Click here to load reader

Heart Failure and VADs: Bridges for Broken Hearts

  • View
    1.703

  • Download
    3

Embed Size (px)

Text of Heart Failure and VADs: Bridges for Broken Hearts

  • 1. Heart Failure and VADs Bridges for Broken Hearts Priya Gaiha MD MBA May 26 th2010 University of KentuckyGrand Rounds

2. Objectives

  • What is the pathophysiology of heart failure?
  • Why is heart failure relevant?
  • What is the history of mechanical circulatory support?
  • What are the various types of ventricular assist devices (VADs)?
  • How and when are VADs used?
  • What is the next generation of VADs?

3. Etiologies of cardiac failure

  • Coronary artery disease
  • Idiopathic cardiomyopathy
  • Peripartum cardiomyopathy
  • Dilated cardiomyopathy
  • Ischemic cardiomyopathy
  • Acute valvular disease
  • Arrhythmia (supraventricular or ventricular)
  • Myocarditis
  • Congenital heart disease
  • Drug induced
  • Diabetes mellitus
  • Hypertension

4. Pathogenesis of Heart Failure Mann, D. Circulation 1999;100;999-1008 5. NYHA classes Class Patient Symptoms Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath). Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea. Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. Class IV (Severe) Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased. 6. Relevance 7. 8. 9. NCHS 2006 CVD deaths vs. cancer deaths by age (US) 10. A CVDB Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimers Disease NCHS and NHLBI 2006 CVD and other major causes of death for all males and females 11. NHDS/NCHS and NHLBI 2006 Hospital Discharges (in millions) for the 10 Leading diagnostic Groups 12. Economic Ramificationswww.americanheart.org Prevalence1-2% population 5 million individuals Cost 1-2% total health care spending $35 billion Incidence (per year) 550,000 new diagnoses 300,000 deaths Hospitalizations 6 days (average) 50% rehospitalized within 6 months 13. Options for Advanced CHF

  • Transplant ($$$$$$)
  • Assist Device ($$$)
  • Die($)
    • Preceded by 6-12 months of medical therapy
    • Multiple hospital re-admissions
    • Hospice ($$$)

14. Transplant 15. 16. UK 17. ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by Era(Transplants: 1/1982 6/2005) Survival (%) ISHLT 2007 J Heart Lung Transplant 2007;26: 769-781 18. ADULT HEART RECIPIENTS Functional Status of Surviving Recipients (Follow-ups: 1995 - June 2008) ISHLT 2009 19. Historical Events 1950196019701980199020002010 1953: Gibbons heart-lung machine successfully used during ASD repair 20. John Gibbon

  • Born in 1903 in Philadelphia
  • 4th generation physician
  • 1931: watched a young woman postop from cholecystectomy die from PE
  • Worked for 20 years on dogs to refine bypass machine
  • Received financial and technical support from Thomas Watson of IBM
  • 1953: first successful use of machine on patient during ASD repair

21. Historical Events 1950196019701980199020002010 1953: Gibbons heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 22. Historical Events 1950196019701980199020002010 1953: Gibbons heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1967: Barnard performs first heart transplant 23. Christian Barnard

  • Born in South Africa in 1922
  • Studied heart surgery at the University of Minnesota then returned to set up a cardiac unit in Cape Town.
  • December 1967: transplanted the heart of a road accident victim into a 59 year old patient
  • Patient only survived 18 days due to infectious complications

24. Historical Events 1950196019701980199020002010 1953: Gibbons heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1967: Barnard performs first heart transplant 1968: Shumway performs first heart transplant in US 25. Norm Shumway

  • Stanford University
  • 1959: transplanted the heart of a dog into a 2-year-old mongrel
  • 1968: performed the first heart transplant in the US on a 54 year old steel worker who lived 14 days
  • Pioneered immunosuppression
  • 1981: performed the worlds first successful heart-lung transplant

26. Historical Events 1950196019701980199020002010 1953: Gibbons heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1967: Barnard performs first heart transplant 1969: Cooley implants VAD as bridge to transplant 1968: Shumway performs first heart transplant in US 27. Willem Kolff

  • Father of artificial organs
  • 1911: Born in the Netherlands
  • 1940: Established the first blood bank in Europe
  • 1943: Developed the first artificial kidney
  • 1957: Developed the first artificial heart that was successfully transplanted into an animal

28. Historical Events 1950196019701980199020002010 1953: Gibbons heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1984: implantation of Jarvik-7 artificial heart by DeVries 1967: Barnard performs first heart transplant 1969: Cooley implants VAD as bridge to transplant 1968: Shumway performs first heart transplant in US 29. William DeVries

  • Born in 1943
  • Trained at the University of Utah and Duke University
  • Worked with Kolff to implant artificial heart in animals
  • 1982: Implanted first artificial heart into Seattle dentist Barney Clark
  • 1985: Implanted 2nd Jarvik into Bill Schroeder in Louisville KY

30. Historical Events 1950196019701980199020002010 1953: Gibbons heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1984: implantation of Jarvik-7 artificial heart by DeVries 1994: FDA approval of LVAD as bridge to transplant 1967: Barnard performs first heart transplant 1969: Cooley implants VAD as bridge to transplant 1968: Shumway performs first heart transplant in US 31. Historical Events 1950196019701980199020002010 1953: Gibbons heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1984: implantation of Jarvik-7 artificial heart by DeVries 1994: FDA approval of LVAD as bridge to transplant 1967: Barnard performs first heart transplant 2004: REMATCH trial 1969: Cooley implants VAD as bridge to transplant 1968: Shumway performs first heart transplant in US 32. Historical Events 1950196019701980199020002010 1953: Gibbons heart-lung machine successfully used during ASD repair 1963: DeBakey implants first VAD in patient with postcardiotomy shock 1984: implantation of Jarvik-7 artificial heart by DeVries 1994: FDA approval of LVAD as bridge to transplant 1967: Barnard performs first heart transplant 2004:REMATCHtrial 1969: Cooley implants VAD as bridge to transplant 1968: Shumway performs first heart transplant in US Heart mate II approved for destination therapy 33. 34. 35. Criteria for patient selection

  • Class IV HF
  • Failing hemodynamics
  • Persistent pulmonary edema
  • Neurologic impairment or renal failure due to low perfusion
  • Fluid and electrolyte imbalance related to low cardiac output
  • Severe arrhythmias despite medical therapy

36. Indications for support

  • SBP70-80s
    • High PVR > 5 Wood units
    • Malnutrition
    • multiorgan system failure: hepatic, renal
  • Heartmate II implanted
  • Improvement in pulmonary hypertension, renal dysfunction and nutritional status
  • Duration of therapy 9 months
  • Orthotopic transplant successful August 2009

58. Implantation of device N Engl J Med 2007;357:885-96 59. Implantation 60. Implantation 61. Implantation 62. Implantation 63. Implantation 64. Implantation 65. Implantation 66. Implantation 67. Device complications

  • Early
    • Bleeding
    • Right sided heart failure
    • Progressive multiorgan system failure
  • Late
    • Infection
      • Nosocomial
      • Device related
    • Thromboembolism
    • Failure of device

68. Next generation of V