Università degli Studi di Torino

Prof Mauro Rinaldi

Heartline, Genova - Novembre 2015

TURIN

MCS and HTX program since 2005…

255 heart transplantations

273 short term VAD implantations

76 permanent VAD implantations

Short term VAD - Indications

Acute Cardiogenic Shock Precardiotomy Postcardiotomy

SCENARIO

Cardiology – Cardiac Surgery

Clinical status – INTERMACS Level 1

• Mean arterial pressure < 55 mhg

• Cardiac Index less than 1.8 L/min/m2

• Wedge p > 18 mmHg and CVP > 16 mmhg

• SvO2 less than 50% and/or Lactates increase (>3)

• Urine output < 60 cc/per hour

Unresponsive

Hypotension

High filling pressures

Inadeguate perfusion

Acidosis

Inotropic drugs

LOS despite 2 high dose inotropic drugs and IABP

IABP

…as soon as possible…

Short-term VAD

Short term VAD - Indications SCENARIO

Cardiology – Cardiac Surgery

Acute Cardiogenic Shock Precardiotomy Postcardiotomy

MCS Strategy

Acute setting Chronic setting

Short term VAD Long term VAD

Bridge to Decision Bridge to Recovery

Emergency Htx

Permanent VAD

?unknown patients? !known patients!

Dynamic strategy

BRIDGE to LIFE

Refractory Failure and Treatment The ECMO galaxy

CARDIAC CARDIOPULMONARY PULMONARY

Pulm+ RV Pulm+ BiV or LV

RA-LA ECMO

RVAD ECMO

BiV

V-V ECMO

RV LV

RVAD LVAD

JACC - 2011

V-A ECMO

V-A ECMO

BiVAD

ROTAFLOW- CARDIOHELP

Maquet

LEVITRONIX

Centrimag

Tandem

Heart

Impella Recover

LVAD- RVAD

Portata Fino a 8 l/min Fino a

7 l/min

Fino a

6 l/min 2,5 l/min 5 l/min

Cannulazione Periferica / Centrale Periferica /

Centrale Periferica Periferica

Periferica / Centrale

Durata max del

supporto 10 giorni 2 settimane 2 settimane 2 settimane

Anticoagulazione ACT > 180 ACT > 160 ACT > 180 aPTT > 60 sec

Short term VAD

V-A ECMO approach

• Peripheral (pre- cardiotomic shock)

• Central (post- cardiotomic shock)

Central VA ECMO: Aorta and Right atrium

Atrial cannula

Aortic cannula

Peripheral VA ECMO implant under CPR

Cut down

5 to 10 minutes

necessary!!

-Gloves

-Blade

-Scissors

VA ECMO: Peripheral F-F + shunt configuration

V-A ECMO critical issues

• Bleeding and thrombosis

• Aortic flow competition

• Left heart overload

• Pulmonary function impairment

Bleeding and Thrombosis

ANTICOAGULATION aPTT 50-60 sec ACT > 160 VAD or ECMO> 4l/min

aPTT 60-70 sec ACT > 180 ECMO < 4l/min

aPTT 70- 80 sec ACT > 200 low Flow ECMO

Platelets count >50.000

TEG – 40< MA< 60

…to prevent Mayor Bleedings

Examination after the ECMO explant

Cannulas and tubes

Oxygenator

Pump

Ultrafilter

Hypercoagulation bleeding paradox

Aortic flow competition

The “HARLEQUIN” syndrome

Flow competition in the Aorta Desaturation in the upper body

Blue Head Red Arms

Coronary and Brain

issue

Left ventricular function on ECMO LV thrombosis LV overload

LV stasis

Lung Function on ECMO Clinical case

Peripheral LV Vent Central LV Vent

Approach

Effect of elevated LVEDP On coronary flow

Myocardial perfusion pressure

LV Vent

Right Atrium

LV apex

Femoral artery

Centrifugal pump Oxigenator

LV apex Femoral

Axillary artery

Centrifugal pump

Permanent LVAD

Bridge to Bridge

Temporary RVAD

• PGD after Heart Transplant

• RV Failure after LVAD

• Postcardiotomic ischaemic damage

• Acute Myocardial Infarction

• Pulmonary embolism

• Sternum closed

• Decannulation

through a left anterior

minithoracotomy

TOTAL PERCOUTANEOUS

Temporary RVAD

VA ECMO vs RVAD VA ECMO RVAD

Pheripheral approach yes yes

Oxygenator yes no

Rpm speed +++ +

Haemolysis +++ +

Shear stress +++ +

Anticoagulation +++ +

Durability 1 week 2 weeks

Harlequin syndrome yes no

Limb Ischaemia yes no

Preserved pulmonary function

Plus LV vent yes

Biventricular Failure Right Ventricular Failure

Left Atrial Pressure

LAP > 16 mmhg LAP < 16 mmhg

Echo TE

VA ECMO

+IABP + LV vent

LV EF < 30% LV EF > 30%

VA ECMO RVAD

CVP / LAP < 1 CVP / LAP > 1

0%

10%

20%

30%

40%

50%

60%

70%

VAECMORVAD

31%

63%

48%

22%

35%

18%

Recovery Inhospitalmortality Majorbleedings

Recovery and Survival

VA ECMO vs RVAD

University of Turin Experience 2005-

2015

Hub and Spoke NETWORK University of Turin

Experience 2005-2014

205 pts INTERMACS Level 1

• Early Referral • Increasing Experience • Systematic LV venting

VADs/ECMO changing outcomes

INTERMACS Level 1

VADs-ECMO outcomes

0

10

20

30

40

50

60

70

80

2005- 2008 2009- 2011 2012-2014

Permanent VAD

H transplant

recovery

died

30-day

mortality

60%

30-day

mortality

52%

30-day

mortality

44%

INTERMACS Level 1

VAD/ECMO Risk factors for death Multivariate analysis

Postcardiotomic p 0,003 No left ventricular venting p 0,01 Central approach p 0,01 External ECMO p0,22 “Unstable” ECMO p 0,02 Previous cardiac arrest (CPR) p 0,15 Miocardial infarction p 0,32 Previous MOF p 0,04

“UNSTABLE” ECMO

•Surgical Bleeding •Inadequate heart drainage

2014

University of Turin Cardio-Thoracic Surgery St. Giovanni Battista Hospital

0,00

0,10

0,20

0,30

0,40

0,50

0,60

0,70

0,80

0,90

1,00

0 2 4 6 8 10 12 14 16 18 20 22 24

Su

rviv

al

(%)

tempo (mesi)

Actuarial Survival

VAD LTx

p= 0,01 p= 0,05 p= 0,15 p= 0,31

Numbers at Risk Baseline 6 months 12 months 18 months 24 months

Group A 26 11 10 10 10

Group B 27 23 17 14 11

Event VAD: Death (not censored at transplant)

Group A: HTx

Group B: VAD

Results

Long-term LVAD implanted- University of Turin

Hub and Spoke

NETWORK

Long-term VAD- University of Turin

Neurological dysfunction

TET: Transcoutaneous Energy

Transmission

LION HEART

The next future

Biventricular failure

•Age (over 65 years)

•Comorbidities

•Severe Pulmonary Hypertension

•Cardiac tumors

TOTAL ARTIFICIAL HEART TAH

CUORE MECCANICO

CardioWest Total Artificial Heart

CardioWest TAH

CUORE BIOLOGICO

FIRST STEP

BIVENTRICULAR

HEART SUPPORT ??

Biventricular permanent continuous flow devices (Berlin solution)