EMGuideWire's Radiology Reading Room: Mechanical Circulatory Support Devices

1. Mechanical Circulatory Support Devices Blaire Langa, NP, Claire Lawson, NP, Morgan Penzler, MD, Ashley Moore Gibbs, DNP, Jenna Pallansch, MD, Gabriella Rivera Camacho, MD Department of Emergency Medicine Sanger Heart & Vascular Institute Michael A. Gibbs, MD, Lead Editor Richard Musialowski, MD, Cardiology Editor Laszlo Littmann, MD, ECG Subject Matter Expert Carolinas Medical Center Imaging Mastery Project: Cardiology

2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The Sanger Heart & Vascular Institute provides expert Cardiology support.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and all ages have been changed to protect patient confidentiality.

3. Process • Many are providing clinical cases and presentations are then shared with all contributors on our departmental educational website. • Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. • We will review a series of chest X-ray/imaging case studies and discuss an approach assessing patients with Mechanical Circulatory Support Devices.

4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum

6. It’s All About The Anatomy!

7. Selected Embedded References: Sternberg R. Targeted Evaluation of Patients With Left Ventricular Assist Devices and Shock or Hypotension. Annals of Emergency Medicine. 2020; 76:34-41. Devore AD. Medical Management of Patients With a Left Ventricular Assist Device for the Non-Left Ventricular Assist Device Specialist. Journal of the American College of Cardiology. 2017; 5(9):621-631. Long B. Left Ventricular Assist Devices And Their Complications. American Journal of Emergency Medicine. 2019; 37:1562-1570. Cook JL. Recommendations for the Use of Mechanical Circulatory Support: Ambulatory and Community Patient Care. Circulation. 2017; 135:e1145–e1158. DOI: 10.1161/CIR.0000000000000507. Kreiger J. The Use of ECMO in Cardiopulmonary Failure in Patients with COVID-19. Journal of the American College of Cardiology. 2020. www.jacc.org. August 4, 2020. Mehra MR. A Fully Magnetically Levitated Circulatory Pump for Advanced Heart Failure. New England Journal of Medicine. 2017:376:440-50.

8. Mechanical Circulatory Support Devices Carolinas Medical Center Case Studies Are Included

9. Mechanical Circulatory Support Devices Percutaneous • Intra aortic balloon pump (IABP) • Impella™ • Extracorporeal membrane oxygenation (ECMO) Durable • HeartMate II™ • HeartMate III™ • HeartWare™

10. Intra Aortic Balloon Pump Femoral Subclavian

11. Intra Aortic Balloon Pump

13. Marker Tip Seen On CXR

14. Read online: Scan this QR code with your smart phone or mobile device to read online. biventricular – and can be temporary or permanent, based on the clinical indication. Temporary VADs are used as a bridge to myocardial recovery or during cardiac transplantation. Permanent VADs may be used for the same reason but are typically selected in patients who require long- term treatment for myocardial dysfunction and who are not fit for cardiac transplantation. An intra-aortic balloon pump (IABP) is a polyethylene balloon that spans the entire length of the thoracic aorta, placed percutaneously via femoral artery access. The IABP comes in different lengths with IABP selection determined based on the patient’s height. The IABP inflates during diastole leading to an increase in blood flow to the coronary arteries, great vessels and renal arteries. Immediately prior to systole, it deflates producing a vacuum effect leading to forward blood flow to the aorta and its branches. Although the IABP is predominately radiolucent on a CXR, it has radiopaque tips proximally and distally. On the CXR, the cephalad radiopaque tip should be 2 cm above the carina (Figure 1). An alternate landmark would be the aorto-pulmonary window. Placing the IABP too caudally may occlude the celiac, superior mesenteric or renal arteries, while placing it too high may occlude the brachiocephalic, subclavian or carotid arteries. Complications that can occur with IABP include vascular (e.g. limb ischaemia, renal insufficiency, mesenteric ischaemia and aortic dissection) and non-vascular (e.g. catheter-related [perforation, tear and incorrect positioning] infection and neurological sequelae).3,4,5

15. 52-Year-Old With With A History Of Cardiac Sarcoid. CXR Just Before Heart Transplant. Arrows Points To The Radiopaque Markers Of The IABP

16. 52-Year-Old With With A History Of Cardiac Sarcoid. CXR Just Before Heart Transplant. Arrows Points To The Radiopaque Markers Of The IABP

17. 52-Year-Old With With A History Of Cardiac Sarcoid. CXR Two Weeks After Transplant!

