Christopher Hayward's SIN Talk: LVAD

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Cardiologist Chris Hayward talks about LVAD (Left ventricular assist devices) for the Sydney Intensive Network. The audio is found on www.intensivecarenetwork.com

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Christopher Hayward's SIN Talk: LVAD

  1. 1. Mechanical Circulatory Support Indications / contraindications Devices and Outcomes Christopher Hayward Cardiologist Heart Failure Transplant Unit
  2. 2. Stevenson Circ 2005
  3. 3. LVAD indications Need LVAD - Bridge to transplant, destination or recovery NYHA IV for 60–90 days Maximal tolerated medical therapy +/- CRT / ICD Chronic inotrope dependence LVEF <25%, PCWP 20 mmHg SBP 80–90 mm Hg or CI 2 L/min/m2 or renal or RV function Consider LVAD NYHA IV for 30 days Maximal tolerated medical therapy and CRT/ICD if indicated Intermittent inotrope dependence LVEF <25%, Peak VO2 <12 mL/kg/min Indication to enable HTx PVR <5 Woods units, reversible secondary PHT to chronic HF Reversible GFR <25–30 mL/min/1.73 m2 Lund et al EJHF 2010
  4. 4. Contraindications Cardiac issues Non-systolic HF Cor pulmonale, Severe RV dysfunction or Multi-organ failure Moderate or severe aortic regurgitation that will not be corrected Mechanical aortic valve that will not be converted to bioprosthesis Hypertrophic cardiomyopathy, VSD or congenital heart disease Non-cardiac issues Terminal co-morbidity; e.g. renal disease (haemodialysis or Crt > 250umol/L) Metastatic or advanced cancer, severe liver disease, severe lung disease or home O2, severe PVD, or unresolved CVA or severe neuromuscular disorder Active uncontrolled systemic infection or risk of infection Active severe bleeding / platelet count <50 000 x109/L, HITTS Management issues Intolerance to the anticoagulant regimen specific to device Body surface area 1.2–1.5 m2 or other dimensional or technical limitation Inability to grasp risks and benefits and provide informed consent / interpret alarms Psychosocial limitations, driveline / medication non-compliance Lund et al EJHF 2010
  5. 5. HeartMate I & II Slaughter et al NEJM 2009
  6. 6. HeartMate XVE HeartMate II
  7. 7. HeartMate XVE / II Survival REMATCH medical therapy Medical therapy Rose et al NEJM 2001 Slaughter et al NEJM 2009
  8. 8. LVAD implants Kirklin et al INTERMACS-5. J Heart Lung Transplant 2013
  9. 9. INTERMACS Level Pre-Implant for 1092 Primary LVAD (June 2006–March 2009) n % 1 Critical cardiogenic shock 328 30 2 Progressive decline 437 40 3 Stable but inotrope dependent 168 15 4 Recurrent advanced HF 106 10 5 Exertion intolerant 21 2 6 Exertion limited 12 1 7 Advanced NYHA III 20 2 Kirklins et al INTERMACS 2. JHLT 2010
  10. 10. HeartWare HVAD Wieselthaler et al JHLT June 2010
  11. 11. VentrAssist HeartWare
  12. 12. HeartWare Aaronson et al Circulation 2012
  13. 13. ADVANCE Trial
  14. 14. HVAD ADVANCE Trial Day/Month/Year Footnote to go here Page 14
  15. 15. • Medical history • • • Aetiology HF Hospitalisations Past chest surgery • Treatment • • • Medications Devices ICU support • Risk of RV failure • • • Echo – RV function RHC – PHT RVSWI • Outcome Risks • • • • Day/Month/Year Footnote to go here Renal function Bleeding risk Infection risk Social support Page 15
  16. 16. LVADs and daily activities Hu et al J Cardiac Failure 2013
  17. 17. LVADs and daily activities Hu et al J Cardiac Failure 2013
  18. 18. Maximum pacing rate 140 p=0.001 120 100 p=0.58 80 p=0.88 60 40 p=0.91 20 0 Baseline Max HR HR (bpm) 85.5 126.1 FLOW (L/min) 5.22 5.16 MAP (mmHg) 75 72.6 LVEDD (mm) 55 53.9 Muthiah et al. ASAIO 2012
  19. 19. Posture and pump flow Muthiah et al ISHLT 2013
  20. 20. Pump power (W) Pump flow estimate (L/min) Pump thrombosis and Rx 12 8 4 0 6 5 4 Baseline Thrombosis Tirofiban 30mins Tirofiban 20 hrs Prethrombolysis Post thrombolysis 20 seconds Alteplase 15mg Muthiah et al Artificial Organs 2013
  21. 21. St Vincent’s Hosp MCS program 145 patients • 36 pulsatile LVAD (HeartMate VE, XVE) • 104 continuous flow LVAD (33 Ventrassist, 71 HeartWare) • 5 Total artificial hearts 25 Survival 1 20 0.9 TAH CF Puls 15 0.8 0.7 0.6 0.5 10 0.4 0.3 5 0.2 0.1 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 0 1994 0 0 100 200 300 400 500 600 700 Days On Pump CF Puls TAH As at June 30 2013
  22. 22. St Vincent’s Hosp MCS program 105 cfLVAD patients • 33 Ventrassist, 72 HeartWare • (5 Syncardia total artificial hearts) 25 • 7 Bi-VAD systems LVAD TAH BiVAD 20 15 10 5 0 04-05 05-06 06-07 07-08 08-09 09-10 10-11 11-12 12-13 13-14 As at Aug 20 2013
  23. 23. BiVAD
  24. 24. BiVAD CXR
  25. 25. Cardioversion
  26. 26. The Future MVAD 1/3 size of HVAD no need for median sternotomy same impeller technology promising in animal studies IV-VAD 1/10 size of HVAD Intravascular pump – percutaneous Not intended to provide full cardiac support TETS - Transcutaneous Energy Transfer System Implanted battery pack to be charged across the skin Will eliminate need for drivelines

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