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
Right Heart Failure Always Worsens Mortality
RV Function in Shock is Poorly Understood RV Shock is just as bad as LV Shock Jacobs A et al. JACC 2003
Why is Univentricular Shock Uncommon? The RV is Highly Sensitive to Increased Afterload Haddad and Hunt et al. Circulation 2008;117;1717-1731
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;125:289-297
PA Pressure Alone is an Insufficient Marker of RV Failure in PH and Heart Failure
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 0.0136 PAD - PCWP Undetermined [36, 37] <15 (RVF after LVAD) [16] <10 (RVF after Acute MI) [40] RV Stroke Work Index (mpa-ra)/ SV Index <0.3-0.6 (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
From Pulsatile Load to PA Pulsatility RAP = 22 RAP = 15 RAP = 7 Kiernan and Kapur. JIC 2009
Hemodynamic Signatures of RV Failure The Pulmonary Artery Pulsatility Index (PAPi) PAPi PA Pulse Pressure (Systolic Diastolic) CVP (RA Pressure) Korabathina & Kapur CCI 2012
Kapur, Esposito and Burkhoff et al Circulation 2017 Not All RV AMCS Devices are Created Equal Note: IABPs are not RV AMCS devices
Kapur et al Circulation 2017 Not All RV AMCS Devices are Created Equal Direct RV Bypass (RA PA) Indirect RV Bypass (RA AO)
TandemHeart in Right Ventricular Failure prvad = 3.4+0.5 LPM srvad = 4.9+1.0 LPM Kapur NK et al. JACC Heart Failure 2013
Kapur et al JHLT 2012 Percutaneous Support for RV Failure 9 patients with MR-RVF between 2008-2010 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
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
Percutaneous Support for RV Failure Size 22 Fr pump on an 11 Fr catheter Flows > 4 L/min Impella RP Implant RECOVER RIGHT TRIAL
The 8 Minute RVAD Implant The 8 Minute RVAD Explant
Dynamics of 3D Construction of the RP Torque Not Push for Delivery
Direct RV Bypass: Impella RP for Acute RVF Kapur, Esposito and Burkhoff et al Circulation 2017
Not All RV AMCS Devices are Created Equal Direct RV Bypass (RA PA) Indirect RV Bypass (RA AO)
Indirect RV Bypass: VA-ECMO for Acute RVF Kapur, Esposito and Burkhoff et al Circulation 2017
Anderson M et al. JHLT 2015
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
Thank you nkapur@tuftsmedicalcenter.org To Learn More about Acute MCS & Hemodynamics December 15-16 2017 Berlin, Germany Interventional Heart Failure August 24-25, 2017: Barcelona, Spain