Cardiologist Chris Hayward talks about LVAD (Left ventricular assist devices) for the Sydney Intensive Network. The audio is found on www.intensivecarenetwork.com

1. Mechanical Circulatory Support
Indications / contraindications
Devices and Outcomes
Christopher Hayward
Cardiologist
Heart Failure Transplant Unit

2. Stevenson Circ 2005

3. LVAD indications
Need LVAD - Bridge to transplant, destination or recovery
NYHA IV for 60–90 days
Maximal tolerated medical therapy +/- CRT / ICD
Chronic inotrope dependence
LVEF <25%, PCWP 20 mmHg
SBP 80–90 mm Hg or CI 2 L/min/m2 or renal or RV function
Consider LVAD
NYHA IV for 30 days
Maximal tolerated medical therapy and CRT/ICD if indicated
Intermittent inotrope dependence
LVEF <25%, Peak VO2 <12 mL/kg/min
Indication to enable HTx
PVR <5 Woods units, reversible secondary PHT to chronic HF
Reversible GFR <25–30 mL/min/1.73 m2
Lund et al EJHF 2010

4. Contraindications
Cardiac issues
Non-systolic HF
Cor pulmonale, Severe RV dysfunction or Multi-organ failure
Moderate or severe aortic regurgitation that will not be corrected
Mechanical aortic valve that will not be converted to bioprosthesis
Hypertrophic cardiomyopathy, VSD or congenital heart disease
Non-cardiac issues
Terminal co-morbidity; e.g. renal disease (haemodialysis or Crt > 250umol/L)
Metastatic or advanced cancer, severe liver disease, severe lung disease or home O2,
severe PVD, or unresolved CVA or severe neuromuscular disorder
Active uncontrolled systemic infection or risk of infection
Active severe bleeding / platelet count <50 000 x109/L, HITTS
Management issues
Intolerance to the anticoagulant regimen specific to device
Body surface area 1.2–1.5 m2 or other dimensional or technical limitation
Inability to grasp risks and benefits and provide informed consent / interpret alarms
Psychosocial limitations, driveline / medication non-compliance
Lund et al EJHF 2010

5. HeartMate I & II
Slaughter et al NEJM 2009

6. HeartMate XVE
HeartMate II

7. HeartMate XVE / II Survival
REMATCH
medical therapy
Medical therapy
Rose et al
NEJM 2001
Slaughter et al
NEJM 2009

8. LVAD implants
Kirklin et al INTERMACS-5. J Heart Lung Transplant 2013

9. INTERMACS Level Pre-Implant
for 1092 Primary LVAD (June 2006–March 2009)
n
%
1
Critical cardiogenic shock
328
30
2
Progressive decline
437
40
3 Stable but inotrope dependent
168
15
4
Recurrent advanced HF
106
10
5
Exertion intolerant
21
2
6
Exertion limited
12
1
7
Advanced NYHA III
20
2
Kirklins et al INTERMACS 2. JHLT 2010

10. HeartWare HVAD
Wieselthaler et al JHLT June 2010

11. VentrAssist
HeartWare

12. HeartWare
Aaronson et al Circulation 2012

13. ADVANCE Trial

14. HVAD ADVANCE Trial
Day/Month/Year
Footnote to go here
Page 14

15. • Medical history
•
•
•
Aetiology HF
Hospitalisations
Past chest surgery
• Treatment
•
•
•
Medications
Devices
ICU support
• Risk of RV failure
•
•
•
Echo – RV function
RHC – PHT
RVSWI
• Outcome Risks
•
•
•
•
Day/Month/Year
Footnote to go here
Renal function
Bleeding risk
Infection risk
Social support
Page 15

16. LVADs and daily activities
Hu et al J Cardiac Failure 2013

17. LVADs and daily activities
Hu et al J Cardiac Failure 2013

18. Maximum pacing rate
140
p=0.001
120
100
p=0.58
80
p=0.88
60
40
p=0.91
20
0
Baseline
Max HR
HR (bpm)
85.5
126.1
FLOW
(L/min)
5.22
5.16
MAP
(mmHg)
75
72.6
LVEDD
(mm)
55
53.9
Muthiah et al. ASAIO 2012

19. Posture and pump flow
Muthiah et al ISHLT 2013

20. Pump power (W)
Pump flow estimate (L/min)
Pump thrombosis and Rx
12
8
4
0
6
5
4
Baseline
Thrombosis
Tirofiban
30mins
Tirofiban
20 hrs
Prethrombolysis
Post
thrombolysis
20 seconds
Alteplase 15mg
Muthiah et al Artificial Organs 2013

21. St Vincent’s Hosp MCS program
145 patients
• 36 pulsatile LVAD (HeartMate VE, XVE)
• 104 continuous flow LVAD (33 Ventrassist, 71 HeartWare)
• 5 Total artificial hearts
25
Survival
1
20
0.9
TAH
CF
Puls
15
0.8
0.7
0.6
0.5
10
0.4
0.3
5
0.2
0.1
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
0
1994
0
0
100
200
300
400
500
600
700
Days On Pump
CF
Puls
TAH
As at June 30 2013

22. St Vincent’s Hosp MCS program
105 cfLVAD patients
• 33 Ventrassist, 72 HeartWare
• (5 Syncardia total artificial hearts)
25
• 7 Bi-VAD systems
LVAD
TAH
BiVAD
20
15
10
5
0
04-05 05-06 06-07 07-08 08-09 09-10 10-11 11-12 12-13 13-14
As at Aug 20 2013

23. BiVAD

24. BiVAD CXR

26. Cardioversion

27. The Future
MVAD 1/3 size of HVAD
no need for median sternotomy
same impeller technology
promising in animal studies
IV-VAD 1/10 size of HVAD
Intravascular pump – percutaneous
Not intended to provide full cardiac support
TETS - Transcutaneous Energy Transfer
System
Implanted battery pack to be charged across the skin
Will eliminate need for drivelines