When Right Ventricular Failure may become a VAD Failure

When Right Ventricular Failure may become a When Right Ventricular Failure may become a VAD FailureVAD Failure

When Right Ventricular Failure may become a When Right Ventricular Failure may become a VAD FailureVAD Failure

Dept. of Cardiothoracic Surgery

Medical University of Vienna

G. M. WieselthalerG. M. Wieselthaler

G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009

-- VAD is established therapy for terminal heart failure

-- 85% of implanted pumps are LVADs

-- natural right ventricular function is the trigger for the LVAD

-- evaluation of right ventricular function in end-stage HF patients

is difficult

-- severe tricuspid insufficiency complicates evaluation process

-- acute right heart failure after LVAD highest peri-operative mortality

Right Ventricular Failure and VAD


Evaluation methods for native right ventricular function:

-- echocardiography

-- ECG gated MRI

-- vaso-active right heart catheterization

Right Ventricular Failure and VAD


Echocardiography:

Pre LVAD

Post LVAD

Evaluation of Right Ventricular Function


Echocardiography:



MRI:

Z. F. 61 a, idiopath. CMP



MRI:

W.K., 56 a, isch. CMP + PH



MRI:

W. K., 56 a, isch. CMP + PH




Hemodynamic Testing before LVAD Implantation in 4 Patients

Baseline Nitro BolusAfter Simdax

2 hours

HR (b/min) 76 ± 11 72 ± 11 80 ± 12

MAP (mmHg) 81 ± 25 79 ± 21 79 ± 23

PAP (mmHg) 45 ± 7 35 ± 6 39 ± 5

PCWP (mmHg) 31 ± 6 17 ± 6 16 ± 1

CVP (mmHg) 17 ± 4 7 ± 2 10 ± 3

CO (L/min) 3,4 ± 0,7 4,3 ± 1,1 4,2 ± 1

SvO2 (%) 41 ± 12 65 ± 3 55 ± 8

Wood U 4,4 ± 1,2 4,5 ± 0,8 5,5 ± 1,5


Patient 2: K. R. m, 66 a, 172 cm/92kg

Dg: isch CM since 2002, St.p. anterior wall infarct, St.p. AICD 5/2005Dg: isch CM since 2002, St.p. anterior wall infarct, St.p. AICD 5/2005 art. Hypertonie, COPDart. Hypertonie, COPD

repeted repeted Levosimendan-infusionsLevosimendan-infusions

Tx: Blopress 16 mg 1/2, Concor 5mg 1/2, Lasix 40 mg 1-1, Spirobene ,Restex, Tx: Blopress 16 mg 1/2, Concor 5mg 1/2, Lasix 40 mg 1-1, Spirobene ,Restex, Seretide, Berodual, MarcoumarSeretide, Berodual, Marcoumar

Lab: Crea 2.0 mg/dl, Bili 2.0 mg/dl, Lab: Crea 2.0 mg/dl, Bili 2.0 mg/dl, Lab preop: Crea 1,15 mg/dl, Bili 1,95 mg/dlLab preop: Crea 1,15 mg/dl, Bili 1,95 mg/dl Right heart catheter vom 29.12.2005:Right heart catheter vom 29.12.2005:

mPAP 52, PCWP 28, CO 5.2, Wood U 4,6mPAP 52, PCWP 28, CO 5.2, Wood U 4,6 Echo: highly reduced LVF EF 10%, EED 8.7 cmEcho: highly reduced LVF EF 10%, EED 8.7 cm




BaselinBaselin

Nach Nach PerlinganiPerlinganit Bolus t Bolus i.v.i.v.

