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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?
