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Heart Failure and VADs Bridges for Broken Hearts

Heart Failure and VADs Bridges for Broken Hearts. Priya Gaiha MD MBA May 26 th 2010 University of Kentucky Grand Rounds. Objectives. What is the pathophysiology of heart failure? Why is heart failure relevant? What is the history of mechanical circulatory support?

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Heart Failure and VADs Bridges for Broken Hearts

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  1. Heart Failure and VADsBridges for Broken Hearts Priya Gaiha MD MBA May 26th 2010 University of Kentucky Grand Rounds

  2. Objectives • What is the pathophysiology of heart failure? • Why is heart failure relevant? • What is the history of mechanical circulatory support? • What are the various types of ventricular assist devices (VADs)? • How and when are VADs used? • What is the next generation of VADs?

  3. Etiologies of cardiac failure • Coronary artery disease • Idiopathic cardiomyopathy • Peripartumcardiomyopathy • Dilated cardiomyopathy • Ischemic cardiomyopathy • Acute valvular disease • Arrhythmia (supraventricular or ventricular) • Myocarditis • Congenital heart disease • Drug induced • Diabetes mellitus • Hypertension

  4. Pathogenesis of Heart Failure Mann, D. Circulation 1999;100;999-1008

  5. NYHA classes

  6. Relevance

  7. CVD deaths vs. cancer deaths by age (US) NCHS 2006

  8. CVD and other major causes of death for all males and females A CVD B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease NCHS and NHLBI 2006

  9. Hospital Discharges (in millions) for the 10 Leading diagnostic Groups NHDS/NCHS and NHLBI 2006

  10. Economic Ramifications www.americanheart.org

  11. Options for Advanced CHF • Transplant ($$$$$$) • Assist Device ($$$) • Die($) • Preceded by 6-12 months of medical therapy • Multiple hospital re-admissions • Hospice ($$$)

  12. Transplant

  13. UK

  14. ADULT HEART TRANSPLANTATIONKaplan-Meier Survival by Era (Transplants: 1/1982 – 6/2005) Survival (%) ISHLT 2007 J Heart Lung Transplant 2007;26: 769-781

  15. ADULT HEART RECIPIENTSFunctional Status of Surviving Recipients(Follow-ups: 1995 - June 2008) ISHLT 2009

  16. Historical Events 1953: Gibbon’s heart-lung machine successfully used during ASD repair 1950 1960 1970 1980 1990 2000 2010

  17. John Gibbon • Born in 1903 in Philadelphia • 4th generation physician • 1931: watched a young woman postop from cholecystectomy die from PE • Worked for 20 years on dogs to refine bypass machine • Received financial and technical support from Thomas Watson of IBM • 1953: first successful use of machine on patient during ASD repair

  18. Historical Events 1953: Gibbon’s heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1950 1960 1970 1980 1990 2000 2010

  19. Historical Events 1953: Gibbon’s heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1950 1960 1970 1980 1990 2000 2010 1967: Barnard performs first heart transplant

  20. Christian Barnard • Born in South Africa in 1922 • Studied heart surgery at the University of Minnesota then returned to set up a cardiac unit in Cape Town. • December 1967: transplanted the heart of a road accident victim into a 59 year old patient • Patient only survived 18 days due to infectious complications

  21. Historical Events 1953: Gibbon’s heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1968: Shumway performs first heart transplant in US 1950 1960 1970 1980 1990 2000 2010 1967: Barnard performs first heart transplant

  22. Norm Shumway • Stanford University • 1959: transplanted the heart of a dog into a 2-year-old mongrel • 1968: performed the first heart transplant in the US on a 54 year old steel worker who lived 14 days • Pioneered immunosuppression • 1981: performed the world’s first successful heart-lung transplant

  23. Historical Events 1953: Gibbon’s heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1968: Shumway performs first heart transplant in US 1950 1960 1970 1980 1990 2000 2010 1969: Cooley implants VAD as bridge to transplant 1967: Barnard performs first heart transplant

  24. Willem Kolff • “Father of artificial organs” • 1911: Born in the Netherlands • 1940: Established the first blood bank in Europe • 1943: Developed the first artificial kidney • 1957: Developed the first artificial heart that was successfully transplanted into an animal

  25. Historical Events 1953: Gibbon’s heart-lung machine successfully used during ASD repair 1984: implantation of Jarvik-7 artificial heart by DeVries 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1968: Shumway performs first heart transplant in US 1950 1960 1970 1980 1990 2000 2010 1969: Cooley implants VAD as bridge to transplant 1967: Barnard performs first heart transplant

  26. William DeVries • Born in 1943 • Trained at the University of Utah and Duke University • Worked with Kolff to implant artificial heart in animals • 1982: Implanted first artificial heart into Seattle dentist Barney Clark • 1985: Implanted 2nd Jarvik into Bill Schroeder in Louisville KY

  27. Historical Events 1953: Gibbon’s heart-lung machine successfully used during ASD repair 1984: implantation of Jarvik-7 artificial heart by DeVries 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1994: FDA approval of LVAD as bridge to transplant 1968: Shumway performs first heart transplant in US 1950 1960 1970 1980 1990 2000 2010 1969: Cooley implants VAD as bridge to transplant 1967: Barnard performs first heart transplant

