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Professor Davor Miličić, MD, PhD, FESC
MECHANICAL SUPPORT TO THE FAILING HEART
Department of Cardiovascular Medicine,
Zagreb University School of Medicine,
University Hospital Center Zagreb
Epidemiology
Heart failure
23 million people 1-2% total population >6% people aged over 65 yrs
End stage heart failure: refractory to maximal conventional treatment (drugs, CRT, AICD, ultrafiltration, mortality ≥ 50% within 1 year)
Heart transplantation ~ 5000/year (ISHLT)
Heart transplantation
“Heart transplantation is an accepted treatment for end stage HF. Although controlled trials
have not been conducted, there is a consensus that transplantation, provided through proper selection criteria, significantly increases survival,
exercise capacity, return to work, and quality of life compared with
conventional treatment.”
ESC guidelines for the diagnosis and treatment of the chronic heart failure, European Heart Journal 2008; 29:2388-2442
Transplantation is insufficient for treatment all patients with the
end stage HF
Limited availability of donor hearts Patients on HTx lists die Problem of a possibly reversible
advanced HF Problem of patients with temporary
contraindication for HTx Problem of patients with absolute
contraindication for HTx Solution: drugs, VAD
Mechanical myocardial support
IABP ECMO VAD TAH
Goals of mechanical support
Temporary treatment - bridging to:
Transplantation Recovery Higher class VAD
Destination therapy
“Mechanical support of the failing heart
is today an established therapy option for
terminal, end-stage heart failure patients”
G.M. Wieselthaler
History
First implantation
VAD (DeBakey 1963) Artificial heart (Cooley
1969)
Criteria for implantation of VAD
Maximal inotropic support, with/without IABP
Hemodynamic criteria BPsyst < 80 mmHg with:
CI < 2.0 (2.2) L/min/m2
ili PCWP > 20 mmHg
Contraindications*
Absolute (?) - multiple previous cardiac surgeries - severe peripheral artery disease
Relative - recent PE - acute GI inflammation or bleeding - cachexia
* Harefield & Royal Brompton Hospital, London, UK
VAD: options?
VAD: classification
Short term
Medium term
Long term
Pulsatile
Nonpulsatile
Criteria for VAD selection
Failure of one or two ventricles?
Prediction of mechanical support duration
Anticipation of final outcome
Logistic circumstances
Ultra short term, percutaneous VAD
Tandemheart Cath lab Fem. approach Up to 14 days Flow 4 L/min
Tandemheart
Short term/Pulsatile VAD
Abiomed Two-chamber Pneumatic Paracorporeal Stroke volume 80 ml Uni or BiVAD Polyurethane valves
Mobilization in hospital
Application 7 days
ABIOMED BVS 5000
Short term/Nonpulsatile VAD
Levitronix Centrimag Magnetic
levitation Up to 30 days Flow up to 9L Minimal
mobilization in hospital
Medium term VAD
Thoratec VAD Paracorporeal Pneumatic pulsatile LVAD, RVAD, BiVAD Stroke vol. 65 ml Polyurethane
bubbles Mechanical valves Application about 6
mo (up to 1.5 yr)
Thoratec VAD
Bridge to HTx (60%) Bridge to Recovery
viral myocarditis, postpartum cardiomyopathy, heart rejection
Cost → 35000 $ Complications – bleeding (31%), infections
associated with device (18%), thromboembolism (14%)
Thoratec IVAD?
Long term VAD
Novacor LVAS 55-65% survival to
HTx Average duration of
support 85 days (max. 962 days)
Anticoagulation necessary
Embolic CV accidents ~ 25%
Redesigned cannula (CVA 10%)
Long term/Pulsatile VAD
HeartMate Increased
mobility Possible hospital
discharge Stroke vol. 83 ml Preperitoneal
location
HeartMate
REMATCH
Post - REMATCH
Long term/Nopulsatile VAD
Advantages Small device Less material
contact - higher durability
Noiseless Disadvantages Hemolysis at high
RPM Intracavitary
negative pressure No solution “B”
Long term/Nonpulsatile VAD
Centrifugal pumps (axial flow)
Continuously rotating propeller
No proof that lack of pulsatility is harmful
First full implantable, miniaturizedFirst full implantable, miniaturized axial-pump for clinical applicationaxial-pump for clinical application
diameter 30,5 mm
length 76,2 mm
weight 93 g
Mechanical Circulatory SupportMechanical Circulatory Support
Centrifugal devices
Jarvik 2000 HeartMate II MicroMed
DeBakey
3rd Generation HeartWare: MVAD3rd Generation HeartWare: MVAD2008 -
FUTURE VS TODAY
Chronic Non-hospitalized HF patient
Quality of life improvement therapy
Partial
Elective
Endovascular
IX Cardiologist or CT Surgeon
Low
Target Patient Population
Treatment Goal
Level of Support
Placement Procedure
Device Implantation
Physician Placing
Implantation Risks
End-Stage Hospitalized HF patient
Life-saving therapy
Full
Emergency
ALWAYS Surgical
CT Surgeon
High
Current Assist Devices
Complications
bleeding/thromboembolism CVA infection device failure ARF Respiratory insufficiency
Total artificial heart
Heart explantation
Wireless energy transmission
Longest implantation 512 days
What can we What can we expect ??expect ??-- next 2 - 5 yrs new pump concepts in clinical application-- next 2 - 5 yrs new pump concepts in clinical application
-- new generation pump is predominantly rotary pump-- new generation pump is predominantly rotary pump-- further improvement of existing pump concepts-- further improvement of existing pump concepts-- challenge will bring prizes down-- challenge will bring prizes down-- very long lasting VADs for chronic implants-- very long lasting VADs for chronic implants-- -- true alternative to clinical heart transplantationtrue alternative to clinical heart transplantation??????
VAD-therapy VAD-therapy today:today:-- -- BRIDGE TO or destination Tx for terminal HF ptsBRIDGE TO or destination Tx for terminal HF pts
-- due to growing experience reasonable outcome-- due to growing experience reasonable outcome-- sophisticated technology provides good long-term results-- sophisticated technology provides good long-term results-- individual pump-types for individual patients-- individual pump-types for individual patients
Future of Mechanical Circulatory Support
Life is like driving a bicycle. To keep your balance you must keep moving.
Albert Einstein
Thank you for your attention attention!