Percutaneous Mechanical Circulatory Support Devices

Transcription

1 Percutaneous Mechanical Circulatory Support Devices Daniel Vazquez RN, RCIS Miami Cardiac & Vascular Institute

2 FINANCIAL DISCLOSURES none

3 CASE STUDY

4 CASE STUDY 52 year old gentlemen Complaining of dyspnea after eating for one week Smallest amounts of food make him bloated He has been walking after meals to help relieve symptoms becomes increasingly short of breath develops significant palpitations Bedtime, becomes markedly SOB, must sleep sitting up Denies any dizziness or chest pain

5 CASE STUDY NO medical history NO previous surgeries Occasional drinker Occasional smoker Exercised regularly up until symptoms developed Takes only omeprazole which had been providing relief

6 CASE STUDY June 4th, sees his Cardiologist Elevated right heart pressure JVD Ascitis Suspects pulmonary hypertension GO Pulmonary TO EMERGENCY Embolism? ROOM!!

7 CASE STUDY CXR unremarkable CT Results pulmonary edema Echo Severely abnormal left ventricle Abnormal systolic function End-stage cardiomyopathy Ejection Fraction 5% Global hypokenesis

8 CASE STUDY June 6th, 2014 Neo-synephrine Brought emergently to Cardiac Cath Lab Dopamine Barely responsive Discolored Intubated Severely hypotensive Bradycardia Access

9 CASE STUDY Ejection Fraction 5%-10% LV-EDP 60 mmhg!!! No? significant obstructive CAD

10 BALLOON PUMP?

11 INTRA-AORTIC BALLOON PUMP Most widely used CIRCULATORY ASSIST DEVICE First used 40 years ago as a last result in patients in cardiogenic shock Today routinely used in a wide range of serious cardiovascular conditions Hemodynamic unstable patients Acute myocardial infarction (AMI) Cardiogenic shock High risk patients undergoing PCI M. Krishna, K. Zacharowski. Principles of intra-aortic balloon pump counter pulsation. Contin Educ Anaesth Crit Care Pain (2009) 9 (1): 24-28

12 INTRA-AORTIC BALLOON PUMP Aorta systolic pressure, diastolic pressure Left ventricle systolic pressure, end-diastolic pressure, volume, wall tension Heart afterload, preload, cardiac output M. Krishna, K. Zacharowski. Principles of intra-aortic balloon pump counter pulsation. Contin Educ Anaesth Crit Care Pain (2009) 9 (1): 24-28

13 INTRA-AORTIC BALLOON PUMP The primary goal of IABP: Improve the ventricular performance Facilitating an increase in myocardial oxygen supply Decreasing myocardial oxygen demand. IABP may also have favorable effects on right ventricular (RV) function Unloading the left ventricle Causing reduction in left atrial and pulmonary vascular pressures Decreases RV afterload. M. Krishna, K. Zacharowski. Principles of intra-aortic balloon pump counter pulsation. Contin Educ Anaesth Crit Care Pain (2009) 9 (1): 24-28

14 INTRA-AORTIC BALLOON PUMP IABP is not a true circulatory support device Not really a pump Does not contribute directly to cardiac output Only rapidly deployable support device available for decades R. Stretch, C. Sauer, D. Yuh, P. Bonde. National Trends in the Utilization of Short-Term Mechanical Circulatory Support -Incidence, Outcomes, and Cost Analysis. JACC (2014) VOL. 64, NO. 14.

15 THE BEST TREATMENT?

16 ASSISTANCE OR SUPPORT?

17 PERCUTANEOUS MECHANICAL LVADS CIRCULATORY SUPPORT DEVICES (LEFT VENTRICULAR ASSIST DEVICES)

18 LVADS Provide mechanical circulation when the heart cannot pump efficiently enough to maintain adequate cardiac output Used in the sickest patients: End-stage heart failure Heart failure after cardiac surgery High-risk cardiac surgery Severe Myocarditis Ventricular dysrhythmia High- Risk PCI Acute MI Sample, S. (2005). Technology today: left ventricular assist devices. Rn, 68(11),

19 LVADS Thoratec PVAD, ECMO Has always been reserved for emergency near-arrest situations. Significant morbidity and mortality associated with these devices Restricted their use to potential transplant candidates. R. Stretch, C. Sauer, D. Yuh, P. Bonde. National Trends in the Utilization of Short-Term Mechanical Circulatory Support -Incidence, Outcomes, and Cost Analysis. JACC (2014) VOL. 64, NO. 14.

20 LVADS Tandemheart Can be deployed in the cardiac cath lab. Can require a multitude of resources TEE/ ICE guidance Specialized training R. Stretch, C. Sauer, D. Yuh, P. Bonde. National Trends in the Utilization of Short-Term Mechanical Circulatory Support -Incidence, Outcomes, and Cost Analysis. JACC (2014) VOL. 64, NO. 14.

21 IMPELLA Worlds smallest pump Inserts like a pigtail catheter

22 IMPELLA Indications Cardiogenic Shock STEMI/ Cardiogenic Shock STEMI/ Urgent CABG Acutely decompensated CHF patients Temporary mechanical support patients with multi-organ failure Bridge to decision or Bridge to transplant Bridge to recovery High-Risk PCI

23 IMPELLA High-risk PCI Un-protected left main Single remaining vessel Compromised LV patients in cardiogenic shock

24 Why use it?

25 IMPELLA Insertion Inserts into femoral artery 13 Fr Sheath(Impella 2.5) 9 Fr catheter shaft Up to 2.5 L/ Min. 14 Fr (Impella CP) 9 Fr catheter shaft Up to 4L/ Min.

26 IMPELLA Protect 1 Trial Determine safety and efficacy of placement Patients having high-risk PCI, all with poor ventricular function Device was placed successfully on all patients None became hemodynamically unstable

27 IMPELLA PROTECT II TRIAL Results: High-risk population that underwent PCI Compared Impella with IABP Significantly lower MAE & MACCE at 90 days Major Adverse Events Major Adverse Cardiac and Cerebral Events

28 IMPELLA Study: STEMI complicated by cardiogenic shock on IABP No difference in 30-day mortality in patients with and without IABP No impact on 1-year mortality A. Dziewierz, Z. Siudak, T. Rakowski, et. al. Impact of intra-aortic balloon pump on long-term mortality of unselected patients with ST-segment elevation myocardial infarction complicated by cardiogenic shock. (2014) 10, 3 (37): , DOI: /pwki

29 IMPELLA Stretch Trial 1511% in use of MCS Correlate Length of Stay Mortality Hospital Costs 25% Cost/ LOS associated with IABP

30 CASE STUDY

31 CASE STUDY Impella CP was placed in Cardiac Cath lab MCVI Transferred to a transplant center A couple weeks post transfer Surgeon removed Impella CP from groin Replace with the Impella 5 - Axillary Allowed patient mobility Inpatient for a little over 2 months Discharged back to a normal life

32 CONCLUSION There are different choices & indications for LVADS No two patients are the same Operators decision Lots of data on the devices available Making the right decision what s best for their patient.

33 Thank you