Mechanical Circulatory SupportIndications / contraindications

Devices and Outcomes

Christopher Hayward

Cardiologist

Heart Failure Transplant Unit

Stevenson Circ 2005

LVAD indications

Need LVAD - Bridge to transplant, destination or recoveryNYHA IV for 60–90 days

Maximal tolerated medical therapy +/- CRT / ICD

Chronic inotrope dependence

LVEF <25%, PCWP 20 mmHg

SBP 80–90 mm Hg or CI 2 L/min/m2 or renal or RV function

Consider LVAD NYHA IV for 30 days

Maximal tolerated medical therapy and CRT/ICD if indicated

Intermittent inotrope dependence

LVEF <25%, Peak VO2 <12 mL/kg/min

Indication to enable HTxPVR <5 Woods units, reversible secondary PHT to chronic HF

Reversible GFR <25–30 mL/min/1.73 m2

Lund et al EJHF 2010

Contraindications

Cardiac issuesNon-systolic HF

Cor pulmonale, Severe RV dysfunction or Multi-organ failure

Moderate or severe aortic regurgitation that will not be corrected

Mechanical aortic valve that will not be converted to bioprosthesis

Hypertrophic cardiomyopathy, VSD or congenital heart disease

Non-cardiac issuesTerminal co-morbidity; e.g. renal disease (haemodialysis or Crt > 250umol/L)

Metastatic or advanced cancer, severe liver disease, severe lung disease or home O2,

severe PVD, or unresolved CVA or severe neuromuscular disorder

Active uncontrolled systemic infection or risk of infection

Active severe bleeding / platelet count <50 000 x109/L, HITTS

Management issuesIntolerance to the anticoagulant regimen specific to device

Body surface area 1.2–1.5 m2 or other dimensional or technical limitation

Inability to grasp risks and benefits and provide informed consent / interpret alarms

Psychosocial limitations, driveline / medication non-compliance

Lund et al EJHF 2010

HeartMate I & II

Slaughter et al NEJM 2009

HeartMate XVE HeartMate II

HeartMate XVE / II Survival

REMATCH

medical therapy

Rose et al

NEJM 2001

Slaughter et al

NEJM 2009

Medical therapy

LVAD implants

Kirklin et al INTERMACS-5. J Heart Lung Transplant 2013

INTERMACS Level Pre-Implantfor 1092 Primary LVAD (June 2006–March 2009)

n %1 Critical cardiogenic shock 328 30

2 Progressive decline 437 40

3 Stable but inotrope dependent 168 15

4 Recurrent advanced HF 106 10

5 Exertion intolerant 21 2

6 Exertion limited 12 1

7 Advanced NYHA III 20 2

Kirklins et al INTERMACS 2. JHLT 2010

HeartWare HVAD

Wieselthaler et al JHLT June 2010

VentrAssist HeartWare

HeartWare

Aaronson et al Circulation 2012

ADVANCE Trial

HVAD ADVANCE Trial

Day/Month/Year Footnote to go here Page 14

• Medical history• Aetiology HF

• Hospitalisations

• Past chest surgery

• Treatment• Medications

• Devices

• ICU support

• Risk of RV failure• Echo – RV function

• RHC – PHT

• RVSWI

• Outcome Risks• Renal function

• Bleeding risk

• Infection risk

• Social support

Day/Month/Year Footnote to go here Page 15

LVADs and daily activities

Hu et al J Cardiac Failure 2013

LVADs and daily activities

Hu et al J Cardiac Failure 2013

Maximum pacing rate

Muthiah et al. ASAIO 2012

0

20

40

60

80

100

120

140

HR (bpm) FLOW(L/min)

MAP(mmHg)

LVEDD(mm)

Baseline 85.5 5.22 75 55

Max HR 126.1 5.16 72.6 53.9

p=0.001

p=0.91

p=0.58

p=0.88

Posture and pump flow

Muthiah et al ISHLT 2013

Pu

mp

flo

w e

stim

ate

(L/m

in)

0

4

8

12

20 seconds

4

5

6

Pu

mp

po

we

r (W

)

Baseline Tirofiban

30mins

Tirofiban

20 hrs

Pre-

thrombolysis

Post

thrombolysisThrombosis

Muthiah et al Artificial Organs 2013

Pump thrombosis and Rx

Alteplase 15mg

St Vincent’s Hosp MCS program

145 patients

• 36 pulsatile LVAD (HeartMate VE, XVE)

• 104 continuous flow LVAD (33 Ventrassist, 71 HeartWare)

• 5 Total artificial hearts

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Days On Pump

0 100 200 300 400 500 600 700

Survival

CF Puls TAH

0

5

10

15

20

25

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

TAH

CF

Puls

As at June 30 2013

St Vincent’s Hosp MCS program

105 cfLVAD patients

• 33 Ventrassist, 72 HeartWare

• (5 Syncardia total artificial hearts)

• 7 Bi-VAD systems

As at Aug 20 2013

0

5

10

15

20

25

04-05 05-06 06-07 07-08 08-09 09-10 10-11 11-12 12-13 13-14

LVAD TAH BiVAD

BiVAD

BiVAD CXR

Cardioversion

The Future

MVAD 1/3 size of HVADno need for median sternotomy

same impeller technology

promising in animal studies

IV-VAD 1/10 size of HVADIntravascular pump – percutaneous

Not intended to provide full cardiac support

TETS - Transcutaneous Energy Transfer

SystemImplanted battery pack to be charged across the skin

Will eliminate need for drivelines