18. 38-Year-Old With With Non- Ischemic Cardiomyopathy. CXR Before Heart Transplant.

19. 38-Year-Old With With Non- Ischemic Cardiomyopathy. CXR Before Heart Transplant. Arrows Points To The Radiopaque Markers Of The IABP

20. 38-Year-Old With With Non- Ischemic Cardiomyopathy. CXR Two Weeks After Transplant!

21. Impella™  Percutaneous femoral artery access – device advanced into the left ventricle (LV)  LV blood drawn into the pump and released across the valve in the proximal aorta  Aortic flow rates up to 5.0 liters/minute  Increases cardiac output & coronary perfusion and decreases myocardial O2 consumption

22. Impella™

23. 62-Year-Old With Ischemic Cardiomyopathy. CXR Just Prior To Orthotopic Heart Transplant.

24. 62-Year-Old With Ischemic Cardiomyopathy. CXR Just Prior To Orthotopic Heart Transplant. Impella™ Inflow Impella™ Outflow

25. 62-Year-Old With Ischemic Cardiomyopathy. CXR Just Prior To Orthotopic Heart Transplant. Impella™ Blood Flow Directed Up The Aorta

26. 62-Year-Old With Ischemic Cardiomyopathy. CXR One Week After Transplant!

27. Extracorporeal Membrane Oxygenation (ECMO)

28. ECMO Indication: Acute, severe reversible respiratory or cardiac failure with a high risk of death that is refractory to conventional therapies. V-V = veno venous V-A = veno-arterial

29. Figure 1: V-V ECMO Blood is drained from the femoral vein and returned to the right heart.

30. Figure 2: V-V ECMO Central venous blood is drained, and oxygenation blood is returned to the right atrium.

31. V-V ECMO Support for severe pulmonary failure (w/o cardiac failure). Clinical Condition Appropriate For V-V ECMO • Pneumonia • ARDS • Acute GVHD • Pulmonary contusion • Smoke inhalation • Status asthmaticus • Airway obstruction • Aspiration • Bridge to lung transplant • Drowning

32. Figure 3: V-A ECMO Central venous blood is drained, and oxygenation blood is returned to the arterial system.

33. V-A ECMO Support for cardiac failure (+/- pulmonary failure). Clinical Condition Appropriate For V-A ECMO • Graft failure post heart or heart lung transplant • Non-ischemic cardiogenic shock • Failure to wean post cardiopulmonary bypass • Bridge to LVAD • Drug overdose • Sepsis • Pulmonary embolus • Cardiac or major vessel trauma • Massive pulmonary hemorrhage • Pulmonary trauma • Acute anaphylaxis

34. 50-Year-Old In Cardiogenic Shock.

35. Tip Of Venous ECMO Cannula V-A ECMO 50-Year-Old In Cardiogenic Shock.

36. 47-Year-Old In Cardiogenic Shock.

37. 47-Year-Old In Cardiogenic Shock. Tip Of Venous ECMO Cannula V-A ECMO

38. 55-Year-Old With A Large Tracheal Laceration.

39. 55-Year-Old With A Large Tracheal Laceration. Reinjection Cannula V-V ECMO

40. Implant Volumes Of Left Ventricular Assist Systems (LVAS) Reported To INTERMACS (Interagency Registry For Mechanically Assisted Circulatory Support) Registry 2006-2017.

