rosenberg circulatory assist devices(1)
DESCRIPTION
Types Circulatory Assist DevicesTRANSCRIPT
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Circulatory Assist Devices
Andrew Rosenberg MDChief, Division of Critical Care Anesthesiology
Assistant Professor Anesthesiology & Internal MedicineMedicine
University of Michigan
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Circulatory Assist
High
Low
Low High
CardiacAssist
Invasiveness
Inotropes
IABP
External cardiacassist (BVS 5000)
Implantable LVAD
TAH
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Long term use of VADS
NEJM, 06
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Future CVC
Research Bldg
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CVC Level 5
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Epidemiology of Heart Failure5 million Patients with CHF in US1% of population over 65 years old
160% increase in hospitalizations due to CHF CHF over past decadeSymptomatic CHF = 45% 1-year mortality. < half of 4200 patients on Tx list will receive a receive a heart Tx.
15%/year die waiting for organ
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Case Study: Acute Cardiac FailureFailure
52 yo male Hx; CAD, HTN, now with large Anterior Wall Wall MI, Cardiogenic Shock, hypoxemic.VS; HR=105, BP=80/67, CI=1.5, PAOP=28,CVP=16Intubated, 100% Fi02Meds;
Dobutamine 12mcg/kg/min12mcg/kg/minMilrinone .375mcg/kg/min.375mcg/kg/minNorepinephrine .13mcg/kg/min
Oliguric, Rising creat, LFTs,, prothrombin time.
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Circulatory Assist DevicesIABP (Intra-aortic, counterpulsation Balloon pumpsECLS (Extra-corporeal Life Support)
Cardio-pulmonary bypassECMO-cardiac {VA ECMO}
(VADS)Ventricular Assist DevicesMinimally invasiveBridge to recovery/transplantDestination therapies
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IABPsIntroduced 1960’s.Most widely used mechanical circ. Support
deviceReduces cardiac work by ↓afterloadIncreases coronary blood flow
Indications;1. Cardiogenic shock
Fail to wean from CPBAcute MI
2. Acute mitral regurgitation3. Unstable angina4. Support during high-risk
procedures/eventsPTCAUnstable Pts. Prior to CPB.Ventricular arrhythmias refractory to Rx.
Contraindications;1. Aortic insufficiency2. Aortic dissection3. Prosthetic graft in thoracic
aorta4. Severe aortoiliac disease
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Practical IABPSystolic time intervals used to coordinate patients electrical and mechanical events of cardiac cycle.Polyethylene balloon, mounted on hollow catheter(arterialpressure monitor) advanced to 2cm below left sublcavian artery30-40 cc volume displacementBalloon deflates at beginning of systole, increasing stroke volume by as much at 40%
↓ LV stroke work, 02 consumption.
Ballon inflates during diastole increasing coronary artery perfusion.
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IABP; ComplicationAortic dissection or arterial perforationFailure to advance catheter beyond iliofemoral system due to atherosclerotic diseaseLimb ischemia requiring IABP removal
11-27%ThrombocytopeniaSepsisBalloon rupture w/ helium embolization (2%)
Heralded by high balloon inflation pressures, blood in connecting tubingtubing
HematomasPseudoaneurysmAV fistulas
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IABP Consol Controls
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IABP Waveforms Early Inflation
Late Inflation
Slow Deflation
Abrupt Deflation
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ECMO Setup
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ECLS CircuitCannulaBladder boxPumpOxygenatorBridgeMonitoringHemofilter
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ECLS: World Outcomes (12/04)ELSO Registry Univ. of Michigan
n (%survive to D/C) n (%survive to D/C)Neonatal Respiratory 18,703 (77%) 690 (85%)Cardiac 2,246 (39%) 122 (44%)
PediatricRespiratory 2,640 (56%) 183 (75%)Cardiac 3,073 (42%) 132 (42%)
AdultRespiratory 933 (53%) 255 (52%)Cardiac 568 (35%) 141 (38%)
