heart failure device therapy
TRANSCRIPT
Newer advancements in heart failure device therapy
» DR. GOPI KRISHNA
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Introduction• Heart failure prevalence is rising throughout the world.• The reasons for this pandemic include
• the aging populations of both industrialized and developing nations;
• a growing incidence of obesity, diabetes, and hypertension .
• improved survival after myocardial infarction; and success in preventing sudden cardiac death .
• Fortunately, therapies that have emerged during the past few decades can greatly improve outcomes in heart failure patients.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Prevalence rates of heart failure by gender and age in the United States
Data from American Heart Association: Heart Disease and Stroke StatisticsNEWER ADVANCES IN HEART FAILURE
DEVICE THERAPY
Stages of Heart Failure
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
management
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
• I.C.D• C.R.T.-P/D.• TEMPERORY SUPPORT DEVICES.• PERMENENT SUPPORT DEVICES.• OTHER SUPPORT DEVICES.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
17
8
20
15
9
19
76
4
11
0
10
20
30
CHF-STAT GESICA SOLVD V-HeFT I MERIT-HF CIBIS-II CARVEDILOL-US
Con
trol
Gro
up M
orta
lity
Total Mortality
Sudden Death
Total Mortality ~15-40%; SCD accounts for ~50% of the total deaths.
12 months 16 months41.4 months 27 months 13 months45 months 6 months
I.C.DSCD Rates in CHF Patients with LV Dysfunction
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
ICD
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Evolution of ICD Therapy: 1980 to Present
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
1980 1985 1990 1995 2000 2005
Number of Worldwide ICD Implants Per Year
First Human Implant
FDA Approval of ICDs
•Transvenous Leads•Biphasic Waveform
Smaller Devices
Dual-Chamber ICDsSize ReductionAVIDCASHCIDS
AT Therapies MUSTT
ICDs with Cardiac Resynch
1980
1985
1989
1993
1996
1997/8
1999
2000
2002
1988
Tiered Therapy MADIT
Steroid-eluting Leads Increased Diagnostic and
Memory Capacity
MADIT-II
2004 SCD-HeFT
COMPANION
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Cardiac resynchronistion therapy
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
60%
70%
80%
90%
100%
0 60 120 180 240 300 360
Days
Cu
mu
lati
ve S
urv
ival
Duration (msec)
<90
90 120
120 170
170 220
• QRS duration is an independent predictor of mortality (>140 ms)
• Other factors are: age, creatinine, EF, and HR
.
-
-
-
QRS
-
-
-
>220
SCD in Heart FailureSCD in Heart Failure
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Cardiac resynchronistion therapy
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Right AtrialLead
Right VentricularLead
Left VentricularLead
Achieving Cardiac Resynchronization
Goal: Atrial synchronous biventricular pacing
Transvenous approach for left ventricular lead via coronary sinus
Back-up epicardial approach
Right AtrialLead
Right VentricularLead
Left VentricularLead
Cumulative Enrollment in Cardiac Cumulative Enrollment in Cardiac Resynchronization Randomized Resynchronization Randomized
TrialsTrials
0
1000
2000
3000
4000
1999 2000 2001 2002 2003 2004 2005
Results Presented
Cum
ulat
ive
Pati
ents
PATH CHF
MUSTIC SR
MUSTIC AF
MIRACLE
CONTAK CD
MIRACLE ICD
PATH CHF II
COMPANION
MIRACLE ICD II
CARE HF
NEWER ADVANCES IN HEART NEWER ADVANCES IN HEART FAILURE DEVICE THERAPYFAILURE DEVICE THERAPY
Anatomical Challenges
• Enlarged right atrium• Abnormal CS location• Presence of valves in CS• Altered CS angulation • Acute branch take offs • Tortuous vessel anatomy
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
CRT Procedure and Device Related Risks relative to CS placement
• CS lead dislogdement 8%• CS dissection or perforation 5%• Failure of lead placement 8%• Phrenic nerve stimulation 2%
– ALL other risks associated with pacer or ICD implantation and anesthesia in these patients.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
The 3 levels of asynchrony
1. Intraventricular asynchrony is best treated by placing the LV lead in the best anatomic location-usually the lateral or posterolateral (proven my multiple studies). Get the LV working.
