Outpatient Treatment of MCS Patient. F. Bennett Pearce, MD Professor of Pediatrics Med Director Heart Transplant COA
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1 Outpatient Treatment of MCS Patient F. Bennett Pearce, MD Professor of Pediatrics Med Director Heart Transplant COA
2 Disclosure Statement I DO NOT HAVE ANY RELEVANT FINANCIAL RELATIONSHIPS WITH ANY COMMERCIAL INTERESTS TO DISCLOSE.
3 History of MCS ADULT 1963 Successful VAD 1980s-1990s FDA approval 1998 REMATCH begins 2000 continuous flow devices Destination rx replacing transplant PEDIATRIC 1980 s ECMO 1990 s ECMO, Adult VAD implants 1991-Berlin Heart Excor-Germany June 2000-Berlin Heart First US implant 2011 Berlin Heart FDA approval BTT
4 1963 VAD
5 Figure 1 Source: The Journal of Heart and Lung Transplantation 2010; 29: (DOI: /j.healun ) Copyright 2010 International Society for Heart and Lung Transplantation Terms and Conditions
6 Pediatric VAD 1990s , 2375 children listed for transplant 99 VAD, median age 13 y Length 57 d 77% successful bridge Transplant outcome similar to non-vad
7 THORATEC Paracorporeal Pneumatic Mechanical tilting disc valves Thoralon HR down to 20-lower rates allow blood stasis
8 MORTALITY RISK FACTORS Figure 5. Survival to transplant Copyright American Heart Association
9 Pediatric Specific Device Miniaturization 1991 Berlin Heart Prototype 8 year old/27kg Cardiogenic shock Extubted/ ambulatory-8 days support Successful transplant Mechanical left ventricular support as a bridge to cardiac transplantation in childhood
10 Berlin Heart 10,25,30,50,60 ml. stroke volume Pneumatic Carmeda coating children bridged to Tx. 72% survival (Germany) Total experience 45-5 recovered function
11
12
13
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15 Chest X-Ray on Admission
16 ECMO
17 5 Weeks into Berlin Heart
18 Journal of Thoracic and Cardiovascular Surgery 2009
19
20 NEJM Aug 2012
21 Berlin Heart 800 US implants 80-90/year In hospital Portable control unit
22 REMATCH Trial NYHA Class IV Heart Mate XVE pulsatile, intracorporeal DT 365d 52% Device, 25% medical
23 Original Article Advanced Heart Failure Treated with Continuous- Flow Left Ventricular Assist Device Mark S. Slaughter, M.D., Joseph G. Rogers, M.D., Carmelo A. Milano, M.D., Stuart D. Russell, M.D., John V. Conte, M.D., David Feldman, M.D., Ph.D., Benjamin Sun, M.D., Antone J. Tatooles, M.D., Reynolds M. Delgado, III, M.D., James W. Long, M.D., Ph.D., Thomas C. Wozniak, M.D., Waqas Ghumman, M.D., David J. Farrar, Ph.D., O. Howard Frazier, M.D., for the HeartMate II Investigators N Engl J Med Volume 361(23): December 3, 2009
24 Pulsatile-Flow (Panel A) and Continuous-Flow (Panel B) Left Ventricular Assist Devices (LVADs) Slaughter MS et al. N Engl J Med 2009;361:
25 Survival Rates in Two Trials of Left Ventricular Assist Devices (LVADs) as Destination Therapy. Fang JC. N Engl J Med 2009;361:
26 Adverse Events and Associated Relative Risks from the As-Treated Analysis, According to Treatment Group Slaughter MS et al. N Engl J Med 2009;361:
27 Continuous Flow VAD Axial Flow-HM2 Centrifugal Flow- HeartWare Smaller Valveless Magnetic levitation AXIAL 63ml/390g CENTRIFUGAL50ml/160g
28 No Caption Found John R. et al.; J Thorac Cardiovasc Surg 2008;136:
29 : June 2006 June 2011 Implants per year Primary Implant Enrollment: n=4366 Continuous Flow Intracorporeal LVAD Pump Pulsatile Flow Intracorporeal TAH Pulsatile Flow Intracorporeal LVAD Pump Pulsatile Flow Paracorporeal LVAD Pump Cont Intra Pump Puls Intra TAH Puls Intra Pump Puls Para Pump Figure 3 12/14/2011
