VAD heart failure mechanical support

1. Ventricular Assist Devices
T.Ruangpratyakul, MD.

4. Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, et al. Long-term use of a left ventricular
assist device for end-stage heart failure. N Engl J Med. Massachusetts Medical Society; 2001 Nov 15;345(20):1435–43.

5. Strategies for MCS
• Bridge to Transplantation
• Destination therapy
• Bridge to Candidacy
• Bridge to Decision
• Bridge to Recovery

6. Indication
• Cardiogenic shock after acute MI
• Cardiogenic shock after cardiotomy
• Myocarditis
• Refractory ventricular arrhythmia
• chronic advanced heart failure

7. Patient selection
appropriate candidates
*high risk of RV failure
BIVAD

8. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

9. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

10. Contraindication
• Pulmonary Hypertension with elevated PVR (>5wood u)
• irreversible end organ failure
• severe, unrecoverable neurologic injury
• systemic sepsis

11. Type of Devices
type
short
term
long
term

12. Type of Devices
type
short
term
long
term
Abiomed BVS500
AB50000
Heartmate
PHP
Abiomed Impella
TandemHeart
CentriMag

13. Tandem Heart
• percutaneous
• centrifugal pump
• inflow: LA
• outflow: FA
• Flow rate 5 L/min, 7500 rpm
• improve CI, decrease PCWP,
recovery in end-organ function
• no RCT
*requiring trans-septal puncture

14. Abiomed Impella
• percutaneous
• intravascular microaxial rotary pump
• inflow: LV
• outflow: AsAo
• Flow rate 5 L/min for Impella 5
2.5 L/min for Impella 2.5
• superior hemodynamic support
compared with IABP
similarly to ECMO, TandemHeart

15. Heartmate PHP
• catheter-based axial flow pump
• Flow 4-5 L/min
• in development
• no clinical trials

16. Abiomed BVS 5000
and AB5000
• dual-chambered pneumatically
driven
• extracorporeal pump
• Flow 6 L/min
• acceptable result

17. CentriMag
• extracorporeal centrifugal
pump
• FDA approved 6 hr support
• Flow 10 L/min

18. Type of Devices
type
short
term
long
term
Abiomed BVS500
AB50000
Heartmate
PHP
Abiomed
Impella
TandemHeart
CentriMag

19. Type of Devices
type
short
term
long
term
Abiomed BVS500
AB50000
Heartmate
PHP
Abiomed
Impella
TandemHeart
CentriMag
Pulsatile Flow
3rd
generation
Axial
continuous
Total Artificial
Heart

20. Long-term devices
Pulsatile Flow
3rd
generation
Axial
continuous
Total Artificial
Thoratec
HeartMate XVE
Thoratec
paracorporeal VAD
Thoratec
intracorporeal VAD
Thoratec
HeartMate II
HeartWare
HVAD
Jarvik 2000
MicroMed
Dabakey
Thoratec
HeartMate III
DuraHeart
SynCardia

21. HeartMate XVE
• For BTT and DT
• SV 83 ml
• FLow 10 L/min
• long term used is limited by
high probability of device-
related complication

22. Thoratec
Paracorporeal VAD
• allowed in BSA <1.5 m2
• pneumatic control
• inflow: LV apex/LA, RA/RV
• outflow: AsAo/PA
• max SV 65 ml
• Flow 7.2 L/min
• requires systemic
anticoagulantion

23. Thoratec
Intracorporeal VAD
• 1st FDA approved implantable
VAD
• improved result from
Paracorporeal VAD
• need Anticoagulation

24. Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J
Med. Massachusetts Medical Society; 2009 Dec 3;361(23):2241–51.

25. Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J
Med. Massachusetts Medical Society; 2009 Dec 3;361(23):2241–51.

26. Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J
Med. Massachusetts Medical Society; 2009 Dec 3;361(23):2241–51.

27. Thoratec HeartMate II
• Flow 10 L/min
• 6000-15000 rpm
• Inflow: LV apex
• outflow: AsAo
• reduced risk of infection, patient
comfort, QOL, durablility
• RCT compare XVE :
1year overall survival 68%>85%
2year overall survival 58%>63%

28. Jarvik 2000
• electromagnetically
• 8000-12000 rpm
• Flow 7 ml/min
• implanted at LV
• outflow Des thoracic Ao

29. MicroMed DeBakey
• small
• Flow 10 L/min
• FDA approved for BTT in
children 5-16 year old
• relative high no. of report
stroke and microemboli

30. 3rd Generation pumps

31. Rogers JG, Pagani FD, Tatooles AJ, Bhat G, Slaughter MS, Birks EJ, et al. Intrapericardial left ventricular assist device for advanced heart failure. N Engl J Med.
Massachusetts Medical Society; 2017 Feb 2;376(5):451–60.

