Mechanical Therapies for Heart Failure 2020 Annual Chattanooga Cardiovascular Symposium Alan Simeone, MD, FACS
Mechanical Therapies for Heart Failure
2020 Annual Chattanooga Cardiovascular SymposiumAlan Simeone, MD, FACS
Nothing to Disclose
What’s on the Agenda?
Acute Systolic Heart Failure
• Intra-aortic Balloon Pump
• Impella
• Extra Corporeal Membrane
Oxygenation (ECMO)
Chronic End-stage Systolic Heart Failure
• Key Concepts• Implantable Devices• Bridge vs Destination
• LV Failure • Implantable LVAD
• Bi-Ventricular Failure• Bi-VAD• Total Artificial Heart
Cardiogenic Shock
First Step is RecognitionArterial 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 Shock after Acute Myocardial Infarction
• Difficult to study – small numbers, many variables
• Newer percutaneous devices offer more quantifiable levels of support
• IABP remains very beneficial in the End-Stage chronic heart failure population
• Specifically, those failing on Inotropic support who are potential Transplant or Implantable Device Candidates
• 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
• Provides Forward Flow
• Can Decompress the LV• Reduces LVEDP
• - LA and Pulmonary Venous Pressure
• Reduce Wall Tension and O2 Demand
• Can Be a Percutaneous Option
• Expensive – Impella 2.5 20k to 23k
• Relatively large sheaths
• Malpositioning not unusual
• Hemolysis
• Short-term
• Good Evidence Still Sparse
Veno-Arterial Extra Corporeal Membrane OxygenationV-A ECMO
• Portable, Miniaturized Cardiopulmonary Bypass
• Venous Drainage Cannula
• Circuit Tubing
• Centrifugal Pump
• Oxygenator
• Arterial Return Cannula
V-A ECMOAdvantages
• Full Support of Perfusion – Flows depend on Cannula size assuming constant preload and afterload
• Support for Pulmonary Dysfunction
• Permits Recovery of Organ Function and Diuresis
• Hardware and Circuit can be inexpensive
• Can be instituted Quickly
Disadvantages• Bleeding
• Clotting
• Bleeding and Clotting
• Inflammatory Response
• Perfusion at the expense of LV Unloading
• Limb Malperfusion
• 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 worse than a
VAD!Right?
Classification - Heart Failure
New York Heart Association (NYHA) Heart Failure Symptom Classification System
• I: No symptom limitation with ordinary physical activity
• II: Ordinary physical activity somewhat limited by dyspnea (e.g., long-distance walking, climbing two flights of stairs)
• III: Exercise limited by dyspnea with moderate workload (e.g., short-distance walking, climbing one flight of stairs)
• IV: Dyspnea at rest or with very little exertion
American College of Cardiology-American Heart Association Classification of Chronic Heart Failure
• A: High risk for developing heart failure: Hypertension, diabetes mellitus, CAD, family history of cardiomyopathy
• B: Asymptomatic heart failure: Previous MI, LV dysfunction, valvular heart disease
• C: Symptomatic heart failure: Structural heart disease, dyspnea and fatigue, impaired exercise tolerance
• 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• Axial Flow
• Continuous Flow
• Mechanical Bearings
• Driveline
• External Battery Power
• Bridge to Transplant
• Destination Therapy
• HeartMate 3• Centrifugal Flow
• Continuous Flow, Pulsatility from algorithmic speed changes
• No Mechanical Bearings –Magnetically Levitated
• Modular Driveline
• External Battery Power
• 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