Circulatory Assist Devices

Andrew Rosenberg MD Chief, Division of Critical Care Anesthesiology Assistant Professor Anesthesiology & Internal Medicine Medicine University of Michigan

Circulatory Assist
High TAH Implantable LVAD Cardiac Assist IABP Inotropes Low High External cardiac assist (BVS 5000)

Low

Invasiveness

Long term use of VADS

NEJM, 06

Future CVC Research Bldg

CVC Level 5

Epidemiology of Heart Failure

5 million Patients with CHF in US 1% of population over 65 years old

160% increase in hospitalizations due to CHF CHF over past decade Symptomatic 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

Case Study: Acute Cardiac Failure Failure

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=16 Intubated, 100% Fi02 Meds;
Dobutamine 12mcg/kg/min

12mcg/kg/min Milrinone .375mcg/kg/min .375mcg/kg/min Norepinephrine .13mcg/kg/min

Oliguric, Rising creat, LFTs,,

prothrombin time.

Circulatory Assist Devices

IABP (Intra-aortic, counterpulsation
Cardio-pulmonary bypass ECMO-cardiac {VA ECMO} Minimally invasive Bridge to recovery/transplant Destination therapies

Balloon pumps ECLS (Extra-corporeal Life Support)

(VADS)Ventricular Assist Devices

IABPs
Introduced 1960s. Most widely used mechanical circ. Support device Reduces cardiac work by afterload Increases coronary blood flow Indications; 1. Cardiogenic shock
Fail to wean from CPB Acute MI

2. 3. 4.

Acute mitral regurgitation Unstable angina Support during high-risk procedures/events

PTCA Unstable Pts. Prior to CPB. Ventricular arrhythmias refractory to Rx.

Contraindications;
1. 2. 3. 4. Aortic insufficiency Aortic dissection Prosthetic graft in thoracic aorta Severe aortoiliac disease

Practical IABP
Systolic time intervals used to coordinate patients electrical and mechanical events of cardiac cycle. Polyethylene balloon, mounted on hollow catheter(arterial pressure monitor) advanced to 2cm below left sublcavian artery 30-40 cc volume displacement Balloon 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.

IABP; Complication
Aortic dissection or arterial perforation Failure to advance catheter beyond iliofemoral system due to
atherosclerotic disease Limb ischemia requiring IABP removal

Thrombocytopenia Sepsis Balloon rupture w/ helium embolization (2%)

11-27%

Hematomas Pseudoaneurysm AV fistulas

Heralded by high balloon inflation pressures, blood in connecting tubing tubing

IABP Consol Controls

IABP Waveforms

Early Inflation

Late Inflation

Abrupt Deflation

Slow Deflation

ECMO Setup

ECLS Circuit
Cannula Bladder box Pump Oxygenator Bridge Monitoring Hemofilter

ECLS: World Outcomes (12/04)

ELSO Registry Univ. of Michigan n (%survive to D/C) n (%survive to D/C)

Neonatal

Respiratory Cardiac

18,703 (77%) 2,246 (39%)

690 (85%) 122 (44%)

Pediatric
Respiratory Cardiac

2,640 (56%) 3,073 (42%)

183 (75%) 132 (42%)

Adult
Respiratory
Cardiac

933 (53%) 568 (35%)

255 (52%) 141 (38%)

Total

28,163 (67%)

1,520 (67%)

Cardio-pulmonary Bypass

Describing Ventricular Assist Devices

Extra/para-coporeal

Intracoporeal

IABP Tandem Heart ECMO Abiomed Thoratec Berlin Heart

Ventricular Assist type

Right Left Biventricular

Flow Type

Pulsatile Non-pulsatile

Heartmate Novacor Jarvik 2000 DeBakey Micromed

Drive Train

Pneumatic Electric Magnetic

Tandem Heart

Abiomed Impella Recover

4.5 liter flow 7 day use 9Fr cannula

Hemodynamic effects from Impella Impella

Extra/Paracoporeal Support
Thoratec Vad system Paracorporeal 7 liter blood flow BSA > 0.7 Full anticoagulation

Biventricular Support: Abiomed BVS 5000

Extracorporeal;LVAD, RVAD, BiVad. Sized for BSA >1 5 Liter blood flow

RVAD<LVAD flow; avoid edema

Intermediate-term support Full anticoagulation Thermodilution, mixed venous saturations not accurate. Height adjustment to balance R & L flows. Clotting at low flow

(<2 liters/min) >65% post cardiotomy

>6000 patients supported

Abiomed BVS5000 Setup

Abiomed AB5000 Ventricle

Paracorporeal, Biventricular support Same cannula as BVS5000 6 liter blood flow 21 day average support >300 day longest to date

Thoratec IVAD
Only Intra-corporeal Bivad >2800 patient implants Pulsatile flow,

VAD support for arrythmia

Multicenter, RCT 129 Patients end-stage Heart Fail. Ineligible for cardiac tx Heartmate XVE vs Best Med Rx 48% reduced risk of death
52% 1 yr survival vs 25% 23% 2 yr survival vs 8%

Serious adverse events;

Infection Bleeding Device malfunction

First Generation LVAD

Thoratec VAD

HeartMate LVAD

Novacor LVAD

Thoratec Heartmate I

Heartmate IP Heartmate XVE

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

Pushplate pump mechanism

Novacor LVAS
Intra-corporeal 6-8 liter flow Long duration ? Best destination therapy device Full anticoagulation

