Professor Davor Miličić, MD, PhD, FESC

MECHANICAL SUPPORT TO THE FAILING HEART

Department of Cardiovascular Medicine,

Zagreb University School of Medicine,

University Hospital Center Zagreb

Epidemiology

Heart failure

23 million people 1-2% total population >6% people aged over 65 yrs

End stage heart failure: refractory to maximal conventional treatment (drugs, CRT, AICD, ultrafiltration, mortality ≥ 50% within 1 year)

Heart transplantation ~ 5000/year (ISHLT)

Heart transplantation

“Heart transplantation is an accepted treatment for end stage HF. Although controlled trials

have not been conducted, there is a consensus that transplantation, provided through proper selection criteria, significantly increases survival,

exercise capacity, return to work, and quality of life compared with

conventional treatment.”

ESC guidelines for the diagnosis and treatment of the chronic heart failure, European Heart Journal 2008; 29:2388-2442

Transplantation is insufficient for treatment all patients with the

end stage HF

Limited availability of donor hearts Patients on HTx lists die Problem of a possibly reversible

advanced HF Problem of patients with temporary

contraindication for HTx Problem of patients with absolute

contraindication for HTx Solution: drugs, VAD

Mechanical myocardial support

IABP ECMO VAD TAH

Goals of mechanical support

Temporary treatment - bridging to:

Transplantation Recovery Higher class VAD

Destination therapy

“Mechanical support of the failing heart

is today an established therapy option for

terminal, end-stage heart failure patients”

G.M. Wieselthaler

History

First implantation

VAD (DeBakey 1963) Artificial heart (Cooley

1969)

Criteria for implantation of VAD

Maximal inotropic support, with/without IABP

Hemodynamic criteria BPsyst < 80 mmHg with:

CI < 2.0 (2.2) L/min/m2

ili PCWP > 20 mmHg

Contraindications*

Absolute (?) - multiple previous cardiac surgeries - severe peripheral artery disease

Relative - recent PE - acute GI inflammation or bleeding - cachexia

* Harefield & Royal Brompton Hospital, London, UK

VAD: options?

VAD: classification

Short term

Medium term

Long term

Pulsatile

Nonpulsatile

Criteria for VAD selection

Failure of one or two ventricles?

Prediction of mechanical support duration

Anticipation of final outcome

Logistic circumstances

Ultra short term, percutaneous VAD

Tandemheart Cath lab Fem. approach Up to 14 days Flow 4 L/min

Tandemheart

Short term/Pulsatile VAD

Abiomed Two-chamber Pneumatic Paracorporeal Stroke volume 80 ml Uni or BiVAD Polyurethane valves

Mobilization in hospital

Application 7 days

ABIOMED BVS 5000

Short term/Nonpulsatile VAD

Levitronix Centrimag Magnetic

levitation Up to 30 days Flow up to 9L Minimal

mobilization in hospital

Medium term VAD

Thoratec VAD Paracorporeal Pneumatic pulsatile LVAD, RVAD, BiVAD Stroke vol. 65 ml Polyurethane

bubbles Mechanical valves Application about 6

mo (up to 1.5 yr)

Thoratec VAD

Bridge to HTx (60%) Bridge to Recovery

viral myocarditis, postpartum cardiomyopathy, heart rejection

Cost → 35000 $ Complications – bleeding (31%), infections

associated with device (18%), thromboembolism (14%)

Thoratec IVAD?

Long term VAD

Novacor LVAS 55-65% survival to

HTx Average duration of

support 85 days (max. 962 days)

Anticoagulation necessary

Embolic CV accidents ~ 25%

Redesigned cannula (CVA 10%)

Long term/Pulsatile VAD

HeartMate Increased

mobility Possible hospital

discharge Stroke vol. 83 ml Preperitoneal

location

HeartMate

REMATCH

Post - REMATCH

Long term/Nopulsatile VAD

Advantages Small device Less material

contact - higher durability

Noiseless Disadvantages Hemolysis at high

RPM Intracavitary

negative pressure No solution “B”

Long term/Nonpulsatile VAD

Centrifugal pumps (axial flow)

Continuously rotating propeller

No proof that lack of pulsatility is harmful

First full implantable, miniaturizedFirst full implantable, miniaturized axial-pump for clinical applicationaxial-pump for clinical application

diameter 30,5 mm

length 76,2 mm

weight 93 g

Mechanical Circulatory SupportMechanical Circulatory Support

Centrifugal devices

Jarvik 2000 HeartMate II MicroMed

DeBakey

3rd Generation HeartWare: MVAD3rd Generation HeartWare: MVAD2008 -

FUTURE VS TODAY

Chronic Non-hospitalized HF patient

Quality of life improvement therapy

Partial

Elective

Endovascular

IX Cardiologist or CT Surgeon

Low

Target Patient Population

Treatment Goal

Level of Support

Placement Procedure

Device Implantation

Physician Placing

Implantation Risks

End-Stage Hospitalized HF patient

Life-saving therapy

Full

Emergency

ALWAYS Surgical

CT Surgeon

High

Current Assist Devices

Complications

bleeding/thromboembolism CVA infection device failure ARF Respiratory insufficiency

Total artificial heart

Heart explantation

Wireless energy transmission

Longest implantation 512 days

What can we What can we expect ??expect ??-- next 2 - 5 yrs new pump concepts in clinical application-- next 2 - 5 yrs new pump concepts in clinical application

-- new generation pump is predominantly rotary pump-- new generation pump is predominantly rotary pump-- further improvement of existing pump concepts-- further improvement of existing pump concepts-- challenge will bring prizes down-- challenge will bring prizes down-- very long lasting VADs for chronic implants-- very long lasting VADs for chronic implants-- -- true alternative to clinical heart transplantationtrue alternative to clinical heart transplantation??????

VAD-therapy VAD-therapy today:today:-- -- BRIDGE TO or destination Tx for terminal HF ptsBRIDGE TO or destination Tx for terminal HF pts

-- due to growing experience reasonable outcome-- due to growing experience reasonable outcome-- sophisticated technology provides good long-term results-- sophisticated technology provides good long-term results-- individual pump-types for individual patients-- individual pump-types for individual patients

Future of Mechanical Circulatory Support

Life is like driving a bicycle. To keep your balance you must keep moving.

Albert Einstein

Thank you for your attention attention!