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Presentation Slides & Transcript
OPTIMIZING OUTCOMES IN PATIENTS WITH RIGHT HEART FAILURE IN NEED OF MECHANICAL CIRCULATORY SUPPORTTOTAL ARTIFICIAL HEARTVigneshwar Kasirajan, MDVCU Medical Center, Richmond, VA
DISCLOSURESPI FOR FREEDOM TRIAL – SYNCARDIACONSULTANT – SYNCARDIARESEARCH GRANT – THORATECCONSULTANT – ATRICURERESEARCH GRANT – ATRICURE
BIVENTRICULAR ASSIST DEVICES VS TAH ( BIVENTRICULAR REPLACEMENT)
Chest roentgenogram of patient 9 after switch of the right HeartWare HVAD pump from the anterior free wall of the right ventricle to the right atrium.Krabatsch T et al. Circulation 2011;124:S179-S186Copyright © American Heart Association30% of patients may have BiV Failure
WHAT IS RV FAILURE ?NEED FOR RVADPROLONGED INOTROPIC SUPPORTMULTISYSTEM FAILURE, FAILURE TO THRIVE, DEATH INCIDENCE 5 – > 10 % DEPENDS ON INTERMACS CLASS.
EVALUATING RV FUNCTIONAdapted from Slaughter, Pagani, Rogers et al JHLT 2010;29:S1-S39
N = 16N = 17
Six (35%) patients who received an LVAD developed right ventricular failure. Four (24%) had a right ventricular assist device implanted while the remaining two patients required extended inotrope therapy. All six of the patients who developed right ventricular failure were in the “high” or “very high risk” group.
VOLUME OF MCS DEVICESfrom The Fourth INTERMACS Annual Report. Kirklin, Naftel, Kormos et al JHLT 2012;31:117(copyright Elsevier, reproduced with permission)
PERCENTAGE OF PATIENTS RECEIVING MCS BY INTERMACS CLASS (PROFILES)Adapted from The Fourth INTERMACS Annual Report. Kirklin, Naftel, Kormos et al JHLT 2012;31:117
CLINICAL OUTCOMES FOR CONTINUOUS FLOW LVADS BY INTERMACS CLASSBoyle, Ascheim, Russo et al JHLTx 2011;30:402-7Can we produce better outcomes ?
SURVIVAL LVADS VS TAH VS BIVADS from The Fourth INTERMACS Annual Report. Kirklin, Naftel, Kormos et al JHLT 2012;31:117COPYRIGHT ELSEVIER REPRODUCED WITH PERMISSION
Survival after biventricular mechanical circulatorysupport: Does the type of device matter?Kirsch, Mazzucotelli, Roussel et al J Heart Lung Transplant 2012;31:501–8
Source: The Journal of Heart and Lung Transplantation 2012; 31:501-508 (DOI:10.1016/j.healun.2011.11.024 )Copyright © 2012 International Society for Heart and Lung Transplantation Terms and ConditionsSURVIVAL AFTER BIVENTRICULAR ASSIST BY TYPE OF DEVICE
TAH - ETIOLOGY OF HF
Failed LV, Ao Valve prosthesis (replaced twice), ascending aortic dissection with aneurysmLVAo VAneury
Acute Myocarditis with VF for 2 months on BIVAD
Cannula pointed into septum
ComplicationsNeurological Injury 4%Bleeding 25%Sternal Infection 4%Dialysis 13%
Early RehabilitationInitiated Physical Therapy - 5 days post Implant. Time to Treadmill – 19 days post ImplantKohli, Canada, Arena et al JHLT 2011;30(11):1207
SURVIVAL AFTER TRANSPLANT FROM TAH
Fig 2 Continuous-flow right ventricular assist device (RVAD) pump placement with a continuous-flow left ventricular assist device. The continuous-flow RVAD pumps can be placed (A) in the right preperitoneal space or (B) in the right chest cavity....Kiyotaka Fukamachi , Akira Shiose , Alex L. Massiello , David J. Horvath , Leonard A.R. Golding , Sangjin Lee , Ra...Implantable Continuous-Flow Right Ventricular Assist Device: Lessons Learned in the Development of a Cleveland Clinic DeviceThe Annals of Thoracic Surgery Volume 93, Issue 5 2012 1746 - 1752http://dx.doi.org/10.1016/j.athoracsur.2012.02.026
Why the TAH ( BiV Replacement)Pts who are likely to do poorly with LVAD onlyComplex anatomy Ventricular arrhythmiasDead hearts Failed mechanical ventricular assistPost Transplant, restrictive CM There is a need beyond BiV assist….. INTERMACS PROFILE 1, 10 % OF MCSThe concept of biventricular replacement is important, not the state of existing technology
Complete BiV ExcisionNo Felt strips
Two separate ventricles move independentlyOPEN CHEST 80%
Re opening chestArtificial membrane to prevent adhesions
