Mechanical Circulatory Support
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This document summarizes guidelines for the treatment of heart failure. It describes the New York Heart Association classification system for heart failure severity. It lists drug and device therapy recommendations for heart failure, including levels of evidence. Device therapies discussed include implantable cardioverter-defibrillators, cardiac resynchronization therapy, ventricular assist devices, and the total artificial heart. Contraindications and outcomes for long-term and short-term ventricular assist device support are outlined.
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Mechanical Circulatory Support
- 2. • Non-ischemic cardiomyopathy• Ischemic cardiomyopathy
- 3. Increasing Severity Class I • Cardiac disease • No symptoms • No limitation in ordinary physical activity Class II • Mild symptoms (mild shortness of breath and/or angina) • Slight limitation during ordinary activity Class IIIa and IIIb • Marked limitation in activity due to symptoms • Comfortable only at rest Class IV • Severe limitations • Symptoms even while at rest • Mostly bedbound patients NewYork Heart Association Functional Classification of Heart Failure
- 6. (Strength of Evidence = A) • ACE inhibitors • ARBs • Warfarin • In patients with atrial fibrillation, pulmonary embolism, orTIA • Beta Blockers • Aldosterone Antagonists • Hydralazine and Isosorbide Dinitrate • Loop Diuretics Lindenfeld, J, et al. J Card Failure 2010; 6, 486-491
- 7. Strength of Evidence = B • Antiplatelet agents (Aspirin) • Ischemic etiology of HF • Digoxin • In stage II and III HF • Thiazide diuretics • Warfarin • MI patients with LV thrombus Strength of Evidence = C • Digoxin • In stage IV HF • Metalazone Lindenfeld, J, et al. J Card Failure 2010; 6, 486-491
- 8. Inotropes • Commonly used on an outpatient basis for stage IIIb – IV heart failure • Milrinone and Dobutamine are the only FDA approved drugs for outpatient use • Not recommended for acute heart failure exacerbations in ischemic patients • Probable benefit in non-ischemic exacerbations • OPTIME-CHF JAMA 2002; 287:1541-7
- 9. Cardiac ResynchronizationTherapy (CRT) • LVEF <35% • NYHA class III – IV • QRS > 120 ms • Optimal medical therapy
- 10. Implantable Cardiac Defibrillators • Ischemic Etiology (Strength of Evidence = A) • Non-ischemic Etiology (Strength of Evidence = B) • Primary prevention of ventricular arrhythmias • LVEF <35% Lindenfeld, J, et al. J Card Failure 2010; 6, 486-491
- 11. Decreased end organ perfusion • Renal function • Liver function • Pulmonary function We need more support!
- 12. Ventricular Assist Device (VAD) Long-Term LVAD Short-Term LVAD A mechanical circulatory device used to partially or completely replace the function of either the left ventricle (LVAD); the right ventricle (RVAD); or both ventricles (BiVAD)
- 13. ANY • Rule out any contraindications toVAD support? • End-stage lung, liver, or renal disease • Metastatic disease • Medical non-adherence or active drug addiction • Active infectious disease • Inability to tolerate systemic anticoagulation (recent CVA, GI bleed, etc.) • Moderate to severe RV dysfunction • What are our other issues in this particular patient?
- 14. Lietz and Miller Curr OpinCardiol 2009, 24:246–251 INTERMACS SCORE Interagency Registry for Mechanically Assisted Circulatory Support Long-Term LVAD Ideal candidates are INTERMACS classes 3-4 Short-Term LVAD Candidates are INTERMACS classes 1-2 Not a LVAD Candidate INTERMACS 1 or those with multisystem organ failure
- 15. • Recovery • Decision • Surgery • Transplantation • Destination
- 16. Long-term placement :Terminal heart failure DestinationTherapy (DT) • Not a heart transplant candidate • NYHA IV • LVEF <25% • Maximized medical therapy >45 of 60 days; IABP for 7 days; OR 14 days • Functional limitation with a peak oxygen consumption of less than or equal to 14 ml/kg/min • Life expectancy < 2 years Bridge toTransplantation (BTT) • Patient is approved and currently listed for transplant • NYHA IV • Failed maximized medical therapy
- 17. Bridge toTransplantation (BTT) DestinationTherapy (DT) HeartMate II (Thoratec)
- 18. Throratec Heartmate XVE Thoratec paracorporeal Thoratec intracorporeal Thoratec Heart mate II Jarvik 2000 Micromed De Bakey Incor Berlin heart VentracorVentrassist Terumo Duraheart Worldheart LevaCor Thoratec HeartMate III
- 19. Rotor Magnet Rotor Bearings Inlet Stator Motor WindingOutlet Stator
- 20. Pump Speed (RPM) – How quickly the pump rotates Pump Power (Watts) – Measure of motor voltage and current Pump Flow (L/min) - Estimated value of the volume running through the pump Pulsitility Index –The measure of the left ventricular pressure during systole
- 22. Inflow cannula (poor position, obstruction) Pump/rotor dysfunction (thrombus) Battery dysfunction Outflow graft (kink , leak) Drive line infection / fracture Controller malfunction
- 24. Rose, EA; et al NEJM 2001; 345:1435-1443
- 27. • Utilized for LV support only; not appropriate to use with RV failure • Impella 2.5 can be inserted through the femoral artery during a standard catheterization procedure; provides up to 2.5 L of flow • Impella 5.0 inserted via femoral or axillary artery cut down; provides up to 5L of flow • The catheter is advanced through the ascending aorta into the left ventricle • Pulls blood from an inlet near the tip of the catheter and expels blood into the ascending aorta • FDA approved for support of up to 6 hours
- 28. • Used for LV support; not appropriate in RV failure • Cannulas are inserted percutaneously through the femoral vein and advanced across the intraatrial septum into the left atrium • The pump withdraws oxygenated blood from the left atrium and returns it to the femoral arteries via arterial cannulas
- 29. • Can be used for LV and/or RV support • Cannula are typically inserted via a midline sternotomy • Capable of delivering flows up to 9.9 L/min • Can be used for up to 30 days
- 30. • Used for patients with a combination of acute cardiac and respiratory failure • A cannula takes deoxygenated blood from a central vein or the right atrium, pumps it past the oxygenator, and then returns the oxygenated blood, under pressure, to the arterial side of the circulation
- 34. ThankYou