1. Ihab Alomari, MD, FACC Assistant professor – Interventional Cardiology University of California, Irvine Division of Cardiology Cath Lab Essentials : LV Assist Devices for Hemodynamic Support (IABP, Impella, Tandem Heart)

2. Goals To compare mechanical LV assistance and percutaneous support devices in terms of their designs and ideal applications To compare mechanical LV assistance and percutaneous support devices in terms of their designs and ideal applications Review current indications for commonly used devices Review current indications for commonly used devices Describe the factors that should be considered when choosing the most appropriate devices Describe the factors that should be considered when choosing the most appropriate devices

3. Causes of Cardiogenic Shock Predominant LV Failure 74.5% Acute Severe MR 8.3% VSD 4.6% Other 7.5% Shock Registry JACC 2000 35:1063

6. Diastolic pressure  CO  MAP  LV Wall Tension  PCWP  Oxygen Demand  LV Volume  Coronary Blood Flow 

8. Nair et al Journal of Invasive Cardiology 2011

9. Indications of IABP : High Risk PCIHigh Risk PCI Cardiogenic ShockCardiogenic Shock Refractory IschemiaRefractory Ischemia MR or VSD after MIMR or VSD after MI Contraindications : Peripheral vascular diseasePeripheral vascular disease Aortic regurgitationAortic regurgitation Aortic Dissection Aortic Dissection

10. Complications of IABP Vascular Access bleeding/complications Limb Ischemia Infection Aortic arch trauma Balloon rupture Air embolism risk

13.  CO  MAP  PCWP Hemodynamic Effects Tandem Heart Left atrial-to-femoral arterial LVAD Left atrial-to-femoral arterial LVAD 21F venous transeptal cannula 21F venous transeptal cannula 17F arterial cannula 17F arterial cannula Maximum flow 4-5L/min Maximum flow 4-5L/min

16. Impella Axial flow pump Axial flow pump Much simpler to use Much simpler to use Increases cardiac output & unloads LV Increases cardiac output & unloads LV LP 2.5 – CO 2.5 L/min LP 2.5 – CO 2.5 L/min CP CP 14 F percutaneous approach; Maximum 4 L flow 14 F percutaneous approach; Maximum 4 L flow LP 5.0L LP 5.0L 21 F surgical cutdown; Maximum 5L flow 21 F surgical cutdown; Maximum 5L flow

17. Impella insertion The Impella CP is built on the same foundation as the Impella 2.5, but provides more than a 50% increase in pumped blood volume (approx. 4L/min)

18. Mimic Heart’s Natural Function Inflow (ventricle) Outflow (aortic root) aortic valve O 2 Demand O 2 Supply Cardiac Power Output EDV, EDP AOP Flow Principles of Impella Design Myocardial ProtectionSystemic Hemodynamic Support Naidu S S Circulation 2011;123:533-543

19. Impella 2.5 High risk PCI patient Demonstrated net CO increase with simultaneous ventricular unloading 7.4 L/min Native CO Impella (2.4) LV unloading CO Increase 6.0 L/min Systemic Hemodynamic Support CO Increase … Valgimigli et al.,Cath Cardiov Interv (2005) 5.0

23. Extra Corporeal Membrane Oxygenation (ECMO) Compared to IABP, Impella and Tandem heart ECHO has shown to improve long term survivability