ManagementofAdvancedHeartFailure
MechanicalCirculatoryAssist&CardiacTransplantation
Geetha Bhat,Ph.D.,M.D.,FACCMedicalDirector
CenterforHeartTransplantAndAssistDevicesAdvocateChristMedicalCenter
PrimaryObjectives1. EpidemiologyofHeartFailure
2. IndicationsandTypesofVentricularAssistDevices(VAD)
3. CandidateSelectionforVAD
4. SelectionCriteriaforHeartTransplant
5. ISHLTRegistryData
ChronicCongestiveHeartFailure
The Problem (USA)Prevalence:5,000,000patients.
550,000newcasesCHFeachyear.
Incidence x2inlast tenyears.
300,000deaths /year.
Mostfrequentreasonforhospitalizationinpatients> 65yearsofage.
15million officevisits and6.5million hospitaldays each year.
Rehospitalization within6monthsashighas50%.
5.4%ofhealth care budget ($38billion).
AHA/ACC 2005 Heart Failure Guideline Update
By2010~60%oftheWorldsHeartDiseasewillbeinIndia!
Lancet,2008
TotalYearsofLifeLostDuetoCVDamongpopulationsaged35to64
2000 2030YearsLost(millions) YearsLost(millions)
Brazil 1.06 1.74
Russia 3.31 3.21
India 9.22 17.94
China 6.67 10.46
U.S. 1.63 1.97
RiskFactorsforSurvivalinHF
OLD
NYHA Class
Ejection Fraction
Etiology-ischemic
LVEDD
Hemodynamics
Peak O2 Consumption
Norepinephrine level
Serum Sodium
NEW
*BUN/Creat/CreatClear.
*Diuretic Dose >1.5 mg/kg/d
*QRS Width >150 msec
*BNP > 1,000
*Cant take ACEI/ARB/BB
*Multiple HF Admissions
*Hematocrit < 34
More than 3 risk factors warrants referral to Advanced HF Program
TreatmentOptionsforAdvancedHeartFailure
1. MedicalManagement2. ImplantableCardioverterDefibrillator(ICD)/
BiventricularPacemaker ICD (MADITII/SCDHeFT) BiVPacemaker/ICD (MIRACLE/COMPANION)
3. SurgicalManagement ValveRepair/Replacement;CABG.
4. MechanicalCirculatorySupportDevices VentricularAssistDevice(VAD)
5. CardiacTransplantation Limitedbydonorshortage
VentricularAssistDevices(VAD)
AMechanicalHeartPumpthatProvidesCirculatorySupporttotheFailingVentricle.
CanBeUsedToSupporttheRight,LeftorBothVentricles.
LeftVentricularAssistDevice
HemodynamicEffect: LVADincreasescardiacoutput/index. Improvedcardiacoutputincreasesendorganperfusion UnloadsLVtherebydecreasingleftheartfillingpressures. LVunloadingdecreasespulmonaryarterypressuresleadingtoareductioninRVafterload.
LVunloadingalsoreversesventricularremodeling1improveschambergeometry1,andreducesfibrosis2
However IncreasedvenousreturntotherightventriclemayunmaskpreexistingRVdysfunction.
1. Barbone et al. Circulation 2001; 104:6702. Bruckner et al. JHLT 2001; 20: 457
IndicationsforVentricularAssistDevices
1. Bridge to Recovery Short term support during acute cardiogenic shock or with potentially reversible cases of heart failure.
2. Bridge to Transplantation Short to intermediate term support while awaiting transplantation.
3. Destination Therapy Long term support as replacement therapy in patients with contraindication to heart transplant.
BridgetoRecovery
BridgetoRecovery
Indications:1. CardiogenicShockfollowing:
a) AcuteMyocardialInfarction
b) PercutaneousCoronaryIntervention
c) CardiacSurgery(PostCardiotomy)
2. AcuteMyocarditis(ViralCardiomyopathy)
BridgetoRecoveryShortTermDevices(Days):
1.IntraAorticBalloonPump2.VentricularAssistDevice
A.Extracorporeal: Abiomed BiVentricular System(BVS) Pulsatile pneumaticpump Thoratec PVAD/IVAD Pulsatile pneumaticpump Biomedicus Continuousflow,centrifugalpump CentriMag Continuousflow,magneticallylevitated,centrifugalpump
Sarns CentrifugalpumpB.Percutaneous:
TandemHeartpVAD Continuousflow,centrifugalpump. Impella Continuousaxialflowpump
JACC2008Nov4;52(19):15848
3.ExtraCorporealMembraneOxygenation(ECMO)
ThoratecpVAD
Pulsatile Pneumatic Pump
Short Term Devices - Extracorporeal
CentriMag
Continuous Flow, Magnetically Levitated, Centrifugal Pump
Short Term Devices - Extracorporeal
TandemHeartpVAD
Continuous Flow, Centrifugal Pump
Short Term Devices - Percutaneous
Impella
Continuous Axial Flow Pump
Short Term Devices - Percutaneous
BridgetoTransplant
BridgetoTransplant
Indications:1. Activehearttransplantcandidate.
