Which device to which patient

Bridge Over Troubled Water: Mechanical Circulatory Support In

Advanced Heart Failure

Which Device for Which Patient?

JoAnn Lindenfeld, MD Professor of MedicineDirector , Heart Failure and Transplantation Vanderbilt Heart and Vascular Institute Nashville, TN

• Scope of the problem

• Categories of Devices and Patients

• Temporary Devices and specific patient indications

• Durable Devices and specific patient indications

Which Device for Which Patient?

The Use of Short-term Percutaneous MCS Devices Increased Rapidly between 2004 and 2011

Stretch R et al. JACC 2015:64: 1407 - 1415

And Mortality Rate Associated With Short-Term Mechanical Circulatory Support (2004 to 2011) Appeared to Decline.

Stretch R et al. JACC 2015:64: 1407 - 1415

Which Device for Which Patient?

Temporary Support Durable Support

High Risk Procedure

Bridge toRecovery

Bridge toTransplant

DestinationTherapy

Bridge toDecision

Which Device for Which Patient?

Temporary Support Durable Support

High Risk Procedure

Bridge toRecovery

Bridge toTransplant

DestinationTherapy

Bridge toDecision

ü Electrical “storm””, or VT ablation

ü Acute MI with cardiogenic shock

ü Percutaneous valve replacement

ü Tachycardia-induced cardiomyopathy ablation

Which Device for Which Patient?

Temporary Support Durable Support

High Risk Procedure

Bridge toRecovery

Bridge toTransplant

DestinationTherapy

Bridge toDecision

√ Acute cardiogenic shockAcute myocardial infarctionAcute myocarditisComplications post MIPapillary muscle ruptureVentricular septal defect √ Post cardiotomy failure √ Acute decompensation of chronic HF √ Myocardial depression in drug overdose √ Hypothermia

Which Device for Which Patient?

Temporary Support Durable Support

High Risk Procedure

Bridge toRecovery

Bridge toTransplant

DestinationTherapy

Bridge toDecision

ü Recovery of CNS functionü Improvement in - Pulmonary hypertension - CNS function - Malnutrition - Debility √ Recovery of a non-cardiac illness√ Evaluation of psychosocial issues

Which Device for Which Patient?Temporary Support

Choices

Adequate Oxygenation

Yes No

• Percutaneous • Surgical

• Percutaneous

• Surgical

Which Device for Which Patient?

Temporary Support Choices

Adequate Oxygenation

Yes No

• Percutaneous √ IABP √ Impella √ Tandem Heart• Surgical

• Percutaneous √ ECMO √ Tandem Heart• Surgical

Which Device for Which Patient?

Temporary Support Choices

Adequate Oxygenation

Yes No

• Percutaneous •Surgical √ CentriMag √ AbiomedBVS 5000

• Percutaneous• Surgical √ ECMO

Abnousi F et al. Curr Cardiol Rep. 2015 ;17:594

√ ECMO

Percutaneous MCS Devices

Surgical Devices

Abiomed Centrimag

Temporary MCS DevicesIABP Impella Tandem

HeartCentrimag Abiomed ECMO

Oxygenation + ++Anticoagulation contraindication

+ +++ +++ +++ +++ +++

ECG timing YesHemodynamic supportRV supportLV VentingMechanical Aortic ValveLV THrombusAortic InsufficiencyR to L shuntKidney injury

Temporary MCS DevicesIABP Impella Tandem

HeartCentrimag Abiomed ECMO

Oxygenation + ++Anticoagulation contraindication

++/- +++ +++ +++ +++ +++

ECG timing YesHemodynamic support

+ ++-+++ +++ ++++ ++++ ++++

RV support ++++LV VentingMechanical Aortic ValveLV THrombusAortic InsufficiencyR to L shuntKidney injury

Temporary MCS DevicesIABP Impella Tandem

HeartCentrimag Abiomed ECMO

Oxygenation + ++Anticoagulation contraindication

++/- +++ +++ +++ +++ +++

ECG timing YesHemodynamic support

+ ++-+++ +++ ++++ ++++ ++++

RV support ++++LV Venting ++Mechanical Aortic ValveLV ThrombusAortic InsufficiencyR to L shuntKidney injury

Left Heart Decompression Strategies During VA-ECMO

Percutaneous

IABP Impella axial flow catheter Transseptal left ventricular cannulation Transseptal LA cannulation Atrial septostomy

Surgical Direct left ventricular apical cannulation Direct LA cannulation

Noninvasive Inotropic support Reducing VA-ECMO flow

Temporary MCS DevicesIABP Impella Tandem

HeartCentrimag Abiomed ECMO

Oxygenation + ++Anticoagulation contraindication

+ +++ +++ +++ +++ +++

ECG timing YesHemodynamic support

+ ++-+++ +++ ++++ ++++ ++++

RV support ++++LV Venting ++Mechanical Aortic Valve

No

LV Thrombus NoAortic Insufficiency No -- -- -- -- --R to L shuntKidney injury

Temporary MCS DevicesIABP Impella Tandem

HeartCentrimag Abiomed ECMO

Oxygenation + ++

Anticoagulation contraindication

+ +++ +++ +++ +++ +++

ECG timing Yes

Hemodynamic support

+ ++-+++ +++ ++++ ++++ ++++

RV support ++++

LV Venting ++

Mechanical Aortic Valve

No

LV Thrombus No

Aortic Insufficiency No -- -- -- -- --

R to L shunt +/- No +/- +/- +/-

Kidney injury ??

Hemolysis in 10% or >

Lauten A Circ HF 2013

Which Device for Which Patient?

Temporary Support Durable Support

High Risk Procedure

Bridge toRecovery

Bridge toTransplant

DestinationTherapy

Bridge toDecision

• HeartMate II• HeartWare

•(CE Mark) Ventrassist,DuraHeart, InCor)

Total Artificial Heart

Severe RV dysfunction LVADs

Durable LVADS

HeartMate II HeartWare

Total Artificial Heart

LVADS far Outnumber Total Artificial Heart Implants

Kirklin JK et al. Journal of Heart and Lung Transplant 2014: 33:585-604..

Which Device for Which Patient?

Temporary Support Durable Support

High Risk Procedure

Bridge toRecovery

Bridge toTransplant

DestinationTherapy

Bridge toDecision

√ Acute decompensation of chronic HF

Which Device for Which Patient?

Temporary Support Durable Support

High Risk Procedure

Bridge toRecovery

Bridge toTransplant

DestinationTherapy

Bridge toDecision

ü Improvement in - Pulmonary hypertension - Malnutrition - Debility √ Recovery of a non-cardiac illness√ Evaluation of psychosocial issues

Durable LVADS

HeartMate II HeartWare

Possible Reasons to Consider

Smaller sizeLateral thoracotomy Lower flow rateThrombosis ?

HeartWare in Situs Inversus

Shah NR et al.. J Heart and Lung Transplant 2015; 32:615-20. ...

• Scope of the problem

• Categories of Devices and Patients

• Temporary Devices and specific patient indications

• Durable Devices and specific patient indications

Which Device for Which Patient?We Need More Data

•Device comparisons

•RV function—long term

•Renal function– long term

•When is temporary to durable best strategy?