Which device to which patient.
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Transcript of Which device to which patient.
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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
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• 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?
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The Use of Short-term Percutaneous MCS Devices Increased Rapidly between 2004 and 2011
Stretch R et al. JACC 2015:64: 1407 - 1415
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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
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Which Device for Which Patient?
Temporary Support Durable Support
High Risk Procedure
Bridge toRecovery
Bridge toTransplant
DestinationTherapy
Bridge toDecision
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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
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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
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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
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Which Device for Which Patient?Temporary Support
Choices
Adequate Oxygenation
Yes No
• Percutaneous • Surgical
• Percutaneous
• Surgical
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Which Device for Which Patient?
Temporary Support Choices
Adequate Oxygenation
Yes No
• Percutaneous √ IABP √ Impella √ Tandem Heart• Surgical
• Percutaneous √ ECMO √ Tandem Heart• Surgical
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Which Device for Which Patient?
Temporary Support Choices
Adequate Oxygenation
Yes No
• Percutaneous •Surgical √ CentriMag √ AbiomedBVS 5000
• Percutaneous• Surgical √ ECMO
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Abnousi F et al. Curr Cardiol Rep. 2015 ;17:594
√ ECMO
Percutaneous MCS Devices
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Surgical Devices
Abiomed Centrimag
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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
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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
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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
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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
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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
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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
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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
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Durable LVADS
HeartMate II HeartWare
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Total Artificial Heart
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LVADS far Outnumber Total Artificial Heart Implants
Kirklin JK et al. Journal of Heart and Lung Transplant 2014: 33:585-604..
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Which Device for Which Patient?
Temporary Support Durable Support
High Risk Procedure
Bridge toRecovery
Bridge toTransplant
DestinationTherapy
Bridge toDecision
√ Acute decompensation of chronic HF
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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
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Durable LVADS
HeartMate II HeartWare
Possible Reasons to Consider
Smaller sizeLateral thoracotomy Lower flow rateThrombosis ?
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HeartWare in Situs Inversus
Shah NR et al.. J Heart and Lung Transplant 2015; 32:615-20. ...
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• 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?