2. Inotropedependentwithorwithoutintraaorticballoonpump(IABP).
3. Cardiacindex20mmHg
BridgeToTransplantIntermediateDevices(DaystoWeeks)
ParacorporealVAD ThoratecPVAD ImplantableVAD ThoratecIVAD
LongTermDevices(MonthstoYears)Approved
Heartmate HeartMateXVE PulsatileflowPump HeartMateII ContinuousAxialflow
NovacorLVAS Pulsatileflowpump TotalArtificialHeart Replacesnativeventricle.
CardioWestInvestigational
Jarvik2000 ContinuousAxialflowimpellerpump Ventrassist Hydrodynamicallysuspendedcentrifugalpump HeartWare Hydrodynamically/Magneticallysuspendedcentrifugalpump Levacor Magneticallylevitatedcentrifugalpump DuraHeartMagneticallylevitatedcentrifugalpump
HeartMateII
Controller
Batteries
PercutaneousLead
ImplantablePump
Continuous Axial Flow Pump
Jarvik2000Long Term Devices - Implantable
Continuous Axial Flow Impeller Pump
Levacor DuraheartLong Term Devices - Implantable
Magnetically Levitated Centrifugal Pump
DestinationTherapy
DestinationTherapy
Indications:
1. NYHAclassIVheartfailurerefractorytomaximalmedicaltherapyincludinginotropes.
2. DepressedLVEFwithpoorpeakoxygenconsumption.
3. Contraindicationtotransplantation.
DestinationTherapy
Indications:
1. NYHAclassIVheartfailurerefractorytomaximalmedicaltherapyincludinginotropes.
2. DepressedLVEFwithpoorpeakoxygenconsumption.
3. Contraindicationtotransplantation.
DestinationTherapy
LongTermDevices(MonthstoYears)Approved
HeartMateXVE PulsatileFlowPump
Investigational HeartMateII ContinuousAxialflow
NovacorLVAS PulsatileFlowPump
Ventrassist Hydrodynamicallysuspendedcentrifugalpump
DisadvantagestoLVADTherapy
Infection
Bleeding
Thromboembolism
PumpFailure
RVDysfunction
Complications
HeartTransplantation
HeartTransplantation
Indications NewYorkHeartAssociationClassIIIIVheartfailure
Refractoryrecurrentventriculararrhythmias
Refractoryrecurrentanginanotamenabletomedical,percutaneous,and/orsurgicalintervention
Cardiogenicshock
Mechanicalassistanceofaventilator,intraaorticballoonpump,ventricularassistdevice
Continuousinotropicsupport/dependence
RelativeContraindicationstoCardiacTransplantation
Obesity(BMI>35)
IrreversiblePulmonaryHypertension
DiabeteswithEndOrganDamage
RenalDysfunction
PeripheralVascularDisease
RelativeContraindicationstoCardiacTransplantation
Malignancy
ActiveSubstanceAbuse
PresenceofaPsychiatricDisorderthatWouldCompromiseAdherencetoMedicalTherapy
PoorSocialSupport/PsychosocialInstability
SevereCNSdisease
WhomtoReferforTransplantation
Age
NUMBEROFHEARTTRANSPLANTSREPORTEDBYYEAR
189 317665
1182
2158
27103137
3362
4001 41714197 4365
4439 4399 4263 41673833
3563 3410 3367 3269 3180 3026 3095
0
500
1000
1500
2000
2500
3000
3500
4000
4500
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Num
ber o
f Tra
nspl
ants
ISHLT 2007 NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as evidence that the number of hearts transplanted worldwide has declined in recent years.J Heart Lung Transplant 2007;26: 769-781
AGEDISTRIBUTIONOFHEARTRECIPIENTS (1/19826/2006)
% o
f Tra
nspl
ants
0
5
10
15
20
25
30
35
40
0-9 10-19 20-29 30-39 40-49 50-59 60+
Recipient Age
ISHLT 2007J Heart Lung Transplant 2007;26: 769-781
ADULTHEARTTRANSPLANTRECIPIENTS:CumulativeIncidenceofLeadingCausesofDeath
(Transplants:January1992 June2005)
0%
1%
2%
3%
4%
5%
6%
0 1 2 3 4 5 6 7 8 9 10Time (years)
CAV Acute RejectionMalignancy (non-Lymph/PTLD) Primary FailureGraft Failure CMVInfection (non-CMV)
Inci
denc
e of
Cau
se-S
peci
fic D
eath
s
ISHLT 2007J Heart Lung Transplant 2007;26: 769-781
HEARTTRANSPLANTATION
KaplanMeierSurvival (1/19826/2005)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Years
Surv
ival
(%)
Half-life = 10.0 yearsConditional Half-life = 13.0 years
N=70,702
ISHLT
N at risk at 22 years: 33
HEART TRANSPLANTATION
Kaplan-Meier Survival (1/1982-6/2005)
J Heart Lung Transplant 2007;26: 769-781
HeartTransplant/VADTeam
ReferringPhysician LocalHospital/FirstResponders Cardi
