Recognizing the Need to Support A Failing Right Ventricular Role of Mechanical Support Mahir Elder, MD, FACC,SCAI Medical Direct of PERT program Medical Director of Endovascular medicine Clinical Professor of Medicine Wayne State University-School of Medicine
Disclosures Abiomed Speakers Bureau BTG
Right Ventricular Failure - Definition Right ventricular chamber overload with contractile abnormalities resulting in compromised ability to deliver blood to the pulmonary circulation Multiple proposed parameters to diagnose RV failure & monitor RV function
Right Ventricular Failure - Parameters Parameters suggestive of RV dysfunction in acute PE Right atrial pressure (mean >5) Pulmonary artery pressure (Systolic > 25, Diastolic > 10) Pulmonary vascular resistance (> 1600 dynes-sec cm -5 ) Right Ventricular stroke work index (< 300 mmhg/ml/m 2 ) RA-to-PCWP ratio (>0.63) PAPi (<1)
Right Ventricular Failure Assessment, PAPi Pulmonary artery pulsatility index (PAPi) PAPi < 1 associated with in-hospital mortality with Inferior AMI (Sn 88.9%, Sp 98.3%) Catheter Cardiovascular Intervention, 2012 Oct 1;80(4):593-600 PAPi studied in LVAD recipients Found that it is an independent predictor of RV failure and the need for RVAD support after LVAD placement J. Heat Lung Transplantation, January 2016 Vol 35, Issue 1, Pages 67 73 No large randomized trial to study predictive value of PAPi in Acute Pulmonary Embolism
Proposed Parameters of Acute RV Failure CT / Echo showing RV/LV Ratio >1 McConnell s Sign Akinesis of mid Free wall and hypercontactile RV apex PA Pressure PA Systolic > 55 mmhg + BNP and/or Troponin Elevated CVP Systemic SBP < 90 PA O2 Saturation
Right Ventricular Failure - Mechanisms JACC, Vol. 56, No. 18, 2010
Cardiac Dysfunction Cascade
Clinical Cases
Case # 1 60 yr old man with history of DVT, off anticoagulation Presented to ER Respiratory Distress, swelling in R calf x 2d CT - massive PE : PESI 132 (class V, mortality 10 24.5% in 30 days), Echo shows McConnell s Sign BP 76/30 (lowest recorded)
Echo
CT Scan and Pulmonary angiogram
Mean RA 28, PA 65 /38, RV Failure with PaPi score of <1 B/L Ekos for 6 hours (total of 20mg TPA)- PE clot improved RV still in failure and hypotensive despite -IV Pressor Decision was made to support RV with RV impella
Step 1: Advancing Impella Sheath under fluoroscopy
Post CDT Oral NOAC Iv fluid RP Impella 2 days at 3.3 L/m on P6 D/C pressor Maintain B/P Recovery of RV function, PaPi Score 3.0 Mean RA 10, PA 40/10 Discharged home 3 month follow up-echo: Mild pulmonary HTN Normal RV/LV ratio and function
Case #2 presentation Chief Complaint 52 year old female who presented with exertional dyspnea for 3 days. History of Present Illness Recent admission for lower extremity cellulitis. finished two weeks course of cefipime and bactrim. Physical examination Unremarkable aside of sinus tachycardia.
Electrocardiogram + Sinus tachycardia. + Inverted T waves in V1-V3. - Left axis. - Lack of classic S1Q3T3. - No new RBBB.
Relevant lab results Creatinine 1.06 mg%, normal electrolytes. Troponin I- 0.434 ng%. Lactic Acid 2.8 mmoles/l. CBC: WBC 7.7 in mm3. Hb 9.5 gr%. PLT 241 in mm3. Risk stratification: PESI 109- moderate range. Modified PESI 8.9% risk of index admission mortality.
Computed Tomography Sub massive pulmonary embolism: the main right and left pulmonary arteries. Severe RV enlargement: RV/LV ratio >> 0.9.
Right heart cath- First day of admission RA: 16/18/17 mmhg. RV: 40/10/20 mmhg. PA: 39/23/30 mmhg. PAPI: PA pulse pressure / mean RA = 0.94. Cardiac output: 4.7 L/min. Cardiac index: 2.15 L/min/m2. Catheter mediated thrombolysis- Two EKOS catheter based ultrasonic filaments were placed into the right and left main pulmonary arteries.
Hemodynamic deterioration- Third day of admission Systolic blood pressure 86 mmhg. Heart rate 105 min. Reduced urine output. Respiratory rate 36 min. Right heart catheterization: RA: 19/24/23 mmhg. RV: 42/11/26 mmhg. PA: 41/28/33 mmhg. PAPI: PA pulse pressure / mean RA = 0.56. Impella RP insertion
Impella RP insertion Impella RP 23 French sheath into the IVC level Platinum plus 0.025 at the level of the left upper pulmonary vein.
Impella RP insertion Impella RP is advanced into the RA level Impella RP is in position
Impella RP for 6 days Marked hemodynamic improvement. Right heart catheterization before Impella removal: RA 18/22/21 mmhg. RV 49/14/20 mmhg. PA 48/31/37 mmhg. PAPI: 0.81. Patient was discharged after 20 days of admission.
