Acute Mechanical Circulatory Support Right Ventricular Support Devices
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1 Acute Mechanical Circulatory Support Right Ventricular Support Devices Navin K. Kapur, MD, FACC, FSCAI, FAHA Associate Professor, Department of Medicine Interventional Cardiology & Advanced Heart Failure Programs Executive Director, The Cardiovascular Center for Research & Innovation
2 Right Heart Failure Always Worsens Mortality
3 RV Function in Shock is Poorly Understood RV Shock is just as bad as LV Shock Jacobs A et al. JACC 2003
4 Why is Univentricular Shock Uncommon? The RV is Highly Sensitive to Increased Afterload Haddad and Hunt et al. Circulation 2008;117;
5 Hemodynamics of the RV-PA-LV Axis Effect of elevated pulmonary capillary wedge pressure (PCWP) on pulmonary vascular resistance-compliance relationship (RPA-CPA). Pulm. Venous Congestion PCWP = PA Compliance PA Resistance Tedford R J et al. Circulation 2012;125:
6 PA Pressure Alone is an Insufficient Marker of RV Failure in PH and Heart Failure
7 Hemodynamic Formulas to Assess RV Function Cardiac Filling Pressures PA Pulsatility Index Pulmonary Vascular Resistance RA / PCWP (PASP-PADP) / RA >0.63 (RVF after LVAD) [14] >0.86 (RVF in Acute MI)[31] <1.85 (RVF after LVAD) [42] <1.0 (RVF in Acute MI) [41] mpa-pcwp / CO >3.6 (RVF after LVAD) [16] Trans-pulmonary Gradient mpa-pcwp Undetermined [36] Diastolic Pulmonary Gradient RV Stroke Work (mpap-ra) x SV x PAD - PCWP Undetermined [36, 37] <15 (RVF after LVAD) [16] <10 (RVF after Acute MI) [40] RV Stroke Work Index (mpa-ra)/ SV Index < (RVF after LVAD) [14,42] Pulmonary Artery Compliance Pulmonary Artery Elastance SV / (PASP-PADP) <2.5 (RVF in Chronic Heart Failure) [39] PASP/ SV Undetermined [38] Right atrial (RA); Pulmonary artery (PA); PA systolic pressure (PASP); PA diastolic pressure (PADP); mean PA pressure (mpap); Pulmonary capillary wedge pressure (PCWP); Right ventricular failure (RVF); Left ventricular assist device (LVAD); Myocardial infarction (MI); Stroke volume (SV) Kapur, Esposito, and Burkhoff et al Circulation 2017
8 From Pulsatile Load to PA Pulsatility RAP = 22 RAP = 15 RAP = 7 Kiernan and Kapur. JIC 2009
9 Hemodynamic Signatures of RV Failure The Pulmonary Artery Pulsatility Index (PAPi) PAPi PA Pulse Pressure (Systolic Diastolic) CVP (RA Pressure) Korabathina & Kapur CCI 2012
10 Kapur, Esposito and Burkhoff et al Circulation 2017 Not All RV AMCS Devices are Created Equal Note: IABPs are not RV AMCS devices
11 Kapur et al Circulation 2017 Not All RV AMCS Devices are Created Equal Direct RV Bypass (RA PA) Indirect RV Bypass (RA AO)
12 TandemHeart in Right Ventricular Failure prvad = LPM srvad = LPM Kapur NK et al. JACC Heart Failure 2013
13 Kapur et al JHLT 2012 Percutaneous Support for RV Failure 9 patients with MR-RVF between received a TandemHeart RV support device. Etiologies included sepsis, post-cardiotomy, and acute RVMI Five underwent RIJ-to-femoral, four femoral-to-femoral Earlier support = better outcomes
14 TandemHeart in Right Ventricular Failure (THRIVE) Major Predictors of In-hospital Mortality 1. Advanced Age 2. Biventricular Failure 3. TIMI Major Bleeding Kapur NK et al. JACC Heart Failure 2013
15 Percutaneous Support for RV Failure Size 22 Fr pump on an 11 Fr catheter Flows > 4 L/min Impella RP Implant RECOVER RIGHT TRIAL
16 The 8 Minute RVAD Implant The 8 Minute RVAD Explant
17 Dynamics of 3D Construction of the RP Torque Not Push for Delivery
18 Direct RV Bypass: Impella RP for Acute RVF Kapur, Esposito and Burkhoff et al Circulation 2017
19 Not All RV AMCS Devices are Created Equal Direct RV Bypass (RA PA) Indirect RV Bypass (RA AO)
20 Indirect RV Bypass: VA-ECMO for Acute RVF Kapur, Esposito and Burkhoff et al Circulation 2017
21 Anderson M et al. JHLT 2015
22 Kapur, Esposito and Burkhoff et al Circulation 2017 Conclusions 1. Afterload is a major determinant of RV Output 2. RV AMCS devices are not created equal (Direct vs Indirect RV Bypass) 3. RV Output is a major determinant of LV Output 4. Early identification of RVF and early use of RV AMCS improves outcomes. Don t hang your hat on a number. 5. Look for hemodynamic signs of Bi-V failure when managing cardiogenic shock
23 Thank you To Learn More about Acute MCS & Hemodynamics December Berlin, Germany Interventional Heart Failure August 24-25, 2017: Barcelona, Spain
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A Randomized Clinical Study To Compare The Intra-Aortic Balloon Pump To A Percutaneous Left Atrial-To-Femoral Arterial Bypass Device For Treatment Of Cardiogenic Shock Following Acute Myocardial Infarction.
Acute peri-operative. Alexandre Mebazaa, Hôpital Lariboisière, Université Paris 7 U942 Inserm
Acute peri-operative left heart failure Alexandre Mebazaa, Hôpital Lariboisière, Université Paris 7 U942 Inserm Conflict of Interest Lecture fee: Orion No other conflicts for this lecture Acute peri-operative