BRAUNWALD’S CLUB

ASSISTED CIRCULATION
IN THE TREATMENT OF
HEART FAILURE
1/13/09
Objectives
 IABP
 Indications
 Insertiontechnique
 Contraindications
 Complications
 VAD
 Therapeutic goals
 Indications
 Contraindications
 Deviceselection
 Complications
Indications for Intraaortic
Balloon Pump
Counterpulsation
 Cardiogenic shock   
 Postcardiotomy   
 Associated with acute myocardial infarction
  
 Mechanical complications of myocardial
infarction   
 Mitralregurgitation   
 Ventricular septal defect   
Indications for Intraaortic
Balloon Pump
Counterpulsation
 In association with coronary artery
bypass surgery   
 Preoperative insertion   
 Patients with severe left ventricular dysfunction
  
 Patients with intractable ischemic arrhythmias
  
 Postoperative insertion   
 Postcardiotomy cardiogenic shock  
Indications for Intraaortic
Balloon Pump
Counterpulsation
 In association with nonsurgical
revascularization   
 Hemodynamically unstable infarct patients
  
 High-risk coronary angioplasty   
 Patients with severe left ventricular dysfunction
  
 Complex coronary artery disease
Indications for Intraaortic
Balloon Pump
Counterpulsation
 Stabilization of cardiac transplant
recipient before insertion of ventricular
assist device
 Post infarction angina
 Ventricular arrhythmias related to
ischemia
IABP- Insertion technique

 30-50 ml balloon distal to subclavian and

proximal to renal arteries
 Percutaneous insertion
 Synchronization with EKG/arterial BP
tracing
 Frequency of balloon inflation
IABP

 Augments coronary blood flow

 Reduces afterload
 Effects the oxygen supply demand ratio
but does not effect cardiac output
Contraindications

 Aortic insufficiency
 Aortic dissection
 Aorto-iliac disease
 Ilio –Femoral disease
 Abdominal/ descending thoracic
aortic aneurysms
Complications
 Rate 1-14%
 Limb ischemia
 Aortic dissection

 Aortoiliac laceration

 Pseudoaneurysm

 Retroperitonial hemorrhage

 Renal ischemia

 Myocardial ischemia

 Deep wound infection

VAD – Therapeutic goals
VAD – Post cardiotomy
Myocardial reserve prior
Dysfunction prior to surgery to surgery

 Pre surgical  Unable to wean

screening for from CP bypass
transplantation but have good
 Surgery with end organ
LVAD backup function-
Temporary VAD
 Stabilize and
transfer
Post MI
 >40% loss of ventricular mass -80%
mortality
 Early revascularization - 1 yr survival
<50%
 Advocate LVAD and no CABG in this
situation
 Triage with Tandem heart or Impella
 Revascularization if myocardial recovery
 Bridge to transplant VAD if myocardium
fails but end organs recover
 Palliative care if end organs fail
Chronic heart failure

 Transplant eligible
 Acute decompensation – Bridge to
transplant
 Marginal end organ failure – Renal
insufficiency
 Malignancy in remission

 Transplant ineligible
 Permanent use of destination therapy
Acute myocarditis -
Arrythmias
 Acute myocarditis
 Bridge to recovery
 Bridge to transplant

 Advocate Long term therapy

 Ventricular arrythmias
 Failure of antiarrythmics/defibrillators
 Helps control arrythmias

 If persist well tolerated

Predictors of poor prognosis
in chronic heart failure

 Advanced age
 Female gender
 DM
 Preoperative albumin level
Contraindications

 Irreversible end organ failure

 Irreversible neurological injury
 Overwhelming infection / sepsis
Devices

 Short term
 Long term
 Pulsatile
 Total artificial heart
 Non pulsatile
Extracorporeal centrifugal
pumps
 Advantages
 Widely available, inexpensive , simple to
insert and use
 Can be used for right, left or biventricular
support (Biomedicus Biopump)
 Disadvantages
 Systemic anticoagulation
 Interstitial edema due to SIRS

 Requirement for sedation / paralysis

Extracorporeal centrifugal
pumps
ABIOMED BVS 5000 / AB5000
VENTRICLE
 Short term uni/bi ventricular support
system
 External pumps, computer control drive
console
 100 ml Polyurethane blood sacs and
polyurethane valves
 Manual weanability – bedside with ECHO
 Ease of insertion and simplicity of
operation
 Continuous anticoagulation, limited
ABIOMED BVS 5000
Tandemheart
 Short term univentricular – upto 14 days
 Inflow canula in left atrium, outflow in
femoral artery
 Minimally invasive implantation
 Continuous anticoagulation, ICU care,
limited mobility
 Flow 4 lit/min
 Post MI (reverse severe cardiogenic
shock)
Tandem heart
IMPELLA/ORQIS
 IMPELLA
 Percutaneous implantable pump and mobile
console
 Microaxial flow pump at catheter tip in left
ventricle and propels blood to outflow portion
in ascending aorta
 Adjusment under TEE / flouroscopy
 Two sizes (5 lit/min, 2.5 lit/min)

 ORQIS (MOMENTUM Trial)

 Acutely decompensated CHF
 2 catheters (Proximal descending thoracic
aorta, femoral artery and small pump)
IMPELLA
ISAR-SHOCK
Trial design: Patients with cardiogenic shock due to acute MI were randomized
to an Impella LVAD (n = 13) versus an IABP (n = 13) after PCI was performed.

