1. “Rise of the Machines” Todd D. Edwards MD FACC FACP FASNC

2. Merging of the Body and Machine

3. Disclosures I have nothing to disclose (unfortunately)

4. The Future? Number of heart transplant US 2013—2531 (down to 2174 in 2014) Number of LVADs US 2013—-over 2000 “in the future, heart transplants may be for patients than cannot take anticoagulation for their LVAD”-paraphrased from David Taylor MD, 2014 ISHLT President, Cleveland Clinic “I know you have an LVAD on the shelf and you don’t have a heart on the shelf”-paraphrased from Charles Nix, local LVAD recipient, Mississippi

5. Current survival statistics Sixth INTERMACS -JHLT June 2014 8 years of enrollment from >10,000 patients 80 percent 1 year and 70% 2 year survival at 2 years with continuous flow pumps

11. LVAD Survival Compared To OMM Therapy Park SJ. AHA Scientific Sessions, November 2010. a

13. HeartMate II—Widespread Approval And Adoption  Received European CE Mark in November 2005  Received FDA approval for BTT in April 2008  Received Health Canada approval in May 2009  Received FDA approval for DT in January 2010  Distributed throughout Asia and Australia 2010 2005 2008 2007 2006 2009 FDA approval for BTT April 2008 European CE Mark November 2005 FDA approval for DT January 2010

18. Operative 30-day survival was 96% and patients achieved 90% successful outcomes at 6 months and 85% at 1 year. HeartMate II Post-Approval Study Actuarial Survival Starling, Naka, Boyle, et al. JACC, in press 2010.

19. Design Features  Optimized blood flow  Low thrombosis risk  Low anticoagulation requirements  Reliability

24. Drugs and devices used post implant Beta blockers ACE inhibitors (or alternatives) Digoxin Spirinolactone AICD

25. LVAD versus BIVAD CVP less than 10 CVP/PAW ratio less than 0.65 RVSWI greater than 600 and ideally 900 RV appearance on echo with size and contractility Severity of pulmonary hypertension

45. LVAD preimplant goals Renal-BUN less than 50 and Cr less than 2.5 Heme-INR less than 1.2/Hgb greater than 10/platelets greater than 150k Nutrition-albumin greater than 3/prealbumin greater than 15/transferrin greater than 250 Hepatic-total bilirubin less than 2.5/ast and alt less than 2X normal Hemodynamics-RA less than 15 and PAW less than 24

46. Michigan RV risk score Vasopressors—4 points AST greater than 80-2 points Total Bilirubin greater than 2-2.5 points Creatinine greater than 2.3 Total ——less than 3.0 -low risk Total——greater than or equal to 5.5-high risk

51. TAH versus BIVAD BIVAD failure less ominous than TAH failure TAH eliminate issues of malfunctioning heart valves, arrhythmias, and AICD issues Survival to transplant- TAH 89%, BIVAD 50%, and LVAD 79% Survival post transplant same in TAH and BIVAD

52. What pump? choices are LVAD, longterm BIVAD, intermediate term Centrimag, not eligible for any pump

53. What pump? 1) 22 male with fulminant myocarditis over 2 week course with nonspecific endomyocardial biopsy with LVEF 15, Milrinone at 0.75 mcg/kg/min, Dobutamine at 10 mcg/kg/min, CVP 18, RVSWI 350, IABP 1:1, CI 2.0, GFR has dropped over past 3 days but still 45 cc/min

54. What pump? 1) LVAD 2) longterm BIVAD 3) intermediate term Centrimag 4) no pump

55. What pump? 45 female with dilated cardiomyopathy with LVEF 20, mastectomy for breast cancer 2 years ago, CVP 20, RVSWI 450, PVR 3.5 with Flolan challenge, PA mean 45

56. What pump? 1) LVAD 2) longterm BIVAD 3) intermediate term Centrimag 4) no pump

57. What pump? 72 male with ischemic cardiomyopathy with LVEF 25, CPX mvO2 12, PVR 2.5, cvp/paw 0.5, RVSWI 850, GFR 50, bilirubin 1.5

58. What pump? 1) LVAD 2) longterm BIVAD 3) intermediate term Centrimag 4) no pump

59. What pump? 32 male with dilated cardiomyopathy with LVEF 20, active transplant listed at 3 centers due to O blood type, 2 inotropes in ICU, IABP, CVP 14, RVSWI 450, GFR 45, bilirubin 1.8, SVO2 at rest 52 and drops to mid 30”s getting into chair

60. What pump? 1) LVAD 2) longterm BIVAD 3) intermediate term Centrimag 4) no pump

61. I would like to thank my tech support.