30 Pediatric Device Evolution 2010 ASAIO J 4 adolescents Heart Mate 2 Intracorporeal Continuous flow Support d
31 Pediatric Device Evolution HeartWare HeartWare Intrapericardial Magnetic suspension of impellar 1-10 l/min 2 month supportrehab, hospital d/c Successful transplant Ann Thor Surg 2012
32 INTERMACS/PEDIMACS INTERMACS-2006 CMMS mandatory for DT with approved devices >10000 patients PEDIMACS-2012-durable support, excluding ECMO
33 PEDIMACS Goal is to have registry of all VADs placed in children in North America From September 2012 to March devices 102 patients 29 hospitals
34
35 Age at Implant
36 0UTPATIENT VADS IN AL
37 Birmingham News April 10, 2015
38 Current CF Devices HVAD HM2
39
40 ECHOCARDIOGRAPHY Artifacts septal position MR Aortic Valve RV
41 ECHOCARDIOGRAPHY Artifacts septal position MR Aortic Valve RV
42 ECHOCARDIOGRAPHY Artifacts septal position MR Aortic Valve RV
43 ECHOCARDIOGRAPHY Artifacts septal position MR Aortic Valve RV
44 ECHOCARDIOGRAPHY Artifacts septal position MR Aortic Valve RV
45 ECHOCARDIOGRAPHY Artifacts septal position MR Aortic Valve RV-function/TR
46 CARDIAC CATH
47 SUCTION EVENT Acute septal shift Septum obstructs inflow Reduced preload high RPM Acute Drop in flow
48 SUCTION EVENT ECHO LV Tach
49 Normal Operation Parameters
50 Blood Pressure Low pulsatility MAP Brachial Artery Doppler
51 Fig. 1 The Journal of Heart and Lung Transplantation , S91-S92DOI: ( /j.healun ) Copyright 2013 Terms and Conditions
52 ANTICOAGULATION Warfarin, INR 2-3 ASA 325 Anti-platelet Heparin infusion for low INR Heparin infusionprocedures
53 Thrombosis Markers of hemolysis LDH>600 PFH>40 Pump design change
54 Acquired VW Deficiency VW multimersdestroyed shear stress é mucosal bleeding GI bleeding
55 Intestinal angioectasia Thin walled mucosal vessels reduced pulse pressure Anywhere in colon Reduce anticog Octreotide, thalidomide NEJM now Feb 2015
56 Mechanisms implicated in gastrointestinal (GI) tract bleeding in patients with axial-flow left ventricular assist devices (LVADs): Patients treated with axial-flow LVADS are at increased risk of developing GI tract bleeding. Jorge Suarez et al. Circ Heart Fail. 2011;4: Copyright American Heart Association, Inc. All rights reserved.
57 HOME WOUND CARE Gloves/Mask Remove Dressing Clean Exit Site New Bandage REPORT Redness/swelling Odor/warmth/100.5 Drainage
58 SITE CARE
59 CF VAD SUMMARY Optimum pump speed RPM Flow index Power Watts, alarm at +2Watts CF pumps are prelaod dependent and afterload sensitive Warfarin INR 2-3, ASA
60 CF VAD SUMMARY OK to defibrillate CPR OK-check driveline Not MRI compatible Local ER/EMS notification and training Family training, onging education
61 OUO VADIS? Miniaturization Longer support, Ped DT? good VAD> bad transplant PumpKIN Recovery enhancement Levee Road, Convent, LA Andrew Boyd MVAD
62 Acknowledgements SPCS and sponsors Mike Warren-CEO-COA COA Pediatric Cardiology, CV Surgery, CICU, Nurse Practitioners, Perfusion, Nursing, Respiratory, Child Life, Social Services, Counselors, Transplant Coordinators, Ped Cardiology Office Staff, Pastoral Care Bruno and Russell Family Foundations Families and Children with Cong Heart Disease
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I have nothing to disclose.
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