Advances in LVADs
Smaller sizes DeBakey

Jarvik 2000 Increased durability/duration

WorldHeart Novacor II

Thoratec IVAD

Second Generation LVAD Axial Flow Pumps

Jarvik 2000

HeartMate II

DeBakey

Thoratec Heartmate II
Intr-coporeal High-speed, axial flow(non-pulsatile), rotary pump BSI<1 possible 6,000 to 15,000 rpm (usual 9200 rpm) 4-8 liter blood flow Fixed and auto speed modes

Thoratec Heartmate II; Axial flow

Small size No hemolysis Flow= 5-10
liters/minU

Third Generation LVAD

HeartMate III HeartQuest

Centrifugal flow
design Magneticallylevitated Long pump durability DuraHeart

WorldHeart Novacor Rotary VAD

Total Artificial Hearts: Abiomed AbioCor AbioCor

First Completely selfcontained total artificial heart 2 lbs. Still in FDA review Not eligible for natural heart transplant

Artificial Hearts; Syncardia Heart

Intra-corporeal Biventricular support Bridge to Transplant 7-10 liter flow Full anticoagulation

Jarvik Heart

VAD Controllers

VAD Management Issues

Hemodynamics (0-12 hrs.)

Adequate LVAD filling

MAP70mmHg. Flow rate 3-4 l/min, Fixed rates of 75, changing to auto rate control over time. RPMs 8000-9000, Pulsatility index > 4 HR 96-110, small volumes ejected,more frequently from RV

Collapsed LV interventricular septum bowing Increased venous return RV dilation, reduced effective RV geometry, tricuspid regurgitation RV ischemia

CVP 8-15 mmHG (prompt response to increases!)

Low LVAD flow + low/nl CVP= hypovolemia Low LVAD flow + high CVP= RV overload/failure, PHTN

CVP >20 associated w/ GFR, diuretic unresponsiveness, ARF.

CVVH to remove extra volume if diuretic resistant

Complications:Hypotension
LVAD

RV failure

Low intravascular volume, obstructed LV filling, Aortic emptying Because 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 Fluid overload, excessive LVAD flow, PVR, excessive systemic vasopressors, vasopressors, acid-base SIRS Milrinone, dobutamine

Systemic Vasodilation

Hemorrhage {remember abdominal}, tamponade Obstructive shock; tamponade, auto-peep Sepsis, anaphylaxis, adrenal insufficiency

Managing Hypotension-contd
Normal RV + low or nl SVR

Fluids to maintain CVP 10mmHg milrinone to .125 mcg/kg or turn off if LVAD flow flow are > 4l/min Increase Nor-epi, vasopressin Increase LVAD flow Maintain Nitric Oxide 5 to 20 ppm Milrinone 0.5 mcg/kg/min Dobutamine 8-10 mcg/kg/min Epi, Dopamine, Isuprel Isuprel

Poor RV fxn +nl SVR

Avoiding Right Heart Failure

Pre-op Inotropic support

Improve R heart volume overload

PA-Catheter, Echo Milrinone, Vassopressin, Dobutamine, Nor-epi Diuretics CVVH

Correct Coagulopathy {vitamin-k, Intra-op

Post-operative

Same inotropic support Aprotinin Nitric Oxide Warm Correction of acidosis, Mild respiratory alkalosis Fast RV heart Rate, A-V pacing Aggressive correction of volume overload, increasing CVP

Effects of nonpulsatile blood flow

Benefits of pulsatile flow;

Adverse effects of nonpulsatile flow

Reduces critical capillary closing pressure Improves lymphatic flow Improves tissue perfusion; enhances diffusion of oxygen and other substrates Neuroendocrine responses from lack of baroreceptor, renal and endothelial stimulation;

Vasoconstriction Increased oxygen consumption Acidosis Edema formation

Renal Effects;
Increased renin, angiotensin II, Aldosterone Reduced cortical and medullary blood flow

Decreased gastric mucosal pHi

Wienstein et al. ATS, 79 Hamulu, Perfusion, 98

Effects on Systemic Perfusion with Pulsatile and NonPulsatile Blood Flow

Yes

Non-Pulsatile
4000cc/80kg= 50cc/kg/min

Shock Acidosis Oliguria Epinephrine

No
50 60 70 80 90 100110120

+/-

Pulsatile

Flow cc/Kg

Bartlett, ELSO,2000 Tominaga, JTCS,94 Golding, ASAIO,82 Bernstein, TransASAIO,74

RecentPost-operative anticogaulation/antiplatelet therapy

Antiplatelet Agents;

plts50,000, CT drainage <30 to 50ml/hr x 4 hours ASA 81-325mg/d; POD 1-3, Dipyridamole (Persantine) 75mg tid; POD1-2 Pentoxifylline (Trental) 400mg tid; POD 1-2 Heparin 2-5 U/kg/hr; POD 1-3, no bolus Warfarin 2mg hs; POD 5 to 7; nl hepatic/renal fxn

Anticoagulants

Other Post-operative issues

Turn on AICD if present Out of bed, incentive spirometry Nutrition; early enteral feed (may require
require feeding tube) Plasma free hemoglobin (3-10 mg/dl)

Weaning from VADs

As flow is decreased, native ejections should become more prminent on arterial waveform.

VAD Comparison Chart

VAD ABS500 0

The End

Cannulation

Oxygenators & CO2 Sweep

ECMO circuit pump and controller

Cardiac Output and Mixed venous monitor

Cardio-pulmonary Bypass

Abiomed AB5000

Abiomed BVS clinical pearls