2. Interventricular asynchrony is dealt with by adjusting the V-V interval. Get the RV and the LV to work together.
3. A-V asynchrony is dealt with by adjusting the A-V interval. Get the atria and the ventricles working together.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Extending indications to class II
• REVERSE. • MADIT-CRT.• RAFT
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
The HF clinical composite response.
Linde C Europace 2009;11:v72-v76
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: [email protected].
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Mean LVESVi, LVEDVi, and LVEF at baseline and 12-month follow-up in the CRT-OFF and CRT-ON groups.
Linde C Europace 2009;11:v72-v76
. NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Time to first HF hospitalization or death in the 18-month follow-up period in the CRT-OFF and CRT-ON groups.
Linde C Europace 2009;11:v72-v76
. NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Other trials
• rethinQ• PROSPECT trial.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Assist devices
• Percutaneous.• Implanted.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
I.A.B.P balloon
I.A.B.P
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Indications for Intraaortic Balloon Pump Counterpulsation
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
complications
• vascular compromise• aortic dissection,• aortoiliac laceration, • femoral artery pseudoaneurysm• retroperitoneal hemorrhage, • renal ischemia from malposition, • myocardial ischemia from poor timing of balloon
augmentation,• deep wound infection requiring operative débridement
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
TANDEM HEART
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
IMPELLA LP2.5 SYSTEM
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Effect of IABP and Impella 2.5 device on important hemodynamic parameters
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Contraindications• 1. Mural thrombus in the left ventricle• 2. The presence of a mechanical aortic valve device• 3. Moderate aortic stenosis or moderate to severe aortic
insufficiency • 4. Abnormalities of the aorta that would preclude surgery,
including aneurysms and extreme tortuosity or calcifications.
• 5. Renal failure (creatinine>4 mg/dL)• 6. Liver dysfunction or markedly abnormal coagulation
parameters.• 7. Recent (within 3 months) stroke or transient ischemic attack
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
THE REITAN CATHETER PUMP
PUMP IMPLANTATION HEMODYNAMIC EFFECTS
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Algorithm for device selection.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
PERMENENT V.A.D.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
History of lvad
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Mechanical Circulatory Support
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Mechanical Circulatory SupportINDICATION NOMENCLATURE DEFINITION
Bridge to transplantation Patient is listed for heart transplantation
Bridge to candidacy
Patient initially deemed ineligible for heart transplantation because of comorbidity (cardiorenal syndrome or pulmonary hypertension), which improves during mechanical support
Bridge to recovery
Patient with a potentially reversible cause of cardiac decompensation (acute myocarditis, postcardiotomy syndrome, peripartum cardiomyopathy)
Bridge to decision Patient in whom the potential for transplantation or recovery is yet unclear
Destination therapy Patient in whom recovery or transplantation is not feasibleNEWER ADVANCES IN HEART FAILURE
DEVICE THERAPY
First generation Second generation
Third generationNEWER ADVANCES IN HEART FAILURE
DEVICE THERAPY
1st generation
2nd generation
3rd generationNEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
FIRST GENERATION DEVICES
FEATURES• is a short-term uni- or
biventricular support system .
• comprised of two 100 mL polyurethane blood sacs.
• the inlet and outlet portions of which are guarded by polyurethane valves
The Abiomed BVS 5000i
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Pulsatile Devices
• has a titanium-alloy external housing, with inflow and outflow conduits that use porcine xenograft valves.
• Internal blood-contacting surface is made of textured titanium that results in the development of a pseudo-neointima on which thrombus formation is greatly reduced, thereby decreasing the need for anticoagulation.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Thoratec paracorporeal VAD
• actual pump chamber is outside of the body.
• this device can be used on patients with body sizes too small to house the HeartMate or Novacor devices (i.e., <1.5 m2).
