Mechanical Therapies for Heart Failure
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Mechanical Therapies for Heart Failure 2020 Annual Chattanooga Cardiovascular Symposium Alan Simeone, MD, FACS Nothing to Disclose What’s on the Agenda? Acute Systolic Heart Failure Chronic End-stage Systolic Heart Failure • Intra-aortic Balloon Pump • Key Concepts • Implantable Devices • Impella • Bridge vs Destination • Extra Corporeal Membrane • LV Failure • Implantable LVAD Oxygenation (ECMO) • Bi-Ventricular Failure • Bi-VAD • Total Artificial Heart Cardiogenic Shock First Step is Recognition Arterial Access > Acid/Base, Lactate Venous Access > PA Catheter Additional Data Cardiac Power Output (MAP x CO)/451 Pulmonary Artery Pulsatility Index (sPAP – dPAP )/CVP Intra Aortic Balloon Pump First used in 1967 Counterpulsation device most commonly inserted via femoral artery 7 to 9F catheter, 30, 40 or 50 cc Helium driven balloon Inflates in Diastole, deflates prior to Systole Timing by ECG or Arterial pressure tracing Increases Diastolic Coronary Perfusion Pressure Decreases LV Afterload IABP Waveform IABP • Falling out of Favor in Cardiogenic • IABP remains very beneficial in the Shock after Acute Myocardial End-Stage chronic heart failure Infarction population • Difficult to study – small numbers, • Specifically, those failing on Inotropic many variables support who are potential Transplant • Newer percutaneous devices offer or Implantable Device Candidates more quantifiable levels of support • Also useful as a temporary adjunct to medical therapy in Acutely Decompensated Chronic Heart Failure • Remains useful in Post-Cardiotomy Shock Impella Miniature Axial Flow Pump mounted on a Catheter Impella • Impella 2.5 • About 2.5 L/min, Femoral, 14F Sheath • Impella CP • About 4 L/min, Femoral, 14F Sheath • Impella 5.0 • About 5 L/min, Cut-down, 23F Sheath • Impella LD • About 5 L/min, Open Chest Asc. Aorta • Impella 5.5 • About 6 L/min, Cut-down, 23F Sheath • Impella RP • About 4 L/min, Femoral VEIN, 23F Sheath Impella Pros and Cons • A True Mechanical Blood Pump • Expensive – Impella 2.5 20k to • Provides Forward Flow 23k • Can Decompress the LV • Relatively large sheaths • Reduces LVEDP • Malpositioning not unusual • - LA and Pulmonary Venous Pressure • Hemolysis • Reduce Wall Tension and O2 • Short-term Demand • Good Evidence Still Sparse • Can Be a Percutaneous Option Veno-Arterial Extra Corporeal Membrane Oxygenation V-A ECMO • Portable, Miniaturized Cardiopulmonary Bypass • Venous Drainage Cannula • Circuit Tubing • Centrifugal Pump • Oxygenator • Arterial Return Cannula V-A ECMO Advantages Disadvantages • Full Support of Perfusion – Flows depend on • Bleeding Cannula size assuming constant preload and • Clotting afterload • Bleeding and Clotting • Support for Pulmonary Dysfunction • Inflammatory Response • Permits Recovery of Organ Function and Diuresis • Perfusion at the expense of LV Unloading • Hardware and Circuit can be inexpensive • Limb Malperfusion • Can be instituted Quickly • Limited Duration • Personnel and Expertise required • Exit Strategy essential V-A ECMO • Outcomes Depend on Patient Characteristics • Age • Presence of Acute complications of Low Pressure/Low Flow • Chronic Disease Burden • Etiology and potential for recovery • Downtime prior to initiation of support • Suitability for more durable method of support • An Excellent bridge to Durable Mechanical Support or Transplant in Patients with Decompensated End-Stage Heart Failure How bad can living with end- stage heart failure be? It can’t be Right? worse than a VAD! Classification - Heart Failure New York Heart Association American College of Cardiology- (NYHA) Heart Failure Symptom American Heart Association Classification System Classification of Chronic Heart Failure • I: No symptom limitation with ordinary physical activity • A: High risk for developing heart failure: Hypertension, diabetes mellitus, CAD, family history of • II: Ordinary physical activity cardiomyopathy somewhat limited by dyspnea (e.g., long-distance walking, climbing two flights of stairs) • B: Asymptomatic heart failure: Previous MI, LV dysfunction, valvular heart disease • III: Exercise limited by dyspnea with moderate workload (e.g., short-distance walking, climbing • C: Symptomatic heart failure: one flight of stairs) Structural heart disease, dyspnea and fatigue, impaired exercise tolerance • IV: Dyspnea at rest or with very little exertion • D: Refractory end-stage heart failure: Marked symptoms at rest despite maximal medical therapy 550,000 Americans Hospitalized yearly despite best medical therapy When Hospitalization Required • 30 to 50% re-admitted within the first 6 months One Year Mortality Class II: 10 - 15% Class III: 15 – 25% Class IV: 30 – 50% Inotrope-Dependent Advanced Heart Failure: 70 – 90% one-year mortality • Transplant Effective but limited, prior to early 80’s was discarded • Devices for Mechanical Support have existed since the early 1960’s • Emphasis shifted from heart replacement to Ventricular Assistance • TAH has lingered – Current SynCardia TAH began life as the Jarvik-7 • Progress has seen transition from bulky, pulsatile mechanical pumps with complex moving parts to small, continuous-flow devices • Compared to Medical Therapy, LVADs have significantly improved survival, Quality of Life and Functional Status since the landmark study in 2001. Durable Mechanical Support Devices HeartMate II HeartMate 3 • HeartMate II • HeartMate 3 • Axial Flow • Centrifugal Flow • Continuous Flow • Continuous Flow, Pulsatility from • Mechanical Bearings algorithmic speed changes • Driveline • No Mechanical Bearings – • External Battery Power Magnetically Levitated • Modular Driveline • Bridge to Transplant • External Battery Power • Destination Therapy • Bridge to transplant • Destination Therapy • Two Year Survival 82% • Any Stroke 9% • Pump Thrombosis 1% n engl j med 380;17 nejm.org April 25, 2019 LVAD - Not Perfect • Require Anticoagulation • Bleeding • Thrombosis • Acquired von Willebrand’s syndrome • Infection – Driveline is the Achilles Heel • Aortic Regurgitation • The Right Ventricle Biventricular Failure • Most Common Cause of RV Failure is LV Failure • RV can usually recover with temporary medical and mechanical support • Centrimag RVAD • Impella RP Total Artificial Heart • SynCardia TAH approved as a Bridge to Transplant • A descendant of the Jarvik 7 • Pneumatically Driven, 4 valves • Intractable Arrhythmia • Restrictive Cardiomyopathy • ?Cardiac Tumor • Mechanical Complication of MI • Heart Failure in Adult Congenital Biventricular Failure • Magnitude of the problem dependent on potential for Transplant • In a patient who is not a candidate for transplant > • No good options for long-term support • BiVAD implantable VADs have been used • The RV VAD requires modification The Future? • Bivacor • Investigational • Centrifugal total artificial heart with a single magnetically levitated double-sided impeller Thank You.