plot of coronary artery bypass graft surgery (CABG) (circles) versus percutaneous coronary intervention (PCI) (squares)

29. Copyright ©2001 American College of Cardiology Foundation. Restrictions may apply. Morrison, D. A. et al. J Am Coll Cardiol 2001;38:143-149 AWESOME Kaplan-Meier plot of survival free of unstable angina (UA) or repeat revascularization for coronary artery bypass graft surgery (CABG) (circles) versus percutaneous coronary intervention (PCI) (squares)

30. DES in Higher Risk Settings

31. DES vs CABG Trials Syntax Cardia Freedom

32. Percutaneous Therapy for DCM PCI (with or without hemodynamic support) Percutaneous valve therapies Cellular therapies