Total 28,163 (67%) 1,520 (67%)
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Cardio-pulmonary Bypass
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Describing Ventricular Assist Devices
Extra/para-coporealIABPTandem HeartECMOAbiomedThoratecBerlin Heart
IntracoporealHeartmateNovacorJarvik 2000DeBakey Micromed
Ventricular Assist typeRightLeftBiventricular
Flow TypePulsatileNon-pulsatile
Drive TrainPneumaticElectricMagnetic
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Tandem Heart
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Abiomed Impella Recover
4.5 liter flow7 day use9Fr cannula
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Hemodynamic effects from ImpellaImpella
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Extra/Paracoporeal SupportThoratec Vad systemParacorporeal7 liter blood flowBSA > 0.7Full anticoagulation
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Biventricular Support: AbiomedBVS 5000
Extracorporeal;LVAD, RVAD, BiVad.Sized for BSA >15 Liter blood flow
RVAD<LVAD flow; avoid edemaIntermediate-term supportFull anticoagulationThermodilution, mixed venous saturations not accurate.Height adjustment to balance R & L flows.Clotting at low flow
(<2 liters/min)>6000 patients supported
>65% post cardiotomy
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Abiomed BVS5000 Setup
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Abiomed AB5000 VentricleParacorporeal, Biventricular support
Same cannula as BVS5000
6 liter blood flow
21 day average support
>300 day longest to date
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Thoratec IVADOnly Intra-corporeal Bivad>2800 patient implantsPulsatile flow,
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VAD support for arrythmia
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Multicenter, RCT129 Patients end-stage Heart Fail.Ineligible for cardiac txHeartmate XVE vs Best Med Rx48% reduced risk of death
52% 1 yr survival vs 25%23% 2 yr survival vs 8%
Serious adverse events;InfectionBleedingDevice malfunction
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HeartMate LVAD
Thoratec VAD
Novacor LVAD
First Generation LVADFirst Generation LVAD
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Thoratec Heartmate I
Heartmate IP
Heartmate XVE
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HeartMate I XVE Intra-coporeal LVAD only
6-?10 liter blood flow
Textured surfaces in blood chamber creates ‘neo-intima
ASA only
Three modes;
Fixed
Auto
External (synchronous)
Portable power pack allows ambulation
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Pushplate pump mechanism
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Novacor LVASIntra-corporeal
6-8 liter flow
Long duration
? Best destination therapy device
Full anticoagulation
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Advances in LVADsSmaller sizesSmaller sizes
Increased durability/durationIncreased durability/duration
Thoratec IVAD
WorldHeart Novacor II
Jarvik 2000
DeBakey
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Second Generation LVAD – Axial Flow Pumps
HeartMate IIHeartMate II
DeBakeyDeBakey
Jarvik 2000Jarvik 2000
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Thoratec Heartmate IIIntr-coporealHigh-speed, axial flow(non-pulsatile), rotary pumpBSI<1 possible6,000 to 15,000 rpm (usual 9200 rpm)4-8 liter blood flowFixed and auto speed modes
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Thoratec Heartmate II; Axial flowSmall size No hemolysisFlow= 5-10 liters/minU
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Third Generation LVADThird Generation LVAD
Centrifugal flow designMagnetically-levitatedLong pump durability
HeartQuestHeartQuest
DuraHeartDuraHeartWorldHeartWorldHeart Novacor Novacor Rotary VADRotary VAD
HeartMate IIIHeartMate III
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Total Artificial Hearts: Abiomed AbioCorAbioCor
First Completely self-contained total artificial heart
2 lbs.