Nach 3 Nach 3 Stunden Stunden PGEPGE22

Nach Nach Anästhesie Anästhesie EinleitungEinleitung

PostoperativPostoperativ15 Stunden 15 Stunden postoperativpostoperativ

HRHR 9090 8787 9292 6060 104104 104104

MAPMAP 7979 7171 7676 7575 7171 7878

mPAPmPAP 5050 3838 4747 4343 2323 2121

CVPCVP 1010 88 99 1212 1212 1111

PCWPPCWP 2929 1919 3535 2121 44 55

COCO 3,93,9 5,15,1 4,34,3 4,54,5 5,45,4 4,94,9

SvO2SvO2 4949 5757 4949 5555 6767 7272

PVRPVR 430430 298298 223223 391391 281281 261261

TPGTPG 2121 1919 1212 2222 1919 1616

Wood UWood U 5,4 3,7 2,8 4,94,9 3,53,5 3,23,2

Pro BNPPro BNP 40204020 64116411 43564356 40494049



General exclusion criteria for VAD implantation:General exclusion criteria for VAD implantation:

absolute contraindications:absolute contraindications: - BUN > 100 mg / l or s-creatinine > 5,0 mg/dl- BUN > 100 mg / l or s-creatinine > 5,0 mg/dl - total bilirubin > 5 mg/ dl- total bilirubin > 5 mg/ dl - active infection- active infection - anamnestic coagulopathy- anamnestic coagulopathy - tumor anamnesis (bridge to transplant)- tumor anamnesis (bridge to transplant) - cerebrovascular disease- cerebrovascular disease - aortic disease- aortic disease

relative contraindications:relative contraindications:

- parenchymatous lung disease (Sarcoidosis)- parenchymatous lung disease (Sarcoidosis) - fixed pulmonary hypertension- fixed pulmonary hypertension - mechanical heart valve- mechanical heart valve - heparin intolerance (HIT)- heparin intolerance (HIT)


2007 in press

Mechanical Circulatory SupportMechanical Circulatory Support


fixed pulmonary hypertension and LVADfixed pulmonary hypertension and LVAD


10 Patients for LVAD Implantation

After Induction

After CPB

OR End postop6 hours postop

12 hours postop

24 hours postop

HR (b/min) 69 ± 24 105 ± 12 109 ± 10 114 ± 14 114 ± 12 110 ± 17 113 ± 14

MAP (mmHg) 68 ± 6 68 ± 7 65 ± 7 72 ± 5 76 ± 4 72 ± 5 68 ± 2

mPAP (mmHg) 37 ± 4 27 ± 5 27 ± 4 27 ± 4 25 ± 5 23 ± 3 28 ± 7

PCWP (mmHg) 24 ± 7 11 ± 4 10 ± 2 14 ± 5 8 ± 0,8 11 ± 3 11 ± 2

CVP (mmHg) 17 ± 5 10 ± 3 11 ± 3 10 ± 2 11 ± 1 12 ± 3 11 ± 3

CO (L/min) 3,7 ± 1 5,7 ± 0,7 5,6 ± 0,7 4,7 ± 0,7 5,4± 0,5 5,6 ± 0,1 4,8 ± 0,3

SvO2 (%) 58 ± 14 70 ± 3 68 ± 4 68 ± 4 66 ± 4 64 ± 8 66 ± 5

Wood U 3,6 ± 1,2 3 ± 1,2 3,1 ± 0,9 2,9 ± 0,9 3,2 ± 1,1 2,9 ± 0,3 3,3 ± 1,5



After Induction

After CPB OP End postop6 hours postop

12 hours postop

24 hours postop

Dobutamin (µg/kg/min)

3,1 12 11,4 11,2 6,8 7,1 7,5

Levosimendan (µg/kg/min) 0,2 0,2 0,2 0,2 0,2 0,2 0,2

Norepinephrine (µg/kg/min)

0,07 0,14 0,22 0,26 0,03 0,05 0,04

Nitric Oxide (ppm) 10 10 10 10

10 Patients for LVAD Implantation

1 Patient additionally had Milrinone intraoperatively, 3 Patients postoperatively2 Patients needed Nitroglycerin postoperatively, 1 Patient was switched from to Nitro to Urapidil



180 patients Heart Mate39% RHF14 Patiens RVAD

Right Heart Failure and LVADRight Heart Failure and LVAD



245 patients 9% RVAD (23 patients)


100 Patients Heart Mate LVAD

In 11 RVAD



Adverse EventAdverse EventDuraHeart DuraHeart (n=33)(n=33)

