Right Heart Failure in LVAD patients: Prevention and Management.
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1 Christian Bermudez MD. Associate Professor Director Thoracic Transplantation Division Cardiac Surgery Department of Surgery University of Pennsylvania Right Heart Failure in LVAD patients: Prevention and Management.
2 Conflict of Interest No Financial Disclosures.
3 Interaction RV and LVAD support
4 INTERMACS definition of RVF Symptoms and Signs of persistent RVF following LVAD implantation characterized by : Elevated CVP documented by: Right atrial pressure >16 mmhg on right heart catheterization Significantly dilated inferior vena cava with no inspiratory variation on echocardiography Elevated jugular venous pressure Manifestations of elevated CVP characterized by: Peripheral edema(>2+) Ascites or hepatomegaly on exam or diagnostic imaging Laboratory evidence of worsening hepatic (total bilirubin >2.0 mg/dl) or renal dysfunction (creatinine >2.0 mg/dl) STS/EACTS Latin America Cardiovascular Surgery Conference
5 Severity of Post-op RV Failure 2.6 fold increase in mortality at 6 months
6 Clinical outcomes associated with INTERMACS-defined right heart failure after left ventricular assist device implantation 306 pt with less than severe RVD and 139 with severe RVD, St Louis Severe RVD has profound effect in survival and clinical outcomes Larue JHLT 2017 STS/EACTS Latin America Cardiovascular Surgery Conference
7 Right Ventricular Failure 9-44% incidence in VAD eligible 5-20% post-lvad incidence RVF: Increased mortality Multi-system organ failure Coagulopathy Hemorrhage Pulmonary failure Thromboembolic complications Circ Cardiovasc Imaging 2014 Kalogeropoulos JHLT 2015 Kormos JTCVS 2010 Genovese Ann Thor Surg 2009 Fitzpatrick JHLT 2008 Morgan Ann Thor Surg 2004 Slaughter JHLT 2010
8 Surgical RVAD s in the US : Eighth INTERMACS Reports 3.5% CF LVAD require RVAD J Heart LungTransplant 2017;36:
9 RV Risk Assessment Risk Scores: Michigan Penn BIVAD Clinical : MV,RF, LVD, INTMCS Hemodynamics: CVP, RVSWI, CVP:PCWP, PVR, TPG, PA pressure Echo: RV Failure, TAPSE, TR, 3D TEE Penn CRITT Berlin Utah U. Pitt HM II Matthews JC JACC 2009 Fitzpatrick JR JHLT 2008 Drakos SGAm J Card 2010 Atluri P Ann Thor Surg 2014 Potapov JHLT 2008 Wang Y JHLT 2012 Kormos JTCVS 2010 Kiernan J Card Failure 2015
10 Clinical Tools for Assessing Risk for Right Ventricular Failure or Mortality After LVAD Since 2008 J HeartLungTransplant 2016;35: STS/EACTS Latin America Cardiovascular Surgery Conference
11 EUROMACS Right Sided-HF Risk Score Includes only the 3 most used CF pumps (HMII, HW, HMIII)
12 How do we prevent and manage acute perioperative RVF.
13 Pre-operative Optimization RV Diuresis (Lasix Drip/ CVVH, target CVP<15 mmhg) Preoperative Inotropic Support (Milrinone preferred over Dobutamine). IABP
14 RV Pre- and Post-Optimization
15 Preoperative IABP Intra-Aortic Balloon Pump Use Before Left Ventricular Assist Device Implantation: Insights From the INTERMACS Registry Cumulative incidence of right heart failure, hepatic dysfunction, renal dysfunction, or death Despite markers of higher risk in patients with IABP use, we found no significant difference in 30 day outcomes compared to those without. The results suggest that IABP use may mitigate risk of early postoperative adverse outcomes in select patients. STS/EACTS Latin America Cardiovascular Surgery Conference 2018 ASAIO Journal 2018; 64:
16 Intra-and Perioperative Strategies to Prevent/Treat RV Failure Surgical Strategies Perioperative management. TV Repair Minimize CPB Avoid bleeding /prevent transfusions Delayed chest closure Adjust LVAd flow (avoid septal shift) RVAD (early implantation) Nitric Oxide or inhaled prostacyclin TEE monitoring of RVF Inotropic support to Maintain systolic BP and avoid vasodilation Milrinone Epinephrine Isoproterenol Ventilator strategies Maintain O2 and reduce CO2 (avoid hypercarbia )
17 Right heart failure and benefits of adjuvant tricuspid valve repair in patients undergoing left ventricular assist device implantation 141 LVAD /69 TVr European Journal of Cardio-Thoracic Surgery (2014) 1 6 STS/EACTS Latin America Cardiovascular Surgery Conference
18 Right heart failure and benefits of adjuvant tricuspid valve repair in patients undergoing left ventricular assist device implantation 141 LVAD /69 TVR Tricuspid valve repair is a useful and durable adjuvant procedure for restoring deteriorated right ventricular function in patients requiring LVAD implantation.. 18 European Journal of Cardio-Thoracic Surgery (2014) 1 6
19 Concomitant tricuspid valve surgery during implantation of continuous-flow left ventricular assist devices: A Society of Thoracic Surgeons database analysis cf LVADs, 588 (27%) LVAD-TVr (TVr in mod-severe TR, annulus >40 mm) No difference in RVAD need or mortality TVP was associated with an increased risk for postoperative renal failure (RR,1.53;95%CI, ; p =0.0061), dialysis (RR,1.49;95%CI, ; p = ), reoperation (RR,1.24;95%CI, ; p = ), greater total transfusion requirement (RR,1.03;95%CI, ; p = ),and hospital length of stay >21 days (RR,1.29;95%CI, ; p o ). Time on the ventilator and intensive care unit length of stay were also significantly prolonged for the LVAD -þtvp group. The Journal of Heart and Lung Transplantation, Vol 33, No 6, June 2014 STS/EACTS Latin America Cardiovascular Surgery Conference
