impella ins & outs - nvhvv carvasz 2014...hemodynamic support effectiveness impella 2.5 vs. iabp...
TRANSCRIPT
Impella Ins & Outs
CarVasz November 21 201410:45 – 12:15
Nicolas M. Van Mieghem, MD, PhD, FESCClinical Director of Interventional Cardiology
Thoraxcenter, Erasmus MCRotterdam
Background
IABP is widely used for LV support in high-risk PCI &
cardiogenic shock
The increase in cardiac output by IABP is limited
Measurable effects on clinical outcome is scarce
What we need…
Assist Device should be safe
User-friendly
Effective LV support
Measurable (clinical) benefit
LV Support in EP?
Ventricular Tachycardia & EP-Ablation
High Risk for Hemodynamic Instability
Complex congenital heart disease (Fontan, …)
Poor LV function
Ischemic
Non-ischemic
LV support to overcome BP drop while inducing & ablating VT
IMPELLA
Impella CP
5 Strut Inlet Cage14 Fr Cannula
• 4.66mm
Optimized Impeller
Up to 4L/min – continuous flow
Impella Principle
PROTECT II Trial Design
IMPELLA 2.5 +
PCI
IABP +
PCI
Primary Endpoint = 30-day Composite MAE* rate
1:1
R
8
Patients Requiring Prophylactic Hemodynamic Support
During Non-Emergent High Risk PCI on
Unprotected LM/Last Patent Conduit and LVEF≤35% OR
3 Vessel Disease and LVEF≤30%
Follow-up of the Composite MAE* rate at 90 days
CPO= Cardiac Power Output = Cardiac Output x Mean Arterial Pressure x 0.0022 (Fincke R, Hochman J et al JACC 2004; 44:340-348)
Hemodynamic Support EffectivenessImpella 2.5 vs. IABP
9
Cardiac Power Output
Maximal Decrease in CPO on device Support from Baseline
IABP Impella
N=138 N=141
- 4.2 ± 24
- 14.2 ± 27
p=0.001
CPO data available only for 279 patients (N=138 IABP and N=141 Impella)
Learning curve - Impella 2.5 vs. IABP
10
N=82N=82 N=63N=63 N=68N=65
IABP
IMPELLA
Per Protocol Population 90day Outcome (N=423)
Impella 2.5 and CP
Impella 2.5 Impella CP
Mean Flow Rate (L/min)
2.3 - 2.5> 1 L/min additional
Flow
Catheter Size 9 Fr 9 Fr
Pump Size 12 Fr 14 Fr
Insertion MethodPercutaneous
via 13 Fr or 14 FrIntroducer Sheath
Percutaneous via 14 Fr Introducer
Sheath
Guidewire0.018” Silicone
Wire0.018” PTFE Wire
Placement Measurement
Fluid-filled Pressure Lumen
Fluid-filled Pressure Lumen
Cannula Geometry
Curved, Pigtail Curved, Pigtail
RPM 51,000 46,000
VT Ablation with Impella or not
Miller et al. JACC 2011;58:1363-71
Impella in VT Ablation
Impella in VT Ablation
Heart Pumps and Hemolysis?
15
• Heart Pumps apply “shear” forces to
red blood cells that if strong enough
can damage cell structure
• Shear forces result from differences
in blood velocity (i.e. force) from
one side of RBC to the other
• Shear forces in a heart pump are
strongest in regions of high blood
velocity differences and small flow
channels
Shear Force
Hgb
Hgb
Hgb
Hgb
Cannula Wall / Fixed Structure
Speed low due to dragging along the wall
Speed high away from wall
Shear forces “pull apart” or distort cell membrane and can cause rupture
Hemolysis with Impella and Other Heart Pumps in Bench Testing?
16
1CentriMag/Industry standard data – Levitronix Website2FDA Comparative Bench Test Data for Impella 2.5 510(k) Clearance
1 1 12 2
Thoratec PHP
• Low-profile
• Designed to provide high forward flow at low RPMs to unload the LV and perfuse end organs
– Designed to deliver 4-5 lpm average flow
• Collapsible elastomeric impeller within expandable nitinol cannula
• 13F insertion profile
• Expands to 24F when unsheathed
Impeller
Coated
CannulaCannula
Inlet
Cannula
Outlet
Insertion Sequence
HeartMate PHP
HeartMate PHP
Pivotal CE Mark study kick-off Q3 2014
Up to 50 patients undergoing high-risk PCI at up to 10
sites in Europe and South America
Primary performance endpoint: Freedom from
hemodynamic compromise during PCI
Primary safety endpoint: Composite of major adverse
events.
Thoratec PHP
PulseCath iVAC 2L
PulseCath Principle
17F catheter across
aortic valve is connected
to an extracorporeal
membrane pump
Pulsecath actively
aspirates blood from the
left ventricle in systole
and ejects this blood into
the ascending aorta
during diastole
Pump is compatible with
standard IABP console as
a driver
PULSECATH iVAC 2L
Hemodynamics Pulsecath
100
40
100
40
Counterpulsation
Diastolic Pressure increases
MAP increases
C.O. increases*
0,00,51,01,52,02,53,03,54,0
C.O.
C.Output
PULSECATH iVAC 2L
LV Support & Access Strategy
Large caliber system (17F)
Pulsatile LV Support
Genuine IABP console
Compared to IABP: C.O. X3
LV Support ≠ replacement
Safety & efficacy Study ongoing in Rotterdam
PULSECATH iVAC 2L
In Conclusion
LV support is valuable in particular clinical settings
Powerful devices are entering the clinical field
LV support may also serve complex EP procedures