Acute Mechanical Circulatory Support Right Ventricular Support Devices

Navin K. Kapur, MD, FACC, FSCAI, FAHA Associate Professor, Department of Medicine Interventional Cardiology & Advanced Failure Programs Executive Director, The Cardiovascular Center for Research & Innovation Right Always Worsens Mortality RV Function in Shock is Poorly Understood

RV Shock is just as bad as LV Shock Jacobs A et al. JACC 2003 Why is Univentricular Shock Uncommon?

The RV is Highly Sensitive to Increased

Haddad and Hunt et al. Circulation 2008;117;1717-1731 HemodynamicsEffect of elevated pulmonary of capillary the wedge RV pressure-PA- (PCWP)LV Axis on pulmonary vascular resistance-compliance relationship (RPA-CPA).

Pulm. Venous Congestion

PA Compliance PCWP = PA Resistance

Tedford R J et al. Circulation 2012;125:289-297 PA Pressure Alone is an Insufficient Marker of RV Failure in PH and Heart Failure Hemodynamic Formulas to Assess RV Function >0.63 (RVF after LVAD) [14] RA / PCWP Cardiac Filling Pressures >0.86 (RVF in Acute MI)[31] <1.85 (RVF after LVAD) [42] PA Pulsatility Index (PASP-PADP) / RA <1.0 (RVF in Acute MI) [41] Pulmonary Vascular mPA-PCWP / CO >3.6 (RVF after LVAD) [16] Resistance

Trans-pulmonary Gradient mPA-PCWP Undetermined [36]

Diastolic Pulmonary PAD - PCWP Undetermined [36, 37] Gradient <15 (RVF after LVAD) [16] RV Stroke Work (mPAP-RA) x SV x 0.0136 <10 (RVF after Acute MI) [40]

RV Stroke Work Index (mPA-RA)/ SV Index <0.3-0.6 (RVF after LVAD) [14,42]

Pulmonary Artery SV / (PASP-PADP) <2.5 (RVF in Chronic Heart Failure) [39] Compliance PASP/ SV Undetermined [38] Elastance Right atrial (RA); Pulmonary artery (PA); PA systolic pressure (PASP); PA diastolic pressure (PADP); mean PA pressure (mPAP); Pulmonary capillary wedge pressure (PCWP); Right ventricular failure (RVF); Left ventricular assist device (LVAD); (MI); Stroke volume (SV)

Kapur, Esposito, and Burkhoff et al Circulation 2017 From Pulsatile Load to PA Pulsatility

RAP = 22 RAP = 15 RAP = 7

Kiernan and Kapur. JIC 2009 Hemodynamic Signatures of RV Failure The Pulmonary Artery Pulsatility Index (PAPi)

PA Pulse Pressure (Systolic – Diastolic) PAPi CVP (RA Pressure)

Korabathina & Kapur CCI 2012 Not All RV AMCS Devices are Created Equal

Note: IABPs are not RV AMCS devices

Kapur, Esposito and Burkhoff et al Circulation 2017 Not All RV AMCS Devices are Created Equal

Direct RV Bypass Indirect RV Bypass (RAPA) (RAAO)

Kapur et al Circulation 2017 TandemHeart in Right Ventricular Failure

pRVAD = 3.4+0.5 LPM sRVAD = 4.9+1.0 LPM

Kapur NK et al. JACC Heart Failure 2013 Percutaneous Support for RV Failure

• 9 patients with MR-RVF between 2008-2010 received a TandemHeart RV support device. – Etiologies included sepsis, post-cardiotomy, and acute RVMI – Five underwent RIJ-to-femoral, four femoral-to-femoral Earlier support = better outcomes

Kapur et al JHLT 2012 TandemHeart in Right Ventricular Failure (THRIVE)

Major Predictors of In-hospital Mortality

1. Advanced Age 2. Biventricular Failure 3. TIMI Major Bleeding

Kapur NK et al. JACC Heart Failure 2013 Percutaneous Support for RV Failure

Impella RP Implant Size 22 Fr pump on an 11 Fr catheter RECOVER RIGHT TRIAL Flows > 4 L/min The 8 Minute RVAD Implant The 8 Minute RVAD Explant Dynamics of 3D Construction of the RP Torque – Not Push for Delivery Direct RV Bypass: Impella RP for Acute RVF

Kapur, Esposito and Burkhoff et al Circulation 2017 Not All RV AMCS Devices are Created Equal

Direct RV Bypass Indirect RV Bypass (RAPA) (RAAO) Indirect RV Bypass: VA-ECMO for Acute RVF

Kapur, Esposito and Burkhoff et al Circulation 2017 Anderson M et al. JHLT 2015 Conclusions

1. Afterload is a major determinant of RV Output

2. RV AMCS devices are not created equal (Direct vs Indirect RV Bypass)

3. RV Output is a major determinant of LV Output

4. Early identification of RVF and early use of RV AMCS improves outcomes. Don’t hang your hat on a number.

5. Look for hemodynamic signs of Bi-V failure when managing

Kapur, Esposito and Burkhoff et al Circulation 2017 Thank you

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December 15-16 2017 Berlin, Germany Interventional Heart Failure August 24-25, 2017: Barcelona, Spain