IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem...
Transcript of IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem...
![Page 1: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/1.jpg)
IABP, Impella, Tandem Heart, ECMO: Compare & Contrast
Rajan Patel, MD FACC FAHA FSCAI
Interventional Cardiology Fellowship Program Director
Ochsner Medical Center
New Orleans, LA
![Page 2: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/2.jpg)
Disclosure
• Abiomed – advisory board
![Page 3: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/3.jpg)
•Access
•Sheath size
•Flow
•Hemodynamic effects
•Oxygenation
![Page 4: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/4.jpg)
IABP
4
![Page 5: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/5.jpg)
IABP
Percutaneous Access Femoral or axillary
Surgical Access Axillary or aortic
Sheath size 7.5Fr*
Flow ~0.75L*
Hemodynamic Effects
Preload
Afterload
Coronary flow
![Page 6: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/6.jpg)
Impella 2.5, CP, 5.0
6
![Page 7: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/7.jpg)
Impella RP
![Page 8: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/8.jpg)
Impella Devices
Impella 2.5 Impella CP Impella 5.0 RP
Percutaneous Access Site
Axillary or Femoral
Axillary or Femoral
NA* Femoral
Surgical Access Site
Axillary or Femoral
Axillary or Femoral
Axillary or Femoral
XXX
Sheath size 13Fr/ 9Fr 14Fr/9Fr 21Fr 22Fr/ 11Fr
Flow (L/min)
2.5 3.5* 5.0 > 4.0
Hemodynamics
Preload
Afterload
Coronary flow
![Page 9: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/9.jpg)
Impella Case
• 24 y/o woman h/o post-partum CM s/p AICD
• 2 weeks post-partum after 2nd child
• Transferred with cardiogenic shock
• CO = 1.8L/min
• PCWP = 35 mmHg
• Dobutamine 5mcg/kg/min
• Epi 0.04 mcg/kg/min
![Page 10: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/10.jpg)
Impella CP Placement
CO = 3.5PCWP = 18CVP = 10UOP
6 hours later…UOP CVP=20PAPi = 0.75
![Page 11: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/11.jpg)
Pulmonary Artery PulsitilityIndex (PAPi)
• PAPi = (PA systolic – PA diastolic) / CVP
• PAPi < 0.9 1 AMI < 1.85 2 surgical LVAD• Severe RV dysfunction
• Potential benefit for percutaneous RV support
1Korabathina R, Heffernan KS, Paruchuri V, et al. Catheter Cardiovasc Interv. 2012; 80(4);: 593-6002Morine KJ, Kiernan MS, Pham DT, Paruchuri V, Denofrio D, Kapur NK. J. Card. Failure. 2016. Feb 22(2): 110-6
![Page 12: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/12.jpg)
Impella Case
• Impella RP placed
• Improved hemodynamics and UOP
• 36 hours – lactate wnl
• 72 hours – creatinine wnl
• Day 5 extubated
• Day 6 listed status 1a
• Day 12 OHT
![Page 13: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/13.jpg)
Kuchibhotla S, Esposito ML, Breton C, Pedicini R, Mullin A, O'Kelly R, Anderson M, Morris DL, Batsides G, Ramzy D, Grise M, Pham DT, Kapur NK.J Am Heart Assoc. 2017 Oct 20;6(10)
![Page 14: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/14.jpg)
Tandem Heart: Left sided
![Page 15: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/15.jpg)
Protek Duo Cannula & Tandem Pump
![Page 16: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/16.jpg)
Tandem Heart
Left (Traditional) Right (Protek Duo)
PercutaneousAccess
Femoral Internal JugularVein
Surgical Access NA NA
Sheath size 21 Fr transeptal LA cannula
17 Fr CFA cannula
29Fr or 31 Fr
Flow 5 L/min
Hemodynamic Effects
Preload
Afterload
Coronary flow
![Page 17: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/17.jpg)
Tandem Heart Case
• 23 y/o woman h/o mitral stenosis
• Bioprosthetic MVR 2 years ago at outside hospital
• 2 weeks post-partum
• Transferred from rural hospital with cardiogenic shock
• Bi-ventricular failure
• Severe MS & moderate MR of bioprostheticmitral valve
![Page 18: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/18.jpg)
Epi 2mcg/kg/minDobutamine 5mcg/kg/min