Echocardiography Before Impella: Severe RV dilatation with reduction in FAC Impella RP day 4: Severe RV dilatation with mild improvement in FAC Post Impella: Severe RV dilatation with significant improvement in FAC
ACC-2017 O'Neil 37 pts @ discharge 80% survival 100% native heart
CARDIOGENIC SHOCK FLOW CHART 30 Reassess Hemodynamics via PAC prior to Discharge from the Cath Lab: 1. Cardiac Power Output (CPO) MAP CO/451 W 2. Pulmonary Artery Pulsatility Index (PAPi) spap-dpap/ra CPO < 0.6 CPO > 0.6 PAPi PAPi 1.5 > 1.5 1.5 > 1.5 RV Dysfunction: Right-sided MCS (Impella RP ) RV Preserved: Escalate MCS or consider transfer to LVAD/Transplant Center RV Dysfunction: Right-sided MCS (Impella RP) Persistent Hypoxemia? PaO 2 < 55 on 100% FiO 2 VA or VV-ECMO: Recommend maintaining Impella at low speed for LV decompression Ye s No Admit to ICU to maximize supportive care and to actively assess for myocardial recovery RV Failure as defined by Recover Right 1 : CI < 2.2 L/min/m 2 (despite continuous infusion of 1 high dose inotrope, ie, da/dobutamine 10 µg/kg/min or equivalent) and any of the following: 1. CVP > 15 mmhg, or 2. CVP/PCWP or LAP ratio >0.63, or 3. RV dysfunction on TTE (TAPSE score 14 mm) Anderson MB, et al. J Heart Lung Transplant. 2015;34(12): 15 49-1560. IMP-127-16
Impella RP in patients with Massive Pulmonary Embolism N. Blank; A. Kaki; M. Elder; W. Htun; T. Mohamad; T. Schreiber. Detroit Medical Center- Heart hospital
Impella RP in a series of 4 patients Four consecutive patients with Massive PE and RV Cardiogenic shock refractory to inotropes treated with RP Impella as bridge to recovery. Prior to Impella RP, all patients treated with EKOS/CDT.
Major parameters: Baseline (before Impella RP insertion): Cardiac index = 1.7 l/min/m2 (range 0.88-2.15). Mean pulmonary blood pressure = 42 mmhg (range 33-57) Impella RP used an average of 3.75 days (range of 1-6). During Impella RP treatment all patients improved clinically & hemodynamically: Cardiac index increased to 2.5 l/min/m2 (range 1.95-3.4), p=0.09 on day 1 Cardiac index increased to 3.1 l/min/m2 (range 2.76-3.7), p<0.05 at day 2. Echocardiography in two patients showed marked improvement in RV size and function. The other two patients had persistent severe RV dilation & hypokinesis. No significant change was found in renal function, hemoglobin and platelets level with Impella RP treatment. No patient required transfusion. One patient treated with Impella RP for 6 days had hemoglobin level drop from 13.7 to 7.3 gm/dl.
RV assessment by Echo at index day and follow up days 3-4
Vital signs and risk stratification. Before and after related to treatment with Impella RP.
Right heart catheterization before & after treatment with Impella RP
Mechanical RV Circulatory Support Impella RP Tandem Heart-Protek ECMO: V-V
Impella RP Indicated for providing circulatory assistance for up to 14 days in patients with a body surface area 1.5 m2 who develop acute right heart failure or decompensation following LVAD, myocardial infarction, heart transplant, or open-heart surgery.
TandemHeart Single IJ Access Double Venous Access - IJ/Femoral - Femoral/Femoral Common uses in Acute RV failure - Acute PE - RV infarction - RV dysfunction post-lvad - ARDS Double or Single Venous Access - In-flow from right atrium - Out-flow to pulmonary artery
ECMO V-V ECMO Refractory respiratory failure Modest cardiac or hemodynamic effects RV and LV pre- and after-load largely unaffected Potential decrease in RV afterload à improved oxygenation V-A ECMO Heart and Lung support RV pre-load and pulmonary flow LV afterload and arterial pulse pressure
Common Veno-Venous ECMO a) Femoral Jugular Cannulation b) Bicaval dual lumen cannulation of right internal jugular c) Femoral Femoral Cannulation. Avalon Cannula Simon J. Finney Eur Respir Rev 2014;23:379-389 2014 by European Respiratory Society
V-A and V-VA ECMO a) Venoarterial ECMO b) Venovenous Arterial ECMO Simon J. Finney Eur Respir Rev 2014;23:379-389 2014 by European Respiratory Society
Impella RP Tandem Heart V-V ECMO (CentriMag) Mechanism Micro-axial Centrifugal Centrifugal Centrifugal V-A ECMO (CentriMag) Cannula Size 24F Peel away, 9Fr catheter 29-31Fr Dual Lumen 31Fr Dual lumen or 18-22 Fr. Single in/outflow 14-16 Fr Arterial 18-21 Fr Venous Insertion Technique Single femoral vein, 9Fr catheter remains in vein Dual lumen IJ IJ dual lumen or fem vein and IJ Peripheral or Central Hemodynamic Support >4 L/min maximum flow Up to 5 L/min Up to 4.5L/ min 5 L/min Implantation Time + +++ + ++ Device Preparation Time + ++ +++ +++ Anticoagulation ++ +++ +++ +++ Post Implant Management + ++ +++ +++ Hemolysis Risk + + ++ ++ Respiratory Support No Yes Yes Yes Risk of Hemolysis + + ++ ++ Pros Single access site BiVAD possible with escalation Ambulate (neck) Oxygenation -+++ Hemodynamic support Oxygenation +++ Cons No intrinsic oxygenator Long insertion time High Transfusion rates Transseptal (LA-FA bypass) No Hemodynamic support LV Distension Vascular complications, SIRS Transfusion (bleed) 23Fr
Conclusion: There are several proposed criteria for assessing RV failure Critical to Recognition of RV failure as an etiology for patient deterioration Time sensitive- implementation of medical & invasive strategies to treat RV failure Several invasive mechanical options are available to offload RV Promote RV recovery and stabilize patients Impella RP provides mechanical circulatory support in PE patients complicated by acute refractory right heart failure despite CDT. Low adverse events rates observed in this small series Tandem Heart ECMO Further study is warranted