Hemodynamics of

Cardiac Assist Devices

Daniel BurkhoffCardiovascular Research Foundation

and

Columbia University

Disclosure

• Unrestricted institutional (CRF) educational grant from Abiomed

• Pharmacology• Inotropic agents

• Pressors

• Devices• IABP

• RA→Ao (ECMO)

• LA→Ao (Tandem)

• LV→Ao (Impella)

• ECMO + Impella

Different Effects on

Heart and Lungs

Trials have shown to be ineffective

Combination Therapies

Therapeutic Options for Shock

Increase LV workload, HR and

oxygen consumption,

associated with high mortality

Impact of IABP in CGS

Pressure-Volume

LVP and AoP

Small PCWP

Small CO

Hemodynamic Parameters Pre vs. PostThiele, Schuler et al Eu Heart J 2005

IABP

pre post pCO (l/min) 3.20.9 3.61.1 0.18

CI (l/min/m2) 1.60.4 1.80.5 0.13

BP mean (mmHg) 6514 7212 0.09

Heart rate (b/min) 11124 10723 0.63

Cardiac Power

Index (W/m2)

0.23 0.07 0.290.07 0.02

PCWP (mmHg) 25±6 22±6 0.10

CVP (mmHg) 15±6 14±6 0.67

PAP mean (mmHg) 32±7 30±8 0.52

Lactate (mmol/l) 6.0±4.6 5.0±3.6 0.34

BE -7.0±5.4 -6.3±5.8 0.72

pH 7.32±0.1 7.33±0.1 0.73

Intraaortic Balloon Pump:No significant effects on hemodynamics (CPO) or

mortality

Impact of LV→Ao MCS on

Hemodynamics and Energetics

Pressure-Volume

LVP and AoP

↓ Peak LVP↓ Preload

↑ AoP↓ LVPLV-Ao

Uncoupling

HRPCI under IMPELLA supportCourtesy of William O’Neill

PV Loops during Impella

support and NTG injectionImpella Removed from LV

REAL PV Loops assume triangular shape during LVAD Support

Hemodynamic Improvement ImpellacVAD Registry™

p<0.0001

Pre-

Support

On Support

62.7±19.2

94.4±23.1

51%

MAP

p<0.0001

31.9±11.1

19.2±9.7

40%

PCWP

Pre-

Support

On Support

O’Neill, et. al. J Interven Cardiol, 2013

p<0.00010.48±0.17

Cardiac Power Output(MAP x CO x 0.0022)

120%

1.06±0.48

Pre-

Support

On Support

(n=143)

(n=25)(n=23)

p<0.0001

Pre-

Support

On Support

3.4±1.3

5.3±1.7

56%

Cardiac Output

(n=23)

cVAD RegistryThe catheter based VAD Registry is a worldwide, multicenter, IRB approved, monitored clinical registry of all patients at participating sites; registry data is used for FDA PMA submissions

VA-ECMORA→FA or RA→Ao

Impact of RA→Ao MCS (ECMO) on

Hemodynamics and Energetics(no contractile reserve)

↑ Afterload↑ Preload

Pressure-Volume

AoP and LVP

↑ AoP↑ LVP

ECMO FLOW

IMPACT OF PUMP FLOW ON HEMODYNAMICS

Harlequin Syndrome / North-South Syndrome

LV Distention and Pressure Overload during ECMO Support

• Loss of aortic valve opening• Lung edema• Bronchial bleeding• LV thrombosis

Curtesy of Dr. Jiri Maly, IKEM, Prague

Several Ways to Deal with LV

Loading during ECMO support

1. Reduce ECMO speed

2. Inotropes

3. Afterload reduction (e.g., nitropruside)

4. IABP

5. Atrial Septostomy

6. LA→FA bypass (TandemHeart)

7. LV Vent

8. LV→Ao bypass (pVADs, e.g., Impella, Protek Duo)

Rao et al, Circ HF 2018

RA→Ao MCS + LV→Ao MCS

(ECPELLA)

↑ Afterload↑ Preload

Pressure-Volume

AoPLVP

Rapid and Marked Reduction of PCWP

with Impella added to ECMO

Schrage et al, JACC:HF, in press

HS Lim, Artificial Organs, 2017; 41:1109

Summary• With acute hemodynamic compromise

• Restore normal hemodynamics

• Minimize LV filling pressure

• prevent remodeling

• Minimize oxygen consumption

• enhance myocardial salvage

• Pharmacological approaches increase

MVO2 and increase load on the LV

• Different MCS options have different

effects on hemodynamics

• Responses to MCS differ among

different devices but, regarding

unloading, LVAD>ECMO