Assisted Circulation in the Treatment of

Heart Failure

Assisted Circulation

MEDICALDrugsEECP

MECHANICAL IABP

( Introaortic balloon pump)

VAD(Ventricular assist device)

Inclusion criteria ofMechanical Circulatory Support

Cardiogenic shock criteriaMaximal inotropic supportIABP

Exclusion criteria of Mechanical Circulatory Support

BUN > 100 mg/dlCr > 5 mg/dlChronic lung diseaseChronic liver diseaseMetastatic cancerSepsisNeurological deficitPost cardiotomy cardiogenic shockAge > 65 yr ( if bridge to transplant )

Definition of cardiogenic shock

Cardiac output index < 2 lit/min/m2

Systolic blood pressure < 90 mmHgLeft or right atrial pressure > 20 mmHgUrine output < 20 cc/hrSystemic vascular resistance > 2100 dynes-sec.cm-5

Indication of IABPCardiogenic shock

PostcardiotomyAssociated with acute myocardial infarctionMechanical complications of myocardial infarction

Mitral regurgitation Ventricular septal defect

In association with coronary artery bypass surgeryPreoperative insertion

Patients with severe left ventricular dysfunction Patients with intractable ischemic arrhythmias

Postoperative insertion postcardiotomy cardiogenic shock

Indication of IABP (continue)

In association with nonsurgical revascularizationHemodynamically unstable infarct patientsHigh-risk coronary angioplasty

Patients with severe left ventricular dysfunction Complex coronary artery disease

Stabilization of cardiac transplant recipient before insertion of ventricular assist device

Postinfarction anginaVentricular arrhythmias related to ischemia

Contraindication of the use of IABPAbsolute:

Aortic valve insufficiencyAortic dissection

Relative: Femoral arterial insertion

Abdominal aortic aneurysm Severe calcific aortoilliac or femoral arterial disease

Percutaneous insertion Recent ipsilateral groin inceision Morbid obesity

Complication of IABPMinor

Bleeding at the insertion siteSuperficial wound infectionLymphocelePeritoneal perforation

MajorLimb ischemia requiring thrombectomy, revascularization, oramputationAortic dissectionAortoiliac lacerationFemoral artery pseudoaneurysmRetroperitoneal hemorrhageRenal ischemia from mal positionMyocardial ischemia from poor timing of balloon augmentationDeep wound infection requiring operative debridement

Medication of VADIntended use Therapeutic Goal Devises

Bridge to recovery Temporary support IABP Centrifugal pumpECMO Abiomed HeartMate Novacor

Bridge to bridge Stabilization toLVAD/BiVAD

Abiomed Centrifugal pumpECMO

Bridge to transplantation

Support to transplantation

HeartMate Novacor Thoratec BiVAD Abiocor/TAH Axial flow pump

Destination Permanent support HeartMateNovacorAbiocor/TAHLionHeart

Comparison between different VADsDevises Quality of

lifeShort –term survival (days per week)

Long-term survival(months)

IABP Centrifugal pumpECMO Abiomed HeartMate Novacor

++++++++++

+++++++++++

0000++++++

Abiomed Centrifugal pumpECMO

+++

++++

000

HeartMate Novacor Thoratec BiVAD Abiocor/TAH Axial flow pump

+++++++++++++

+++++++++++

+++++++++++

HeartMateNovacorAbiocor/TAHLionHeart

++++++++++++

+++UndocumentedUndocumentedUndocumented

+++

LVAD Screening scoreVariable Relative risk weight

Mechanical ventilation 5.3 4

Postcardiotomy 3.3 2

Prior LVAD 3.3 2

Central venous pressure >16 mm Hg 2.1 1

Prothrombin time >16 sec 2.1 1

Excluded by multivariable analysis:Prior RVADCoronary artery diseaseAcute myocardial infarctionUrine output <30 ml/hrReoperative surgery

3.22.01.71.21.2

Hemodynamic status during mechanical of ventricular assistance

CVP (mmHg)

LAP (mmHg)

Systolic Aop

(mmHg)

CI (L/min/m2)

dx

15-20 <15 >90 >2 Satisfactory pumping

<15 <15 <90 <2 Hypovolemia

15-20 >20 <90 <2 Inlet cannula obstraction

>20 <15 <90 <2 RV falure

Device selection depends on:

AvailabilityPhysicians experiences

FDA approved several VADs1. Abiomed biventricular system (BVS) 5000i for

postcardiotomy and post MI cardiogenic shock

2. The thoratic poracorporeal device, Novacor and HeartMate for bridge to transplantation.

3. The HeartMate for destination therapy

4. Implantable device as LionHeart, Jarvik, HeartMate II, DeBakey and Cor-Aide.

Short term devices

Extracorporeal centrifugal pumpExtracorporeal membrane oxygenation (ECMO)ABIOMED BVS 5000i

The Dbiomed biventricular system (BVS) 5000i

Long term devicePulsatile devices

HeartMate LVAD (Implantable)Novacor (Implantable)Thoratic

Total artificial heartCardiowestAbiocor

Axial flow pumpsMicromed debakey VADHeartMate IIJarvik 2000

Totally implantable pulsatile devicesLionHeart LVD 200Novacor II

HeartMate

Novacor

Thoratec paracorporeal VAD

Abiocor

MicroMed DeBakey

Jarvik 2000

LionHeart

Major Complication

Complication Definition

Bleeding Blood loss resulting in at least one of the following:1. Transfusion of >6 units of RBC in 24 h2. Reoperation3. Death4. Any other intervention for a hemorrhage

Cerebrovascular accident

Any central nervous deficit that is sudden in onset and persists for more than 24 h. Deficit must be confirmed as having an embolic origin by conventional diagnostic methods (eg, CT-scan) or can be demonstrated to result from an infarct (at autopsy)

Infection Any confirmed infection All infections should be categorized as: exit site, pump pocket,systemic/septiaemia, other (eg, respiratory)

Right sided heart failure

Cardiac Index <2.2 L/min/m2 for >6 h in the absence of device failure,anatomic restrictions, left-sided dysfunction or hypovolemia(CVP >18 mmHg), requiring intervention

Liver failure Bilirubin >5 mg/dL

Complications during mechanical circulatory support

Novacor (n=95)

HeartMate (n=58)

LionHeart (n=9)

Thoratec IVAD (n=3)

Cerebrovascular accident 30.1% 9.3% 44.4% -

Bleeding 24.7% 35.2% 66.7% 100%

Pocket infection 7.3% 10.2% - -

Driveline infection 20% 25.3% - -

Hemolysis - 1.9% 22.2% -

Liver failure 14.5% 11.1% 44.4% 1/3

Right heart failure 24.5% 25.9% 14.3% -

Gastrointestinal complications 19.3% 9.3% 44.4% -

Arrhythmias 3.15% 1.7% - -