20 Continuous Flow Left Ventricular Assist Device Implant Significantly ImprovesPulmonary Hypertension, Right Ventricular Contractility, and Tricuspid Valve Competence There was an immediate improvement in TR grade and RV function following LVAD implant, which was sustained long term Conclusion: Continuous flow LVAD implant improves pulmonary hypertension, RV function, and tricuspid regurgitation. TR may be managed non-operatively during CF LVAD implant. 20 J CARD SURG ATLURI, ET AL ;28:
21 Inhaled nitric oxide after left ventricular assist device implantation: A prospective, randomized, double-blind, multicenter, placebo-controlled trial 105 patients randomized to receive 40ppm NO vs placebo at time of weaning from bypass Use of ino at 40 ppm given before separation from CPB did not reach statistical significance for the primary end point of reduction in RVD incidence. No statistically significant difference was found for secondary variables, including time on mechanical ventilation, ICU or hospital stay, and the need for RVAD after LVAD placement. J Heart Lung Transplant 2011;30:870 8
22 Surgical Temporary Mechanical RV Support Options Sternotomy/Thoracotomy Centrifugal Pump RVAD FDA approved for RV support
23 Percutaneous Temporary RV Support Options Impella RP * Tandem Heart- Protek-Duo Cann**. ECMO*** *FDA Approval for RV support ** FDA Approval for Circulatory Support 6h *** FDA Approval for Circulatory Support 6h
24 Early, Planned Institution of Biventricular Mechanical Circulatory Support Results in Improved Outcomes Compared to Delayed Conversion of LVAD to BiVAD 167 LVAD alone,71 Planned BIVAD and 28 delayed BIVAD (PVADS) Similar patient characteristics in the BIVAD group When patients at risk for isolated LVAD support failure are identified, proceeding directly to BiVAD implantation is advised, as early institution of biventricular support results in dramatic improvement in survival J Thorac Cardiovasc Surg April ; 137(4): STS/EACTS Latin America Cardiovascular Surgery Conference
25 Outcome of unplanned right ventricular assist device support for severe right heart failure after implantable left ventricular assist device insertion.
26 Clinical experience with Centrimag temporary right ventricular mechanical circulatory support Centrimag Central cann. Risk factors for weaning RVAD J.Thorac Cardiovasc Surg 2018;156:
27 Clinical experience with temporary right ventricular mechanical circulatory support Survival of Centrimag RVAD by Indication, Era and Timing of Implantation Conclusions: Temporary right ventricular mechanical support remains an effective treatment strategy after left ventricular assist device placement with immediate support resulting in superior short-term survival. Caution should be applied in postcardiotomy cardiogenic shock when weaning and survival are poor. Overall survival outcomes have remained relatively static over time. J.Thorac Cardiovasc Surg 2018;156:
28 TandemHeart RVAD (TH pump and Dual Lumen Cannula) Tandem Heart Pump Placement under fluoroscopy using One flow directed PA catheter and COOK.035 Lunderquist guidewire used to advance the Cannula Femoral -RIJ PROTEK-DUO Cannula 29 and 31 FR
29 Outcomes with the Tandem Protek Duo Dual-Lumen Percutaneous Right Ventricular Assist Device Two-center experience using the TPD in 17 patients with right ventricular(rv) failure (12 of whom were post-left ventricular assist device (LVAD) implantation) Complications occurred in 6 (35%): 1 pt epistaxis and hematemesis. 1pt had injury to left internal jugular due to inability to advance the catheter past the RV due to tortuous anatomy. 2 intracranial bleeds 2 bleeding at the catheter insertion site after placement. Ravichandran et al ASAIO Journal 2017
30 Impella RP: Percutaneous Device Pump outflow in 3D catheter-based percutaneous VAD PA (22 Fr pump mounted on a 11 Fr catheter) Treatment: RV dysfunction Flow: > 4 L/min at rpm Duration of support: up to 14 days Pump Inflow: Inferior Vena Cava (IVC) Pump Pump Outflow: Pulmonary Artery (PA) Outflow Anticoagulation: ACT ~ sec in IVC Axial Flow pump (22 Fr) Catheter based (11Fr) IVC implant. RPM up to FDA HDE approval
31 RECOVER Trial :Patient Outcomes and Adverse Events Patient outcomes and adverse events Primary End Points Secondary EndPoints Anderson,et al. J HeartLungTransplant2015;34: Anderson,et al. J HeartLungTransplant 2015;34:
32 Flows and Hemodynamics
33 Summary The presence of acute severe RV failure is associated with increased risk of mortality and morbidity. Preoperative, intraoperative and postoperative management are key to prevent and avoid progression of RVF and may be critical to prevent poor outcomes. There is an increasing number of surgical and percutaneous RVAD options that seem to be efficacious and safe, but timing implantation seems to be a critical step to prevent progression to MOF.
34 THANK YOU
35 Post-Operative/ICU Management Bleeding Nitric Oxide Inotropes Maintain MAP Watch CVP/PA ratio go to RVAD early if any doubts Role of Pump Speed? Don t know, do not over pump
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