hemodynamics of cardiac assist devices€¦ · hemodynamic improvement impella cvad registry ™ p
TRANSCRIPT
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Hemodynamics of
Cardiac Assist Devices
Daniel BurkhoffCardiovascular Research Foundation
and
Columbia University
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Disclosure
• Unrestricted institutional (CRF) educational grant from Abiomed
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• 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
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Impact of IABP in CGS
Pressure-Volume
LVP and AoP
Small PCWP
Small CO
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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
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Intraaortic Balloon Pump:No significant effects on hemodynamics (CPO) or
mortality
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Impact of LV→Ao MCS on
Hemodynamics and Energetics
Pressure-Volume
LVP and AoP
↓ Peak LVP↓ Preload
↑ AoP↓ LVPLV-Ao
Uncoupling
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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
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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
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VA-ECMORA→FA or RA→Ao
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Impact of RA→Ao MCS (ECMO) on
Hemodynamics and Energetics(no contractile reserve)
↑ Afterload↑ Preload
Pressure-Volume
AoP and LVP
↑ AoP↑ LVP
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ECMO FLOW
IMPACT OF PUMP FLOW ON HEMODYNAMICS
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Harlequin Syndrome / North-South Syndrome
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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
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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
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RA→Ao MCS + LV→Ao MCS
(ECPELLA)
↑ Afterload↑ Preload
Pressure-Volume
AoPLVP
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Rapid and Marked Reduction of PCWP
with Impella added to ECMO
Schrage et al, JACC:HF, in press
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HS Lim, Artificial Organs, 2017; 41:1109
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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