Assisted Circulation MEDICAL MEDICAL Drugs EECP MECHANICAL IABP ( Introaortic balloon pump) VAD...
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Transcript of Assisted Circulation MEDICAL MEDICAL Drugs EECP MECHANICAL IABP ( Introaortic balloon pump) VAD...
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Assisted Circulation in the Treatment of
Heart Failure
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Assisted Circulation
MEDICALDrugsEECP
MECHANICAL IABP
( Introaortic balloon pump)
VAD(Ventricular assist device)
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Inclusion criteria ofMechanical Circulatory Support
Cardiogenic shock criteriaMaximal inotropic supportIABP
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Exclusion criteria of Mechanical Circulatory Support
BUN > 100 mg/dlCr > 5 mg/dlChronic lung diseaseChronic liver diseaseMetastatic cancerSepsisNeurological deficitPost cardiotomy cardiogenic shockAge > 65 yr ( if bridge to transplant )
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Definition of cardiogenic shock
Cardiac output index < 2 lit/min/m2
Systolic blood pressure < 90 mmHgLeft or right atrial pressure > 20 mmHgUrine output < 20 cc/hrSystemic vascular resistance > 2100 dynes-sec.cm-5
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Indication of IABPCardiogenic shock
PostcardiotomyAssociated with acute myocardial infarctionMechanical complications of myocardial infarction
Mitral regurgitation Ventricular septal defect
In association with coronary artery bypass surgeryPreoperative insertion
Patients with severe left ventricular dysfunction Patients with intractable ischemic arrhythmias
Postoperative insertion postcardiotomy cardiogenic shock
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Indication of IABP (continue)
In association with nonsurgical revascularizationHemodynamically unstable infarct patientsHigh-risk coronary angioplasty
Patients with severe left ventricular dysfunction Complex coronary artery disease
Stabilization of cardiac transplant recipient before insertion of ventricular assist device
Postinfarction anginaVentricular arrhythmias related to ischemia
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Contraindication of the use of IABPAbsolute:
Aortic valve insufficiencyAortic dissection
Relative: Femoral arterial insertion
Abdominal aortic aneurysm Severe calcific aortoilliac or femoral arterial disease
Percutaneous insertion Recent ipsilateral groin inceision Morbid obesity
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Complication of IABPMinor
Bleeding at the insertion siteSuperficial wound infectionLymphocelePeritoneal perforation
MajorLimb ischemia requiring thrombectomy, revascularization, oramputationAortic dissectionAortoiliac lacerationFemoral artery pseudoaneurysmRetroperitoneal hemorrhageRenal ischemia from mal positionMyocardial ischemia from poor timing of balloon augmentationDeep wound infection requiring operative debridement
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Medication of VADIntended use Therapeutic Goal Devises
Bridge to recovery Temporary support IABP Centrifugal pumpECMO Abiomed HeartMate Novacor
Bridge to bridge Stabilization toLVAD/BiVAD
Abiomed Centrifugal pumpECMO
Bridge to transplantation
Support to transplantation
HeartMate Novacor Thoratec BiVAD Abiocor/TAH Axial flow pump
Destination Permanent support HeartMateNovacorAbiocor/TAHLionHeart
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Comparison between different VADsDevises Quality of
lifeShort –term survival (days per week)
Long-term survival(months)
IABP Centrifugal pumpECMO Abiomed HeartMate Novacor
++++++++++
+++++++++++
0000++++++
Abiomed Centrifugal pumpECMO
+++
++++
000
HeartMate Novacor Thoratec BiVAD Abiocor/TAH Axial flow pump
+++++++++++++
+++++++++++
+++++++++++
HeartMateNovacorAbiocor/TAHLionHeart
++++++++++++
+++UndocumentedUndocumentedUndocumented
+++
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LVAD Screening scoreVariable Relative risk weight
Mechanical ventilation 5.3 4
Postcardiotomy 3.3 2
Prior LVAD 3.3 2
Central venous pressure >16 mm Hg 2.1 1
Prothrombin time >16 sec 2.1 1
Excluded by multivariable analysis:Prior RVADCoronary artery diseaseAcute myocardial infarctionUrine output <30 ml/hrReoperative surgery
3.22.01.71.21.2
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Hemodynamic status during mechanical of ventricular assistance
CVP (mmHg)
LAP (mmHg)
Systolic Aop
(mmHg)
CI (L/min/m2)
dx
15-20 <15 >90 >2 Satisfactory pumping
<15 <15 <90 <2 Hypovolemia
15-20 >20 <90 <2 Inlet cannula obstraction
>20 <15 <90 <2 RV falure
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Device selection depends on:
AvailabilityPhysicians experiences
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FDA approved several VADs1. Abiomed biventricular system (BVS) 5000i for
postcardiotomy and post MI cardiogenic shock
2. The thoratic poracorporeal device, Novacor and HeartMate for bridge to transplantation.
3. The HeartMate for destination therapy
4. Implantable device as LionHeart, Jarvik, HeartMate II, DeBakey and Cor-Aide.
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Short term devices
Extracorporeal centrifugal pumpExtracorporeal membrane oxygenation (ECMO)ABIOMED BVS 5000i
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The Dbiomed biventricular system (BVS) 5000i
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Long term devicePulsatile devices
HeartMate LVAD (Implantable)Novacor (Implantable)Thoratic
Total artificial heartCardiowestAbiocor
Axial flow pumpsMicromed debakey VADHeartMate IIJarvik 2000
Totally implantable pulsatile devicesLionHeart LVD 200Novacor II
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HeartMate
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Novacor
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Thoratec paracorporeal VAD
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Abiocor
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MicroMed DeBakey
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Jarvik 2000
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LionHeart
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Major Complication
Complication Definition
Bleeding Blood loss resulting in at least one of the following:1. Transfusion of >6 units of RBC in 24 h2. Reoperation3. Death4. Any other intervention for a hemorrhage
Cerebrovascular accident
Any central nervous deficit that is sudden in onset and persists for more than 24 h. Deficit must be confirmed as having an embolic origin by conventional diagnostic methods (eg, CT-scan) or can be demonstrated to result from an infarct (at autopsy)
Infection Any confirmed infection All infections should be categorized as: exit site, pump pocket,systemic/septiaemia, other (eg, respiratory)
Right sided heart failure
Cardiac Index <2.2 L/min/m2 for >6 h in the absence of device failure,anatomic restrictions, left-sided dysfunction or hypovolemia(CVP >18 mmHg), requiring intervention
Liver failure Bilirubin >5 mg/dL
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Complications during mechanical circulatory support
Novacor (n=95)
HeartMate (n=58)
LionHeart (n=9)
Thoratec IVAD (n=3)
Cerebrovascular accident 30.1% 9.3% 44.4% -
Bleeding 24.7% 35.2% 66.7% 100%
Pocket infection 7.3% 10.2% - -
Driveline infection 20% 25.3% - -
Hemolysis - 1.9% 22.2% -
Liver failure 14.5% 11.1% 44.4% 1/3
Right heart failure 24.5% 25.9% 14.3% -
Gastrointestinal complications 19.3% 9.3% 44.4% -
Arrhythmias 3.15% 1.7% - -