Transcript First Bridge to Cardiac Transplantation with the DeBakey

When Right Ventricular Failure may become a
VAD Failure
G. M. Wieselthaler
Dept. of Cardiothoracic Surgery
Medical University of Vienna
Right Ventricular Failure and VAD
-- VAD is established therapy for terminal heart failure
-- 85% of implanted pumps are LVADs
-- natural right ventricular function is the trigger for the LVAD
-- evaluation of right ventricular function in end-stage HF patients
is difficult
-- severe tricuspid insufficiency complicates evaluation process
-- acute right heart failure after LVAD highest peri-operative mortality
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Ventricular Failure and VAD
Evaluation methods for native right ventricular function:
-- echocardiography
-- ECG gated MRI
-- vaso-active right heart catheterization
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Echocardiography:
P
r
Post LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Echocardiography:
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Echocardiography:
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Echocardiography:
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Echocardiography:
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Echocardiography:
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Echocardiography:
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
MRI:
Z. F. 61 a, idiopath. CMP
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
MRI:
W.K., 56 a,
isch. CMP + PH
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
MRI:
W. K., 56 a, isch. CMP + PH
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Hemodynamic Testing before LVAD Implantation in 4 Patients
Baseline
Nitro Bolus
After Simdax
2 hours
HR (b/min)
76 ± 11
72 ± 11
80 ± 12
MAP (mmHg)
81 ± 25
79 ± 21
79 ± 23
PAP (mmHg)
45 ± 7
35 ± 6
39 ± 5
PCWP (mmHg)
31 ± 6
17 ± 6
16 ± 1
CVP (mmHg)
17 ± 4
7±2
10 ± 3
CO (L/min)
3,4 ± 0,7
4,3 ± 1,1
4,2 ± 1
SvO2 (%)
41 ± 12
65 ± 3
55 ± 8
Wood U
4,4 ± 1,2
4,5 ± 0,8
5,5 ± 1,5
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Patient 2: K. R. m, 66 a, 172 cm/92kg
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




Dg: isch CM since 2002, St.p. anterior wall infarct, St.p. AICD 5/2005
art. Hypertonie, COPD
repeted Levosimendan-infusions
Tx: Blopress 16 mg 1/2, Concor 5mg 1/2, Lasix 40 mg 1-1, Spirobene ,Restex,
Seretide, Berodual, Marcoumar
Lab: Crea 2.0 mg/dl, Bili 2.0 mg/dl,
Lab preop: Crea 1,15 mg/dl, Bili 1,95 mg/dl
Right heart catheter vom 29.12.2005:


mPAP 52, PCWP 28, CO 5.2, Wood U 4,6
Echo: highly reduced LVF EF 10%, EED 8.7 cm
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Baselin
Nach
Perlingani
t Bolus
i.v.
Nach 3
Stunden
PGE2
Nach
Anästhesie
Einleitung
Postoperativ
15 Stunden
postoperativ
HR
90
87
92
60
104
104
MAP
79
71
76
75
71
78
mPAP
50
38
47
43
23
21
CVP
10
8
9
12
12
11
PCWP
29
19
35
21
4
5
CO
3,9
5,1
4,3
4,5
5,4
4,9
SvO2
49
57
49
55
67
72
PVR
430
298
223
391
281
261
TPG
21
19
12
22
19
16
Wood U
5,4
3,7
2,8
4,9
3,5
3,2
Pro BNP
4020
6411
4356
4049
G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
General exclusion criteria for VAD implantation:
absolute contraindications:
- BUN > 100 mg / l or s-creatinine > 5,0 mg/dl
- total bilirubin > 5 mg/ dl
- active infection
- anamnestic coagulopathy
- tumor anamnesis (bridge to transplant)
- cerebrovascular disease
- aortic disease
relative contraindications:
-
parenchymatous lung disease (Sarcoidosis)
fixed pulmonary hypertension
mechanical heart valve
heparin intolerance (HIT)
G.M.Wieselthaler, Univ. of Vienna 04/2009
Mechanical Circulatory Support
2007 in press
G.M.Wieselthaler, Univ. of Vienna 04/2009
fixed pulmonary hypertension and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009
fixed pulmonary hypertension and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009
fixed pulmonary hypertension and LVAD
10 Patients for LVAD Implantation
After
Inductio
n
After
CPB
OR End
postop
6 hours
postop
12 hours
postop
24 hours
postop
HR (b/min)
69 ± 24
105 ± 12
109 ± 10
114 ± 14
114 ± 12
110 ± 17
113 ± 14
MAP (mmHg)
68 ± 6
68 ± 7
65 ± 7
72 ± 5
76 ± 4
72 ± 5
68 ± 2
mPAP (mmHg)
37 ± 4
27 ± 5
27 ± 4
27 ± 4
25 ± 5
23 ± 3
28 ± 7
PCWP (mmHg)
24 ± 7
11 ± 4
10 ± 2
14 ± 5
8 ± 0,8
11 ± 3
11 ± 2
CVP (mmHg)
17 ± 5
10 ± 3
11 ± 3
10 ± 2
11 ± 1
12 ± 3
11 ± 3
CO (L/min)
3,7 ± 1
5,7 ± 0,7
5,6 ± 0,7
4,7 ± 0,7
5,4± 0,5
5,6 ± 0,1
4,8 ± 0,3
SvO2 (%)
58 ± 14
70 ± 3
68 ± 4
68 ± 4
66 ± 4
64 ± 8
66 ± 5
Wood U
3,6 ± 1,2
3 ± 1,2
3,1 ± 0,9
2,9 ± 0,9
3,2 ± 1,1
2,9 ± 0,3
3,3 ± 1,5
G.M.Wieselthaler, Univ. of Vienna 04/2009
fixed pulmonary hypertension and LVAD
10 Patients for LVAD Implantation
After
Induction
After CPB
OP End
postop
6 hours
postop
12 hours
postop
24 hours
postop
3,1
12
11,4
11,2
6,8
7,1
7,5
0,2
0,2
0,2
0,2
0,2
0,2
0,2
Norepinephrine
(µg/kg/min)
0,07
0,14
0,22
0,26
0,03
0,05
0,04
Nitric Oxide (ppm)
10
10
10
10
Dobutamin
(µg/kg/min)
Levosimendan
(µg/kg/min)
1 Patient additionally had Milrinone intraoperatively, 3 Patients postoperatively
2 Patients needed Nitroglycerin postoperatively,
1 Patient was switched from to Nitro to Urapidil
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVAD
180 patients Heart Mate
39% RHF
14 Patiens RVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVAD
245 patients
9% RVAD (23 patients)
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVAD
100 Patients
Heart Mate LVAD
In 11 RVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009
Comparison of Adverse Event Rates (per pt-yr)
DuraHeart vs. HM VE vs. HM II
As of June 15, 2007
DuraHeart (n=33)
18 pt-yrs
HM VE1 (n=280)
86 pt-yrs
HM II2 (n=133)
62 pt-yrs
(mean:197 days)
(mean:112 days)
(mean:168 days)
Bleeding requiring surgery
0.22
1.47
0.78
Driveline/pocket infection
0.40
3.49
0.37
Adverse Event
Stroke
0.28
0*
0.44
0.19
Non-stroke neurologic
0.28
0.23*
0.67
0.26
0.06
0.3
0.08
Device thrombosis
0
NA
0.03
Pump mechanical failure
0
0.03
0
Hemolysis
0
0
0.06
RHF requiring RVAD
*Event rate after implementing less intensive anticoagulation (n=22, 13 pt-yrs)
1.
2.
Frazier OH, et al. J Thoracic Cardiovasc Surg 2001;122:1186-95.
Miller LW, et al. NEJM 2007;357:885-96.
G.M.Wieselthaler, Univ. of Vienna 04/2009
HeartWare HVAD multi-institutional trial
adverse events in first 23 implants:
Complication
At 180 days
Patients
n
Events
n
Event Rate
per pt yr
Infections (exit site)
3
3
0.28
Bleeding (requiring re-operation)
3
4
0.37
Respiratory Dysfunction
4
4
0.37
Renal Dysfunction
3
3
0.28
Right Heart Failure
1
1
0.09
G.M.Wieselthaler et al, JHLT 2009 submitted
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVAD
Continuous unloading of left ventricle can cause shift of thined, free lateral ventricular
wall and results in reduced pump-flows & can provoke suction
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVAD
thin & flexing interventricular septum in a patient with dilative CMP
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVAD
-- in a patient with a thin & flexing interventricular septum
-- leads to shift of interventricular septum to the left side & increased TI with
consecutive right ventricular failure
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVAD
LVAD vs. BiVAD:
-- extended infarct areas (RCA) -- consider BiVAD
-- patients with malignant arrythmias benefit from BiVAD
-- patients in prolonged cardiogenic shock always BiVAD
-- Patients with two- or multi-organ failure always BiVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVAD
Conclusion:
-- evaluation of native right ventricular function is very difficult and still challenging
-- preservation of right ventricular function in medical heart failure therapy should
be the main target
-- as soon as native right ventricular function starts to decrease refer patient for surgical
evaluation (transplant // bridge to transplant) = vaso-active RHC !!
-- try to avoid last option “BiVAD”
-- quality of life on a LVAD is ten times better than on a BiVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009