Tissue Expander to enlarge pericardium
Reopening Chest takes < 30 mins
Plenty of Space for New Heart
Antimicrobial ProphylaxisTAH n=48 Kristen Bunnell, PharmDStacy Voils, PharmD
Historical DataPrevious studies have shown infection rates from 40 to 83%Duration of prophylaxis lasted till chest tubes were removed historically. Second generation cephalosporin
VCU Antibiotic prophylaxisWe use triple agents for prophylaxisDuration is 48 hours post chest closureNo deaths due to infectionRates comparable to previous reports
ANTICOAGULATIONNO POST IMPLANT EXPOSURE TO HEPARINBIVALRUDIN WARFARINASPIRINPERSANTINE
Use of Nesiritide and Renal Function Following Total Artificial Heart ImplantationW. Kyle Stribling, MD*, Keyur B. Shah, MD*, Kyle J. Gunnerson, MD***, Gundars J. Katlaps, MD**, Michael L. Hess, MD*, Vigneshwar Kasirajan, MD**, Daniel G. Tang, MD***Division of Cardiology, Virginia Commonwealth University, Richmond, VA **Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA***Critical Care Medicine, Virginia Commonwealth University, Richmond, VADisclosure: Drs. Michael L. Hess and Vigneshwar Kasirajan are consultants for Syncardia Corporation. We will be discussing off-label use of Nesiritide.
MethodsTAH Implants (42)No NES at implant (9)Xplant w/in 24 hrs (1) or HD (3)Compared GFR pre/post implant (5) NES at implant (33)Immediate HD (6) or pheresis (1) post-op > 1 NES wean attempt (24)No NES w/drawal prior to Xplant (2)Failed NES wean prior to Xplant (4)Successfully weaned off NES (20) Recovery of renal function (1)Recovery of renal function (1)p = 0.15
DiscussionTAH patients s/p ventriculectomy provide a unique population to assess the effect of abrupt withdrawal of BNPPerioperative use of nesiritide improves renal function after TAH implant The magnitude of the effect of nesiritide on renal function may decrease over timeLimitations:RetrospectiveHeterogenous use of NES A prospective study utilizing a standardized treatment and assessment of renal function with renal biomarkers is ongoing
ANEMIAJ Heart Transplant 1986; 5: 236
Persistent Anemia in Patients Supported with the Total Artificial Heart: Hemolysis and Ineffective ErythropoiesisAnit K Mankad, MD; Maureen Flattery, NP; Daniel G Tang, MD; William Clark, MD; Suzanne Harton, RN, MS; Gundars J Katlaps, MD; Michael L Hess, MD; Vigneshwar Kasirajan, MD; Keyur B Shah, MD
ResultsThirty-six patients (mean age 47±13 years) were supported with a TAH for median of 83 days (IQR: 43,115).
ConclusionsPatients implanted with TAH have persistent hemolytic anemia that resolves after cardiac transplantation.Ineffective erythropoiesis and inflammation likely play a role in this anemia.
Median time to rehab was 5 daysMedian time to treadmill was 19 days
Aerobic activity and rehabilitation are feasible and safe with the TAH in the supervised hospital setting. Utilization of a portable console has been FDA approved. The results of this study are pertinent as patient rehabilitation and mobility will be of increasing concern as TAH patients will be free to go home in the near future. Future studies measuring multiple exercise metrics with more intense exercise in a prospective manner will provide further guidance on rehabilitation for patients with the device.Aerobic activity and rehabilitation are feasible with the TAH. Currently in the United States, patients with the device are bound to the inpatient wards of hospitals, as the size and weight of the device’s console prohibits patient discharge from the hospital. However, utilization of a portable console is currently under investigation. The results of this study are pertinent as patient rehabilitation and mobility will be of increasing concern as TAH patients will be free to go home in the near future. Future studies measuring multiple exercise metrics with more intense exercise in a prospective manner will provide further guidance on rehabilitation for patients with the device.