  28. Historical Events 1953: Gibbon’s heart-lung machine successfully used during ASD repair 1984: implantation of Jarvik-7 artificial heart by DeVries 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1994: FDA approval of LVAD as bridge to transplant 1968: Shumway performs first heart transplant in US 1950 1960 1970 1980 1990 2000 2010 1969: Cooley implants VAD as bridge to transplant 2004: REMATCH trial 1967: Barnard performs first heart transplant

  29. Historical Events 1953: Gibbon’s heart-lung machine successfully used during ASD repair Heart mate II approved for destination therapy 1984: implantation of Jarvik-7 artificial heart by DeVries 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1994: FDA approval of LVAD as bridge to transplant 1968: Shumway performs first heart transplant in US 1950 1960 1970 1980 1990 2000 2010 1969: Cooley implants VAD as bridge to transplant 2004: REMATCH trial 1967: Barnard performs first heart transplant

  30. Criteria for patient selection • Class IV HF • Failing hemodynamics • Persistent pulmonary edema • Neurologic impairment or renal failure due to low perfusion • Fluid and electrolyte imbalance related to low cardiac output • Severe arrhythmias despite medical therapy

  31. Indications for support • SBP<80 mm Hg • MAP<65 mm Hg • CI<2.0 L/min/m2 • PCWP>20 mm Hg • SVR>2100 dynes-sec/cm Circulation 2005; 112: 438-448

  32. INTERMACS: Patient Selection Patient Profile/ Status:INTERMACS Levels • 1. Critical cardiogenic shock • Progressive decline • Stable but inotrope dependent • Recurrent advanced HF • Exertion intolerant • Exertion limited • Advanced NYHA III

  33. INTERMACS Profiles Inotrope Dependent 2006-2007 data

  34. Short term Device options ECMO IABP Tandem Heart Bridge to recovery Bridge to decision Centrimag AbioMed 5000 Impella Circulation 112 (3): 438

  35. Intraaortic Balloon Pump (IABP) • Developed in late 1960s • Counterpulsation is synchronized to the EKG or arterial waveforms • Increase coronary perfusion • Decrease left ventricular stroke work and myocardial oxygen requirements • Most widely used form of mechanical circulatory support • Indications for its use include • Failure to wean from cardiopulmonary bypass • Cardiogenic shock after MI • Heart failure • Refractory ventricular arrhythmias with ongoing ischemia

  36. Bridge to bridge: ECMO • Immediately stabilize circulation • Improve end organ perfusion • Overall survival comparable between ECMO + LVAD versus LVAD alone • Clinical indicators of poor outcome after ECMO: consider VAD implantation carefully • Elevated blood lactate levels • Elevated LFTs Pagani et al. Ann Thorac Surg 2000; 70:1977-85

  37. Case #1 • 57 yo male • Transferred to UK for cardiogenic shock secondary to heart failure • Taken to cath lab for emergent IABP placement • EF<10% • Sv02 20s • Maximal inotropic support: 4 pressors • Stabilized on VA-ECMO • Supported for 7 days • Improvement in hepatic and renal dysfunction • Heartmate II implanted

  38. Centrifugal pumps • Acute hemodynamic support • Continuous flow • Extracorporeal • LV, RV or biventricular support • Wide availability • Ease of use • Relatively low cost • Limited duration of support • Bridge to recovery • Bridge to decision Hoy et al. Ann Thorac Surg 2000; 70:1259-63

  39. Tandem hearts • Acute hemodynamic support • Centrifugal pump • Percutaneous placement • LV support via transseptal cannula • Used in high risk cardiac catheterization procedures • Risk of vascular injuries due to cannula size

  40. Levitronix Centrimag • Newer generation • Centifugal pump • Continuous flow • Extracorporeal • Impellar within the pump rotates in contact-free manner • Increased durability • Minimal thrombus formation and hemolysis of RBCs

  41. Abiomed 5000 • Extracorporeal • Pneumatic pulsatile pumps • Uni- or biventricular support • Bridge to transplant • Easy to insert and operate so used in community hospitals • Flows 6L/min Circulation. 2005;112:438-448.

  42. Impella • Axial flow pumps • Acute hemodynamic support • Miniaturized impellar pump in catheter • Helical catheter tip placed across aortic valve and left ventricle • Percutaneous or direct placement • Flow 4.5L/min • Bridge to recovery

  43. Case #2 • 54 yo male • Postcardiotomy cardiogenic shock after mitral valve repair and CABGx 4v • Came off CPB but then decompensated • Initially treated with Impella placement • Developed hemolysis: converted to Abiomed 5000 BVS pump 48hrs later • Transferred to UK • Successfully explanted after 7 days of support • Functional at home, EF~45%

  44. Long term Device options Heartmate II Heartmate XVE Bridge to transplant Thoratec CardioWest TAH Jarvik 2000 Circulation 112 (3): 438

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