41. U.S. LVAD Statistics • Approximately 2,500 LVADs are implanted in the U.S. annually. • Survival following implantation continues to improve, with a current 1-month survival rate of 95%, and 1 and 2-year survival estimates of 80% and 70% respectively. • There are currently three durable LVADs approved by the FDA: HeartMate II™ St. Jude Medical, St. Paul, MN HeartMate III™ St. Jude Medical, St. Paul, MN HeartWare™ HeartWare, Framingham, MA

43. Basic LVAD Design The HeatMate II™, HeartMate III™, and HeartWare™ are all continuous flow devices with the following analogous components: • An inflow cannula that is surgically implanted into the left ventricular apex • A pump enclosure that houses and impeller that circulates blood • An outflow cannula that carries blood from the pump to the systemic circulation • A surgically tunneled driveline that connects the pump to the system controller • The system controller is connected by 2 power cables to a battery powered source or an AC power source when the batteries are charging

44. Basic Left Ventricular Assist Device Design

48. Key Differences Between Devices HeartMate II™ • Axial flow • Largest profile requiring implantation in preperitoneal pocket HeartMate III™ and HeartWare™ • Centrifugal flow • Smaller profile allows implantation in the chest • More sensitive to preload and afterload than the HeartMate II™ • More accurate cardiac output • “Speed modulation” (rapid slowing and then speeding up of the impeller): reduces the risk of in situ pump thrombosis, and aortic valve insufficiency

49. Basic LVAD Function • LVADs move blood from the LV apex to the systemic circulation in a continuous (non-pulsatile) manner • Pump speed is the fundamental parameter that the provider can alter • As pump speed increases the impeller within the pump housing spins more rapidly and circulates a greater volume of blood, thereby increasing LV unloading and cardiac output • The system controller estimates cardiac output indirectly based on speed and power consumption

50. Rotor bearing Rotor bearing Inflow cannula B Control Device—Axial-Flow Pump Blood flow from left ventricle Blood flow to aorta Rotor Inlet stator and blood-flow straightener Motor Pump housing Outlet stator and diffuser Percutaneous drive line Left ventricle Aorta Heart Pericardial sac Outflow graft Diaphragm Percutaneous drive line connects to external battery pack and controller Axial-flow pump designed for intraabdominal placement HeartMate II™ Axial Flow

52. HeartMate™ II Pump Below The Diaphragm (Arrow) Left Ventricular Inflow Cannula (Arrow) Inflow Cannula (Arrow) Outflow Cannula (Arrowhead)

53. 32-Year-Old With Peripartum Cardiomyopathy.

54. Two Years Later: Worsening Heart Failure.

55. Successfully Implanted HeartMate II™ LVAD As A Bridge To Transplant

56. HeartMate III™

58. 18-Year-Old Female Transferred To CMC In Respiratory Failure After Emergent C-Section. Chest X-Ray 1 Year Ago Hospital Day #1

59. 18-Year-Old Female Transferred To CMC In Respiratory Failure After Emergent C-Section. Hospital Day #2: Worsening Respiratory Failure And Shock

60. 18-Year-Old Female Transferred To CMC In Respiratory Failure After Emergent C-Section. Hospital Day #5: Successfully Implanted HeartMate III™ LVAD As A Bridge To Transplant

61. 49-Year-Old Male With Non- Ischemic Cardiomyopathy. Pre-Procedure

62. 49-Year-Old Male With Non- Ischemic Cardiomyopathy.

63. Impella™ Placed Prior To LVAD Inflow Outflow 49-Year-Old Male With Non- Ischemic Cardiomyopathy.

64. HeartMate III™ 49-Year-Old Male With Non- Ischemic Cardiomyopathy.

65. Chest X-Ray Following Orthotopic Heart Transplant 6 Months Later 49-Year-Old Male With Non- Ischemic Cardiomyopathy.

66. 64-Year-Old With Non- Ischemic Cardiomyopathy. HeartMate III™

67. A StudyDevice—Centrifugal-Flow Pump Pericardial sac Blood flow to aorta Outflow graft Left ventricle Aorta Heart Diaphragm Short inflow cannula Motor Pump housing Percutaneous drive line Magnetic hydrodynamically levitated impeller Percutaneous drive line connects to external battery pack and controller Blood flow from left ventricle 40mm Centrifugal-flow pump designed for intrapericardial placement HeartWare™ Centrifugal Flow

