Cardiac assistance: role of haemodynamics January 14 th, 2016 8h30-10h.

Cardiac assistance: role of haemodynamics

January 14th, 20168h30-10h

What is (are) the correct proposition(s) about LVAD ?

A) Long-term LVAD decreases cardiac myocytes hypertrophy

B) Decreases SRAA activation at the cellular level

C) Favors left ventricle inverse remodeling

D) Inverse remodeling with continuous flow is > pulsatile flow

E) Despite inverse remodeling at the cellular level, myocardial repair with LVEF normalization is scarce

Kato T et al. Circ Heart Fail 2011; 4: 546

Inverse LV remodeling : comparison between pulsatile (P) and continuous (C) flow LVAD

Echocardiographic data evolution(n=61 patients):

What are the predictive factors of good prognosis after LVAD leading to withdrawal?

A) A younger age

B) Non ischemic aetiology (e.g idiopathic DCM)

C) A shorter length of LVAD

D) A continuous flow LVAD versus pulsatile flow

E) Faith

What are the predictive factors of good prognosis after LVAD leading to withdrawal?

A) A younger age

B) Non ischemic aetiology (e.g idiopathic DCM)

C) A shorter length of LVAD

D) A continuous flow LVAD versus pulsatile flow

E) Faith

Of note: LVAD withdrawal= 25% after pulsatile flow versus 3.3% after continuous flow

Krabatsch T et al. Ann Thor Surg 2011; 91: 1335)

Which anticoagulant and antiagregant treatment after HeartMate II or HeartWare?

A) AVK (INR 2-3)

B) AVK (INR 2,5 à 3,5)

C) AVK (INR 2-3) + aspirin

D) AVK (INR 2-3) + aspirin + clopidogrel

E) Aspirin + clopidogrel

INR range after HeartMate II or HeartWare

Device INR rangeAbioCor TAH 2.5-3.5HeartMate II 2.0-3.0HeartWare HVAD 2.0-3.0MicroMed DeBakey 2.5-3.5Syncardia TAH 2.5-3.5Thoratec IVAD 2.5-3.5Thoratec PVAD 2.5-3.5

a) Cournand

b) Rickets et Abrams

c) Gruentzig

d) Campeau

e) Igaki-Tamai

Match the discovery and their discoverer(s)

1) development of the radial route

2) 1st bioabsorbable coronary stent implantation

3) conception of the 1st intra-arterial probe

4) 1st coronary balloon angioplasty

5) 1st coronary angiography through percutaneous transfemoral approach

C: a3; b5; c4; d1; e2

B: a1; b4; c5; d3; e2

A: a4; b5; c3; d1; e2

D: a5; b2; c4; d1; e3

1) Gruentzig : 1st coronary balloon angioplasty

2) Igaki-Tamai : 1st bioabsorbable coronary stent implantation

3) Cournand : conception of the 1st intra-arterial probe

4) Campeau : development of the radial route

5) Rickets et Abrams : 1st coronary angiography through percutaneous transfemoral approach

And now classify them by chronologic order!Oldest

NewestC: 3; 5; 4; 1; 2

D: 1; 4; 5; 3; 2

A: 1; 2; 3; 4; 5

B: 3; 5; 1; 4; 2

Cournand : conception of the 1st intra-arterial probe

Rickets et Abrams : 1st coronary angiography through percutaneous transfemoral approach

Gruentzig : 1st coronary balloon angioplasty

Campeau : development of the radial route

Igaki-Tamai : 1st bioabsorbable coronary stent implantation

And now classify them by chronologic order!

1941

1962

1977

1989

1999

What is (are) the contra-indication(s) to LVAD implantation?

A) Aortic bioprosthesis

B) Aortic mechanical prosthesis

C) Mitral bioprosthesis

D) Mitral mechanical prosthesis

E) Patent foramen ovale (PFO)

Explanations

Aortic mechanical prosthesis: risk of thrombosis due to decreased transprothetic flow

Patent foramen ovale (PFO): refactory hypoxemia due to a right-left shunt induced by LV discharge

Patient with HFpEF Vs HFrEF are more frequently:

A) Men

B) Obese

C) In atrial fibrillation

D) With a coronary artery disease

E) Anemic

Characteristics Reduced EF (n=2429)

Preserved EF (n=2167)

P Value

Age (yr) 71.7±12.1 74.4±14.4 <0.001

Male sex (%) 65.4 44.3 <0.001

Obesity (%) 35.5 41.4 0.007

Hemoglobin on admission (g/dl) 12.5±2.0 11.8±2.1 <0.001

Coronary artery disease (%) 63.7 52.9 <0.001

Atrial fibrillation (%) 28.5 41.3 <0.001

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Adapted from Owan TE, NEJM 2006;355:251-59

Patient with HFpEF Vs HFrEF are more frequently:

Which proposition(s) about fractional flow reserve (FFR) is/are correct?

A) FFR= Aortic pressure/ distal coronary pressure

B) FFR between 0.6 and 0.8= grey zone, no diagnosis

C) FFR < 0.8 = ischemia

D) FFR measurement must be done when the valves are closed

E) FFR measurement must be done after Risordan injection

Which proposition(s) about fractional flow reserve (FFR) is/are correct?

A) FFR= Aortic pressure/ distal coronary pressure

B) FFR between 0.6 and 0.8= grey zone, no diagnosis

C) FFR < 0.8 = ischemia

D) FFR measurement must be done when the valves are closed

E) FFR measurement must be done after Vasopressin injection

FFR in practice

Tonino et al JACC 2010 - De Bruyne FAME 2 Nejm 2014

FFR : major role for coronary lesion functional classification

In which situations should we decrease the speed of the LVAD pump?

A) Digestive Haemorrhage

B) Sepsis

C) No aortic cusps opening

D) Suction phenomenon

E) Suspicion of pump thrombosis

Explanations

Digestive Haemorrhage: decrease of shear stress may be responsible for acquired Willebrandt syndrom

No aortic cusps opening : risk of cusps fusion with thrombosis

Suction phenomenon: favoured by hypovolemia in case of too high speed of pump

Cardiac assistance: role of haemodynamics January 14 th, 2016 8h30-10h.

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