Results
 Cardiac index (CI) at 30 minutes: 2.20
L/min/m2 for Impella vs. 1.84 L/min/m2
for IABP (p = 0.18 for 30-min CI, p =
(p = 0.18) (p = 0.02 for change in CI between groups)
NS)  CI after 30 hours: 2.51 L/min/m2 vs.
2.40 L/min/m2 (p = NS), respectively
2 46 46 30-day mortality: 46% vs. 46%,
L/min/m2

.20 1 respectively
.84 %

Conclusions
30-minute 30-day • In patients with cardiogenic shock due
cardiac index mortality to MI, the Impella device improved the
change in 30-minute CI compared with
IABP
Impella left  Intra­aortic 
ventricular  balloon  • At all time points, including after 30
assist device counterpulsation hours, CI was similar between groups
• 30-day mortality was similar between
groups
Seyfarth M, et al. J Am Coll
ORQIS CANCION
 MOMENTUM
Trial design: Patients with refractory heart failure symptoms were randomized
to the Orqis continuous aortic flow augmentation device for 4 days
(superimposing low-level continuous flow on pulsatile flow) (n = 109) or
continued medical management (n = 59).
Results
 PCWP: 24.5 mm Hg for device vs. 26.7
mm Hg for control (p = 0.074)
(p = (p = 0.05)  Cardiac index: 2.4 L/min/m2 vs. 2.1
0.074) L/min/m2 (p < 0.0001), respectively
 Death or heart failure hospitalization
at 65 days: 53.2% vs. 57.6% (p =
0.51), respectively
1
2 6.5  Major bleeding: 16.5% vs. 5.1% (p =
2 %
mm Hg

6.7 5.1 0.05), respectively

4.5

Pulmonary Conclusions
Major
capillary bleeding • Continuous aortic flow augmentation for
wedge 4 days non-significantly reduces wedge
pressure pressure, although death or HF
Continuous  hospitalization is similar
Medical 
aortic flow 
management • Major bleeding is increased with the
augmentation 
device

Greenberg B, et al.
Circulation 2008;118:1241-9
Long term - Pulsatile

 Require inflow and outflow valves

 Tissue valves / Mechanical valves
 Long term anticoagulation
Heartmate implantable
 60-70% survival to transplantation
 Average duration of implantation in 80-100 days
 Maximum implantation >2 yrs
 Probability of device failure at 2 yrs is 35%
 Titanium alloy external housing
 Inflow and outflow conduits that use porcine xenograft
valves
 Internal blood-contacting surface, which is made of
textured titanium on one side and textured
polyurethane on the other
 Deposition of a fibrin-cellular matrix that forms a
pseudoneointima - deceased need for anticoagulation
 Need ASA for anti-inflammation
 Pumping capacity in excess of 9 liters/min
 Immunologically active entity – limits ultimate
transplantability
NOVACOR
 55-65% survival to transplantation
 Mean time of support 85 days
 Maximal implantation 962 days
 Require anticoagulation
 Embolic CV events is 27-41%
 Gortex inflow canula with CV events 10%
Paracorporeal Pulsatile
Devices
 Univentricular or biventricular
 Used in patients with BSA low for
implantable devices
 Limits mobility
 Anticoagulation
 Survival to transplantation 60-80%
TAH

 79 % survival to transplantation
 BSA 1.7m2
 ASA, Warfarin, Pentoxifylline
Syncardia
TAH
Non pulsatile devices
 Advantages
 Full cardiac support
 Small size - Smaller patients
 Easy implantation and explantation
 Increased durability
 No differences in morbidity / mortality
 Disadvantages
 Hemolysis
 Pump failure – replacement
 Acute AI
 Ventricular arrythmia
 Thrombus formation (due to negative pressure leading
to LV collapse and transient cessation of flow)
Micromed Debakey VAD
 Titanium casing with an impeller-inducer
capable of pumping 10 liters/min
 Chronic anticoagulation with warfarin and
an antiplatelet agent
 Flow probe on its outflow graft allows for
continuous flow monitoring, enabling pump
speed adjustment as well as detection of
extreme suction
 Late bleeding, probably related to the level
of anticoagulation
 High incidence of device thrombosis
requiring thrombolysis or device
replacement has led to a reevaluation of
the pump design
Micromed
Debakey
axial flow
pump
Heartmate II

 Flow rates more than 10 liters/min

 Anticoagulation is currently required to
keep the INR between 1.5 and 2.5
JARVIK 2000
axial flow
pump
Post op management
 Early
 Antibiotic prophylaxis
 Right heart failure is immediately or
prophylactically treated with milrinone
(Primacor) and inhaled nitric oxide
 Vasodilatory hypotension is treated with
intravenous arginine vasopressin (Pitressin)
 Aprotinin is continued in the postoperative
period until bleeding has stopped
 Physical therapy and nutrition
 Late
 Rehabilitation
 immunological changes induced by the LVAD
Complications
 Bleeding (20-40%)
 Thromboemblic events (2-47%)
 Infection (12-55%)
 Device failure
 Right heart failure (10-30%)
 Multiorgan failure
 Immunological phenomena
 Sensitization (66%)
Destination therapy
 REMATCH Trial
 Pulsatile HeartMate device
 LVAD vs. Max medical therapy (followed for
3 yrs)
 End point (death, QOL, complication,
hospitalization)
 48% reduction in death

 Higher complication rate and higher

median no of days spent in hospital
THANK YOU