• Pneumatic drivers provide alternating air pressure to fill and empty the blood pump.
• Anticoagulation with warfarin is necessary, as for patients with mechanical valves.
Para carporial
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
2nd generation
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
The Jarvik 2000 implanted in the apex of the left ventricle outflow graft anastomosed to the
descending aorta.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
• BI VENTRICULAR SUPPORT
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
• A Jarvik 2000-C removed for transplant after 3 months with no thrombus present on the cone bearings.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
• The junction of the microsphere coating with
• the myocardial tissue at the apex is well healed by 2
• months, and free of thrombus.
• A healthy adherent neointema is seen growing into the porous microsphere surface.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Miniature Ventricular Assist Device
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
CircuLite Synergy Pocket Micropump
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
• RV dysfunction is an important source of morbidity and mortality after LVAD
insertion.• Recent data demonstrates that early planned
institution of RV support can mitigate the potential adverse consequences of RV dysfunction after LVAD placement.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Parameters identified as risk factors for RVfailure after LVAD placement
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
INTERMACS: profiles for patient selection
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
The C-Pulse ( implantable, extra-aortic counterpulsationdevice)
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Symphony Counterpulsation Device
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
TOTAL ARTIFICIAL HEART
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Effects of Chronic Hemodynamic Unloading with Ventricular Assist Devices
Structural• Regression of myocyte
hypertrophy.• Reduction in neurohormonal
activation• Normalization in expression of
contractile proteins .• Enhanced electron transport
chain respiratory function• Decreased apoptosis and
cellular stress markers
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
• Functional • Improvement in left ventricular ejection fraction and
diastolic and systolic dimension• Recovery from spherical to more elliptical left
ventricular shape• Improvement in heart failure–specific indices of quality
of life• Improvement in peak aerobic capacity
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
complications
• Anticoagulation.• Drive line infections .• Noise.• Durability.• Activation of immune system.
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
epicardial pads secured and used to tighten the device.
The CorCap device
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Percutaneous Leaflet Repair and Annuloplasty for Mitral Regurgitation
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
90Investigational Device only in the
US; Not available for sale in the US
EVEREST II Randomized Clinical TrialKey Inclusion/Exclusion Criteria
Inclusion– Candidate for MV Surgery– Moderate to severe (3+) or
severe (4+) MR• Symptomatic
– >25% EF & LVESD ≤55mm• Asymptomatic with one or more
of the following– LVEF 25-60%– LVESD ≥40mm– New onset atrial fibrillation– Pulmonary hypertension
Exclusion– AMI within 12 weeks– Need for other cardiac surgery– Renal insufficiency
• Creatinine >2.5mg/dl– Endocarditis– Rheumatic heart disease– MV anatomical exclusions
• Mitral valve area <4.0cm2
• Leaflet flail width (≥15mm) and gap (≥10mm)
• Leaflet tethering/coaptation depth (>11mm) and length (<2mm)
ACC/AHA Guidelines JACC 52:e1-e142, 2008
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY
Figure 6. Core laboratory tracings of the mitral annulus and leaflet line of coaptation from 3D echo data sets recorded at preprocedure baseline and follow-up time points noted from
patients with PTMA implants still observed by x-ray to be in place.
Sack S et al. Circ Cardiovasc Interv 2009;2:277-284
Copyright © American Heart Association
Date of download: 11/6/2012
Copyright © The American College of Cardiology. All rights reserved.
From: Percutaneous Leaflet Repair and Annuloplasty for Mitral Regurgitation
J Am Coll Cardiol. 2011;57(5):529-537. doi:10.1016/j.jacc.2010.10.012
Direct Annuloplasty
The Guided Delivery Systems Accucinch device is delivered through retrograde catheterization of the left ventricle. (Left) Anchors are placed in the posterior mitral annulus and (right) connected with a “drawstring” to cinch the annular circumference.
Figure Legend:
•Thank you
NEWER ADVANCES IN HEART FAILURE DEVICE THERAPY