69. 53-Year-Old Diabetic With Non-Ischemic Biventricular Failure HeartWare™ LVAD As A Bridge To Transplant

70. Evaluation And Management Essentials Of ED Patient With LVADs

71. History • Recent device parameters, alarms, symptoms of infection or heart failure, signs of hemoglobinuria (could indicate LVAD thrombosis), signs/symptoms of GI bleeding • Evaluate tolerability to anti-thrombotic medications (usually aspirin, warfarin) • Call your LVAD coordinator early for assistance with management

72. Physical Examination • Heart rate, blood pressure, drive line, device connections • Auscultation for “whir” of LVAD pump: • Degree of arterial pulsatility depends on AV function, LVAD pump speed, LVAD preload and afterload, underlying LV contractility Whir Absent Pump Malfunction Whir Loud Consider Driveline Thrombosis1 1The device may be warmer to touch than usual

73. Physical Examination • At high pump speeds continuous flow predominates, decreasing pulsatility • Pulses may not be palpable, and standard cuffs will not be effective in measuring the patient’s blood pressure • Measure blood pressure using doppler… inflate the cuff and deflate until doppler sounds are heard • Audible doppler signal approximates mean arterial pressure [MAP]

74. ED Diagnostic Testing Labs: in addition to usual INR, LDH (2.5x upper limit of normal, >600 IU or significantly above baseline suggests hemolysis). Dark, tea-colored urine is a marker of device thrombosis and ongoing hemolysis. CT: evaluate for deep space infection, and can assess LVAD components ECHO: • Evaluation for aortic insufficiency, inflow cannula position, RV, LV function • Can get real-time feedback on adjustments in speed, pacing, positional changes, provocative movements like valsalva • Can be limited by acoustic shadowing from LVAD components

75. THE ECG IN PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES Dr. Laszlo Littmann, MD Department of Internal Medicine Carolinas Medical Center December 2020

76. ECG OF PATIENT WITH HEARTMATE 3 LVAD

77. • In HeartMate 3, an electromagnetic rotor is spinning at 5,000-6,000 rpm, driving the blood from the LV apex to the ascending aorta • The ECG in these patients, therefore, always demonstrates very high frequency gross artifact, which makes the ECGs essentially unreadable • Changing the filter settings of the recording, however, can clean out most high frequency artifacts • The low-pass filter should be changed from 150 Hz to 40 Hz • This maneuver can be easily performed even after the ECG was already recorded by using the following steps:

78. • Cerner-PowerChart • Find the patient (name or MRN) • Provider Workflow • Diagnostics • Cardiology • ECG Electrocardiogram • Click on the current ECG • Click on the icon at the right upper corner (gain and filter settings) • Change the filter setting from 150 Hz to 40 Hz • At a low-pass filter of 40 Hz, most high frequency artifacts will disappear • Unfortunately, pacemaker spikes may also become invisible

80. ECG OF SAME PATIENT WITH LOW-PASS FILTER CHANGED FROM 150 HZ TO 40 HZ

82. LVAD Complications • More than 50% of patients are readmitted in the first 6 months following LVAD implantation • The most common complications are infection, bleeding and dysrhythmia • 80% of patients will experience a complication within the first 2 years

84. Complications: Non-Surgical Bleeding Risk Factors: • Use of antithrombotic therapy [INR keep at 2.0 – 3.0] • Acquired von Willibrand deficiency - vW factor polymers degraded during flow through the LVAD pump • Formation of AV malformations related to continuous blood flow and associated abnormal regulation of angiogenesis1 1Gastrointestinal bleeding from AVMs the most common presentation

85. Complications: Non-Surgical Bleeding Management: • Immediate consultation with the LVAD team • Hold antithrombotic therapy • Control bleeding site if possible • Transfusion based on clinical status – 1st determine the patient’s transplant status [appropriate blood product preparation] • Early involvement of Gastroenterology for GI bleeding • In severe bleeding reversal of anticoagulation [4-factor PCC] is safe