32. Rogers JG, Pagani FD, Tatooles AJ, Bhat G, Slaughter MS, Birks EJ, et al. Intrapericardial left ventricular assist device for advanced heart failure. N Engl J Med.
Massachusetts Medical Society; 2017 Feb 2;376(5):451–60.

33. Mehra MR, Goldstein DJ, Uriel N, Cleveland JC, Yuzefpolskaya M, Salerno C, et al. Two-Year Outcomes with a Magnetically Levitated Cardiac Pump in Heart Failure. N Engl J Med. 2018
Mar 11;:NEJMoa1800866.

34. HeartWare HVAD
• centrifugal pump
• SV 45ml
• Flow 10 L/min at 2000-3000 rpm
• inflow: LV
• outflow: AsAo
• non-inferior 180 day survival to
LVAD control
Aaronson KD, Slaughter MS, Miller LW, McGee EC, Cotts WG, Acker MA, et al. Use of an intrapericardial, continuous-flow, centrifugal pump in patients awaiting heart
transplantation. Circulation. American Heart Association, Inc; 2012 Jun 26;125(25):3191–200.

35. DuraHeart
• magnetic levitation technology
• flow 2-8 L/min at 1200-2400 rpm
• favorable clinical outcome as BTT
in Japan and Europe

36. Thoratec HeartMate III
• centrifugal pump
• Flow 10 L/min
• not current tested in any
clinical trials

37. Synergy
• partial-support LVAD
• intravascularly
• inflow: via subclavian v. to RA
to LA
• outflow: subclavian a.
• improvement hemodynamics
and reduction HF symptom

38. Generation Pump qualities Weak points
First
• pulsatile
• Volume displacement
• intra or para corporeal
• Uni or Bi ventricular support
• short or long-term support
• large size
• need for recipient large body
habitus
• percutaneous lead
• Audible pump operation
• high incidence of device
dynsfunction
Second
• rotary
• axial flow
• LVAD
• intra-corporeal
• Long-term support
• percutaneous lead
• contract bearings
• thrombus formation - Need for
anticoagulation
• risk of ventricular suction
Third
• rotary
• centrifugal pump
• Non-contract bearings
• LVAD
• intra-corporeal
• large size
• percutaneous lead
• lack of enough clinical evidence

39. Total Artificial Heart
• for long-term biventricular support
• continuous flow pumps
• FDA approved only for BTT
• Contraindication: transplant ineligibility, absence of
biventricular failure, inability to have coagulation, small
thoracic cavity size
• survival to transplant rate 68%
• no RCT compared with BiVAD

40. Syncardia
• pneumatic pulsatile
biventricular device
• replace native heart
• max SV 70 ml
• CO >9 L/min
• survival to transplant rate 79%
• 1yr overall survival 70
• most common complication:
infection and bleeding

41. Device selection
• duration of support
• right, left, biventricular
support
• neurological status
• overall prognosis
• goal of treatment

42. Surgical technique
1. skin incision
2. creation of a preperitoneal
pocket
3. mediastinal exposure
4. cannulation of aorta and
venous system
5. CPB commencement
6. coring of LV, sutured, inserting
inflow core into LV apex
7. outflow graft anastomosis
to AsAo
8. de-airing of the device
9. weaning off CPB,
actuating LVAD
10.hemostasis
11.closing sternotomy

45. Concomitant surgery
• moderate-severe AI
• severe MS
• MR is controversial
• ASD
• intracardiac thrombus

46. Postoperative management
• Antibiotic prophylaxis
• MAP 70-80 mmHg
• Optimize RV function
• Anti-arrhythmic agent if arrhythmia
• Anticoagulant: target INR 2.5
• Ambulation and rehabilitation

47. Complication
• Post-op bleeding
• GI bleeding, Epistaxis
• Infection
• Multisystem organ failure
• Thromboembolism
• RV failure
• arrhythmia
• aortic insufficiency
• device malfunction

48. THANK YOU