18 pt-yrs18 pt-yrs(mean:197 days)(mean:197 days)

HM VEHM VE1 1 (n=280)(n=280)


HM IIHM II2 2 (n=133)(n=133)


Bleeding requiring surgeryBleeding requiring surgery 0.220.22 1.471.47 0.780.78

Driveline/pocket infectionDriveline/pocket infection 0.400.40 3.493.49 0.370.37

StrokeStroke 0.28 0.28 0*0* 0.440.44 0.190.19

Non-stroke neurologicNon-stroke neurologic 0.280.28 0.23*0.23* 0.670.67 0.260.26

RHF requiring RVADRHF requiring RVAD 0.060.06 0.30.3 0.080.08

Device thrombosisDevice thrombosis 00 NANA 0.030.03

Pump mechanical failurePump mechanical failure 00 0.030.03 00

HemolysisHemolysis 00 00 0.060.06

1.1. Frazier OH, et al. J Thoracic Cardiovasc Surg 2001;122:1186-95.Frazier OH, et al. J Thoracic Cardiovasc Surg 2001;122:1186-95.2.2. Miller LW, et al. NEJM 2007;357:885-96.Miller LW, et al. NEJM 2007;357:885-96.

Comparison of Adverse Event Rates (per pt-yr) Comparison of Adverse Event Rates (per pt-yr) DuraHeart vs. HM VE vs. HM IIDuraHeart vs. HM VE vs. HM II

As of June 15, 2007

**Event rate after implementing less intensive anticoagulation (n=22, 13 pt-yrs)Event rate after implementing less intensive anticoagulation (n=22, 13 pt-yrs)


HeartWare HVAD multi-institutional trial

ComplicationComplication Patients Patients Events Event Events Event RateRate

n n n n per pt yr per pt yr

Infections (exit site) Infections (exit site) 3 3 3 3 0.28 0.28

Bleeding (requiring re-operation) 3 Bleeding (requiring re-operation) 3 4 4 0.37 0.37

Respiratory DysfunctionRespiratory Dysfunction 4 4 4 4 0.37 0.37

Renal DysfunctionRenal Dysfunction 3 3 3 3 0.28 0.28

Right Heart FailureRight Heart Failure 1 1 1 1 0.09 0.09

At 180 daysadverse events in first 23 implants:

G.M.Wieselthaler et al, JHLT 2009 submitted


Continuous unloading of left ventricle can cause shift of thined, free lateral ventricularContinuous unloading of left ventricle can cause shift of thined, free lateral ventricular

wall and results in reduced pump-flows & can provoke suctionwall and results in reduced pump-flows & can provoke suction



thin & flexing interventricular septum in a patient with dilative CMPthin & flexing interventricular septum in a patient with dilative CMP



-- in a patient with a thin & flexing interventricular septum-- in a patient with a thin & flexing interventricular septum

-- leads to shift of interventricular septum to the left side & increased TI with -- leads to shift of interventricular septum to the left side & increased TI with consecutive right ventricular failureconsecutive right ventricular failure




LVAD vs. BiVAD:

-- extended infarct areas (RCA) -- consider BiVAD -- extended infarct areas (RCA) -- consider BiVAD

-- patients with malignant arrythmias benefit from BiVAD-- patients with malignant arrythmias benefit from BiVAD

-- patients in prolonged cardiogenic shock always BiVAD-- patients in prolonged cardiogenic shock always BiVAD

-- Patients with two- or multi-organ failure always BiVAD-- Patients with two- or multi-organ failure always BiVAD



Conclusion:

-- evaluation of native right ventricular function is very difficult and still challenging

-- preservation of right ventricular function in medical heart failure therapy should be the main target

-- as soon as native right ventricular function starts to decrease refer patient for surgical evaluation (transplant // bridge to transplant) = vaso-active RHC !!

-- try to avoid last option “BiVAD”

-- quality of life on a LVAD is ten times better than on a BiVAD

When Right Ventricular Failure may become a VAD Failure

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