Still in FDA review
Not eligible for natural heart transplant
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Artificial Hearts; Syncardia Heart
Jarvik Heart
Intra-corporeal Biventricular support
Bridge to Transplant
7-10 liter flow
Full anticoagulation
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VAD Controllers
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VAD Management Issues
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Hemodynamics (0-12 hrs.)Adequate LVAD filling
MAP≈70mmHg.Flow rate ≈ 3-4 l/min,Fixed rates of 75, changing to auto rate control over time. RPMs 8000-9000, Pulsatility index > 4HR 96-110, small volumes ejected,more frequently from RV
Collapsed LV interventricular septum bowingIncreased venous returnRV dilation, reduced effective RV geometry, tricuspid regurgitationRV ischemia
CVP 8-15 mmHG (prompt response to increases!)Low LVAD flow + low/nl CVP= hypovolemiaLow LVAD flow + high CVP= RV overload/failure, PHTN
CVP >20 associated w/ ↓ GFR, diuretic unresponsiveness, ARF.CVVH to remove extra volume if diuretic resistant
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Complications:HypotensionLVAD
Low intravascular volume, obstructed LV filling, Aortic emptyingBecause of non-occlusive system; require high enough pump speeds to avoid avoid pressure differentials below expected Ao pressures (avoid regurgitant flow)regurgitant flow)Rotary pumps can generate large negative pressure at inlet Obstruction of inlet/outlet cannulae, inadequate filling conditions
RV failureFluid overload, excessive LVAD flow, ↑ PVR, excessive systemic vasopressors, vasopressors, acid-base
Systemic VasodilationSIRSMilrinone, dobutamine
Hemorrhage {remember abdominal}, tamponadeObstructive shock; tamponade, auto-peepSepsis, anaphylaxis, adrenal insufficiency
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Managing Hypotension-cont’dNormal RV + low or nl SVR
Fluids to maintain CVP 10mmHg↓ milrinone to .125 mcg/kg or turn off if LVAD flow flow are > 4l/minIncrease Nor-epi, vasopressinIncrease LVAD flow
Poor RV fxn +nl SVRMaintain Nitric Oxide 5 to 20 ppmMilrinone 0.5 mcg/kg/minDobutamine 8-10 mcg/kg/min ± Epi, Dopamine, IsuprelIsuprel
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Avoiding Right Heart FailurePre-opInotropic support
PA-Catheter, EchoMilrinone, Vassopressin, Dobutamine, Nor-epi
Improve R heart volume overloadDiureticsCVVH
Correct Coagulopathy {vitamin-k,Intra-op
Same inotropic supportAprotininNitric Oxide
Post-operativeWarmCorrection of acidosis, Mild respiratory alkalosisFast RV heart Rate, A-V pacingAggressive correction of volume overload, increasing CVP
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Effects of nonpulsatile blood flowBenefits of pulsatile flow;
Reduces critical capillary closing pressureImproves lymphatic flowImproves tissue perfusion; enhances diffusion of oxygen and other substrates
Adverse effects of nonpulsatile flowNeuroendocrine responses from lack of baroreceptor, renal and endothelial stimulation;
VasoconstrictionIncreased oxygen consumptionAcidosisEdema formation
Renal Effects;Increased renin, angiotensin II, AldosteroneReduced cortical and medullary blood flow
Decreased gastric mucosal pHiWienstein et al. ATS, ’79
Hamulu, Perfusion, ‘98
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Shock
Acidosis
Oliguria
↑Epinephrine
Yes
+/-
No
50 60 8090100110120
Flow cc/Kg
Non-Pulsatile
Pulsatile
Effects on Systemic Perfusion with Pulsatile and Non-Pulsatile Blood Flow
Bartlett, ELSO,2000
Tominaga, JTCS,94
Golding, ASAIO,82
Bernstein, TransASAIO,74
4000cc/80kg= 50cc/kg/min
70
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RecentPost-operative anticogaulation/antiplatelet therapyAntiplatelet Agents;
plts≥50,000, CT drainage <30 to 50ml/hr x 4 hours
ASA 81-325mg/d; POD 1-3, Dipyridamole (Persantine) 75mg tid; POD1-2Pentoxifylline (Trental) 400mg tid; POD 1-2
AnticoagulantsHeparin 2-5 U/kg/hr; POD 1-3, no bolusWarfarin 2mg hs; POD 5 to 7; nl hepatic/renal fxn
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Other Post-operative issuesTurn on AICD if presentOut of bed, incentive spirometry Nutrition; early enteral feed (may require require feeding tube)Plasma free hemoglobin (3-10 mg/dl)
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Weaning from VADs
As flow is decreased, native ejections should become more prminent on arterial waveform.
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VAD Comparison ChartVAD
ABS5000
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The End
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Cannulation
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Oxygenators & CO2 Sweep
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ECMO circuit pump and controller
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Cardiac Output and Mixed venous monitor
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Cardio-pulmonary Bypass
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Abiomed AB5000
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Abiomed BVS clinical pearls