87. Complications: Infections • The majority of infections involve the percutaneous driveline that is a vulnerable site for local trauma from tension on the line (e.g.: dropping battery pack) • Skin pathogens (coagulase [-] staph, S. aureus) are most common, although Gram [-] organisms (Pseudomonas, Enterobacteriaceae), fungal, and polymicrobial infections can also occur

88. Complications: Infections ED Evaluation: • Driveline drainage culture • Blood culture • CT scan to evaluate for deep tissue involvement

90. Complications: Dysrhythmia • LVAD patients can tolerate dysrhythmias for long periods due to the device’s circulatory support • Hypovolemia can precipitate “suction events” whereby the LVAD left ventricular inflow cannula contacts the ventricular free wall – these patients often present with ventricular tachycardia and Rx = volume resuscitation Atrial Fibrillation 50% Ventricular Dysrhythmias 22% -58%

91. Complications: Dysrhythmia Evaluation And Management: • Assessment similar to the non-LVAD patient • Immediate ECG and early ECHO • Cardioversion safe • Avoid placing defibrillator pads directly over the pump or driveline • The LVAD pump remain running during cardioversion

92. Complications: LVAD Malfunction Electrical Malfunction • Presents with alarm and pump stoppage • Evaluate alarms, patient stability, LVAD flow • Ensure connections are secure • Consult LVAD team at once Pump Thrombosis • Hematuria indicative of hemolysis • Inflow, pump, or outflow sites • Evaluate INR and antithrombotic medications • STAT ECHO to evaluate LVAD dysfunction

93. Complications: Stroke [Ischemic, Hemorrhagic] • Bimodal: 1st peak perioperative; 2nd peak 1-year post-implantation • 9% annual risk • Pump thrombosis a risk for embolic stroke • Urgent CT-A head and neck Management: Hemorrhagic Reversal of anticoagulation, Neurosurgery, LVAD team consultation Thrombotic Evaluate for IV TPA and/or mechanical thrombectomy

94. 50-Year-Old A Undergoes Successful Implantation Of A HeartMate III™. Three Days Post- Op He Develops Right Sided Weakness And Dizziness.

95. 50-Year-Old Male With Right-Sided Weakness And Dizziness

96. Left Middle Cerebral Artery Territory Stroke Right Posterior Cerebellar Artery Territory Stroke 50-Year-Old Male With Right-Sided Weakness And Dizziness

97. Bilaterality Suggests An Embolic Source Left Middle Cerebral Artery Territory Stroke Right Posterior Cerebellar Artery Territory Stroke

99. Complication: Heart Failure • Always consider aortic valve insufficiency when LVAD patient present in heart failure, since even a small opening can lead to large volume regurgitation and a futile circuit from the LV to the pump to the outflow tract to the aorta right back into LV • Heart failure “location” [assessed by history, exam, ECHO] drives care: • Biventricular • Left ventricular • Right ventricular

100. Biventricular Heart Failure • Evaluate for LVAD dysfunction/thrombosis • Vasodilators if elevated BP • Inotropic support if evidence of low output or severe aortic insufficiency • Increase LVAD speed • Diuresis Left Ventricular Heart Failure • Evaluate for LVAD dysfunction/thrombosis • Vasodilators if elevated BP • Inotropic support if evidence of low output or severe aortic insufficiency • Increase LVAD speed • +/- Diuresis Right Ventricular Heart Failure • Diuresis • Inotropic support • Pulmonary vasodilators • Consider right-sided mechanical circulatory support in transplant candidates with refractory HF • Palliative care consult

109. If You Have Interesting Cases Demonstrating Mechanical Circulatory Support Devices, We Invite You To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To: michael.gibbs@atriumhealth.org Your De-Identified Case(s) Will Be Posted On Our Education Website And You And Your Institution Will Be Recognized!

EMGuideWire's Radiology Reading Room: Mechanical Circulatory Support Devices

EMGuideWire's Radiology Reading Room: Mechanical Circulatory Support Devices

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EMGuideWire's Radiology Reading Room: Mechanical Circulatory Support Devices