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Matching Patient and Pump in the New Era of
Percutaneous Mechanical Circulatory Support
Navin K. Kapur, MD, FACC, FSCAI, FAHA
Associate Professor, Department of Medicine
Interventional Cardiology & Advanced Heart Failure Programs
Executive Director, The Cardiovascular Center for Research & Innovation
Relevant Disclosures
Research Funding: Abiomed, Maquet, Cardiac Assist, Abbott, Boston Scientific
Speaker/Consulting Honoraria: Abiomed, Maquet, Cardiac Assist, Abbott
2007: A Turning Point in Interventional Cardiology
TH-RVAD
Impella 5.0 RP
CP
The Field of MCS: Robust with Innovation
2007 2017
IVADs HVAD Impella CP
BiPellasTH + 5.0
5.0 as a
Bridge to
Recovery
Right Ventricle
The Spectrum of Temporary MCS Devices in 2017
Left Ventricle
What is State of the Art in 2017?
CULPRIT SHOCK: Exhausting Coronary
Approaches for a Ventricular Problem
Culprit Only Multivessel
National Cardiogenic Shock Initiative
RAPID Identification of Cardiogenic Shock
Cath Lab Activation
Obtain Femoral Access
LVEDP
< 15 mmHg ≥ 15 mmHg
IMPELLA
Door
To
Support
Time
Target
< 90
minutes
NATIONAL CSI ALGORITHM
Consider Other Causes of
Shock
What’s State of the Art in 2017?
First FDA Approval for Perc MCS in ShockWilliam O’Neill
What’s State of the Art in 2017? The ARMS Registry Jamie McCabe
& Raj Tayal
Tufts Axillary Case
What’s State of the Art in 2017? The ARMS Registry
What’s State of the Art in 2017?
Full Body Recovery: Quantifying Ambulation
Esposito & Kapur et al. ASAIO 2017
Survivors(n=6)
Withdrawal(n=4)
Worsening HF(n=2)
0
2
4
6
8
JH
-HL
M S
co
re
One-way ANOVA p = 0.02
Non-survivors
Survivors(n=4)
Withdrawal(n=4)
Worsening HF(n=2)
0
5
10
15
20
AM
-PA
C S
co
re
One-way ANOVA p = 0.14
Non-survivors
What’s State of the Art in 2017?
The PHP Promise is Still Alive
14Fr Sheath 24Fr Impeller
SHIELD-I : High Risk PCI Trial TCT 2015
SHIELD-II : High Risk PCI Trial in USARandomized 2:1 (HeartMate PHP vs. Impella)
National PIs:
Ulli Jorde
David Kandzari
Navin Kapur
Kapur NK. CathSAP V. 2016
The more dysfunctional the ventricle,
the more functional a CF-AMCS device becomes.
Hemodynamic Principles of Rotary Flow Pumps
Higher Flow with Lower Transvalvular Pressure Gradient
What’s State of the Art in 2017?
First FDA Approval for Perc RV support
Kuchibhotla, Esposito, Annamalai, and Kapur et al. JAHA 2017
What’s State of the Art in 2017?
Interventionalists are becoming VA-ECMO Specialists
Antegrade Perfusion6Fr Braided Sheath
Impella CP 14Fr Sheath
PA Catheter 8Fr Cordis
17Fr Arterial Cannula25Fr MS Venous Cannula
Antegrade Perfusion6Fr Braided Sheath
High Pressure 3-Way + 2 Male-to-Male
Connectors
LVP&
AoP
PAP&
RAP
+IMPELLARV LV
What’s State of the Art in 2017?
Interventionalists are Becoming Hemodynamicists Again
Daniel Burkhoff
What’s State of the Art in 2017?2007 2017
Bi-VADs HVAD Impella CP Bi-Pellas
Cardiac Replacement Cardiac Recovery
Shifting the Paradigm of MCS
What’s State of the Art in 2017? Trials that Move the Dial for AMI and Shock
Kapur and Davila Eur H J 2017
Mechanical Circulatory Support:
An Evolving Field with Expanding Potential
Surgical Percutaneous
Temporary
Use
Durable
UseOpen Space
Where are the new opportunities for Percutaneous MCS?
Acute MI
± Shock
High Risk
Interventions
Acute Systolic
Heart Failure
Cardiogenic
Shock
Chronic Systolic
Heart Failure
HF with
Preserved EF
IABP Impella Tandem VA-ECMO
Adapted from Miller LW Circ 2011Heindrick, Konstam et al. Circ HF 2013
Why is Interventional Heart Failure the Future of Acute MCS?
By 2030, 1 in 33 individuals in the US will have HF.
LVAD and OHTx Candidacy is limited to <15% of patients with HF.
Emerging Opportunity # 1: Acute Heart Failure*
* Diuretic-resistance remains a major clinical problem in heart failure
Where are the opportunities for Percutaneous MCS?
Circulation. 2012;126:501-506
Most heart failure patients
live outside the hospital
Emerging Opportunity # 2: Ambulatory Heart Failure
Where are the opportunities for Percutaneous MCS?
Emerging Opportunity # 3: Heart Failure with Normal EF
Otkay et al Curr HF Rep 2015
HFpEF Patient Profiles
Elderly
Female
Hypertensive
Renal insufficiency
Neurohormonal activation
LV Hypertrophy and Fibrosis
Normal LVEF/Abnormal LV stiffness
Current Treatment:
Blood pressure control
Diuresis
Where are the opportunities for Percutaneous MCS?
Emerging Devices for Cardio-Renal Syndrome 1
Cardiac Goals of Therapy:
1. Reduce LV Afterload
2. Reduce LV Stroke Work
3. Increase Cardiac Output
Renal Goals of Therapy
1. Increase Renal Blood Flow
2. Increase Urine Output
3. Avoid RV / Pulmonary Loading
Sunshine Heart
NuPulse
ReitanAortix SecondHeart
Potential Advantages of Aortic Pumps
1. Extracardiac positioning
2. Reduce LV Afterload & Work
3. Enhance Systemic Perfusion
4. Increase Renal Perfusion & UOP
Emerging Aortic Platforms for CRS Type 1
ReitanAortix SecondHeart
Potential Advantages of Aortic Pumps
1. Extracardiac positioning
2. Reduce LV Afterload & Work
3. Enhance Systemic Perfusion
4. Increase Renal Perfusion & UOP
Advantages of CF-Aortic Pumps
1. Cardiac-Renal Uncoupling
2. Less dependent on LV function
3. Ambulatory/Outpatient Viability
Emerging Aortic Platforms for CRS Type 1
The Tufts Cardiovascular Center for Research and Innovation
The CVCRI Innovation Engine
Clinical
Excellence
Preclinical
Testing
Fundamental
Discoveries
Preclinical
Trials
Novel Clinical
Trials
Micro-Axial Pump
Stentless Anchoring Tines
18Fr Catheter Delivery System
Shabani et al ASAIO 2013
Kapur Lab
Retractable Propeller
Retractable Stent Cage
18Fr Catheter Delivery System
0
100
200
SecondHeart
ON SecondHeart
OFF
SecondHeart
ON
Kapur Lab
Emerging Devices for Cardio-Renal Syndrome 1
White Swell
What’s State of the Art in 2017? Innovative Training Programs
Interventional Heart Failure : A Tufts Trademark
Interventional Heart Failure
Thank you
To Learn More about Acute MCS & Hemodynamics
Interventional Heart Failure
December 15-16 2017
Berlin, Germany
November 8-9, 2018 – CHICAGO, IL