MVO2 sat = 38%Lactate >12Creatinine 2.8
![Page 19: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/19.jpg)
Hemodynamics
• PCWP = 40 mmHg
• LVEDP = 22 mmHg
• PA = 60/40 mmHg
• Mean RA= 25
• PAPi = 0.8
![Page 20: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/20.jpg)
MCS Support Plan
• Bi-ventricular support
• Bridge to Transplant
![Page 21: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/21.jpg)
Left CFA
![Page 22: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/22.jpg)
Iliac Arteries
![Page 23: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/23.jpg)
Antegrade Access
Micro-puncture, ultrasound guided access
6Fr Sheath antegradedirection
Connect to Tandem 17Fr arterial cannula side-port using perfusion connector
![Page 24: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/24.jpg)
Transeptal Crossing
![Page 25: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/25.jpg)
Left Atrial Angiogram
![Page 26: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/26.jpg)
Final Set-up
![Page 27: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/27.jpg)
Tandem Heart Case
• 48 hours – lactate wnl
• 96 hours – creatinine wnl
• Day 7 extubated
• Day 8 listed status 1a
• Day 14 OHT
![Page 28: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/28.jpg)
Tandem Heart – RV Failure s/p LVAD
• 59 y/o man h/o ICM
• s/p Heartmate 2 placement
• Intra-op: RV dilated, poor flow on LVAD
• Increasing dobutamine and epi→minimal increase in LVAD flow
![Page 29: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/29.jpg)
59 y/o s/p LVAD with RV failure
![Page 30: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/30.jpg)
ECMO
• Venous - venous
• Venous - pulmonary artery (with left sided MCS)
• Venous – arterial
• Pump type• Roller• Centrifugal
• Oxygenator type• Polymethylpentene
• Vascular cannula size• Determine flow
Lequier L, et al. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2013;14(5 0 1):S7-12
![Page 31: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/31.jpg)
ECMO
31
![Page 32: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/32.jpg)
ECMO Systems
• Maquet
• Medos
• Sorin
• Thoratec (Abbott)
• TandemLife
![Page 33: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/33.jpg)
ECMO
Percutaneous Access CFA/ CFV
Surgical Access Open chest
Sheath size 17Fr/21Fr
Flow ≥ 5L/min
Hemodynamic Effects
Preload
Afterload
Coronary flow
![Page 34: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/34.jpg)
ECMO Case• 49 y/o woman with non-ischemic cardiomyopathy
• Diagnosed 10 years ago
• Being evaluated for OHT
• Presented to ED with worsening CHF ➔ rapidly deteriorated into cardiogenic shock
• Intubated for hypoxic respiratory failure
• Hypotensive
• UOP, Cr, T bili, Lactate on • dobutamine 5mcg/kg/min
• epi 0.08 mcg/kg/min
![Page 35: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/35.jpg)
Arterial 29 Fr Access
![Page 36: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/36.jpg)
Venous 32 Fr Access
![Page 37: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/37.jpg)
ECMO Case
• 1 hour - UOP 200cc/hr
• 24 hours – lactate normal
• 48 hours – creatinine normal
• 96 hours – T bili normal
• 5 days - extubated
• Listed 1a for OHT
• 10 days after admission - transplant
![Page 38: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/38.jpg)
EC-Pella
• LV venting with Impella during V-A ECMO• Decrease LVEDP
• Decrease afterload
![Page 39: IABP, Impella, Tandem Heart, ECMO: Compare & Contrast · 2018-12-01 · IABP, Impella, Tandem Heart, ECMO: Compare & Contrast Rajan Patel, MD FACC FAHA FSCAI Interventional Cardiology](https://reader030.fdocuments.us/reader030/viewer/2022040810/5e51ca0c9ce748347b4ade48/html5/thumbnails/39.jpg)
Summary
• Understand patient needs
• Know device options and limitations
• Select appropriate device
• Growing number of case reports
• Need for more good data• Pilot studies
• Clinical trials