1. Assistances Circulatoires: actualités
Pr Boumzebra

2. .
Mechanical Device which is used to replace or reproduce the pump function of the left and/or right ventricle
heart transplant: treatment of choice for treating heart failure patients with end-stage
Disproportion between the number of available grafts and the number of transplant candidates => Development of artificial hearts, partial and total
encouraging results of the artificial heart + miniaturization of these devices => consider their usage in final settlement for non-eligible heart failure patients for transplantation
Introduction

3. CVD deaths vs. cancer deaths by age (US)

4. Événements historiques
1953: Gibbon répare une CIA en utilisant une machine coeur-poumon
Heart mate II approuvé comme thérapie de destination
1984: DeVries implante le coeur artificiel Jarvik-7
1963: DeBakey implante la première pompe d’assistance ventriculaire pour un patient en étét de choc cardiogéniqque
1994: FDA approuve le LVAD comme pont pour la transplantation
1968: Shumway réalise la 1ère transplantation cardiaque aux USA
Les techniques d’assistance circulatoire se sont développées dans la seconde partie du Xxeme siècle parallèlement à l’essor de la chirurgie cardiaque et en particulier de la greffe cardiaque
1969: Cooley implant une pompe d’assistance circulatoire comme pont pour une transplantation cardiaque
2004: Essai REMATCH
1967: Barnard performe la 1ère transplantation cardiauqe

5. Indications For mechanical circulatory support
Failure to wean off CPB (post-cardiotomy)
ESHD awaiting Tx failing optimal medical management
Acute viral myocarditis/ post-partum cardiomyopathy
Acute Massive MI with shock
Cardiac arrest in hospital
Destination therapy for non-Tx
Others: ……

6. Hemodynamic Indications for support
SBP<80 mm Hg
MAP<65 mm Hg
CI<2.0 L/min/m2
PCWP>20 mm Hg
SVR>2100 dynes-sec/cm
Consider mechanical circulatory support in patient that cannot sustain adequate systemic oxygen delivery to maintain normal end organ function despite maximal medical therapy
Circulation 2005; 112:

7. Criteria for patient selection
Class IV HF
Failing hemodynamics
Persistent pulmonary oedema
Neurologic impairment or renal failure due to low perfusion
Fluids and electrolytes imbalance related to low cardiac output
Severe arrhythmias despite medical therapy

8. Exclusion Criterias For Mechanical Circulatory Support
Multi-system or irreversible organ failure
Uncontrolled infection/ sepsis
Recent pulmonary infarction
Significant bleeding diathesis
Recent/ significant neurologic insult
No reasonable long-term options
Hx of non-compliance/ inadeq. Social support
Advanced age
Malignancy

9. INTERMACS: Patient Selection
Patient Profile/ Status: INTERMACS Levels
1. Critical cardiogenic shock
Progressive decline
Stable but inotrope dependent
Recurrent advanced HF
Exertion intolerant
Exertion limited
Advanced NYHA III
INTERMACS is a national registry for patients who are receiving mechanical circulatory support device therapy to treat advanced heart failure. This registry was devised as a joint effort of the National Heart, Lung and Blood Institute (NHLBI), the Centers for Medicare and Medicaid Services (CMS), the Food and Drug Administration (FDA), clinicians, scientists and industry representatives in conjunction with the University of Alabama at Birmingham (UAB) and United Network for Organ Sharing (UNOS).
102 sites currently enrolled since creation in 2003

10. Device Selection Duration of support Size of patient
Severity of LV dysfunction
Need for bi-ventricular support
Cause of ventricular failure/likehood of recovery
Surgeon experience
Bleeding issues

11. Short term Device options
ECMO
IABP
Tandem Heart
Bridge to recovery
Bridge to decision
Centrimag
Blue: general shade
Centrifugal: light blue
Axial: purple
Pneumatic: green
AbioMed 5000
Impella
Circulation 112 (3): 438

12. Percutaneous ventricular assistance devices

13. Intraaortic Balloon Pump (IABP)
Counterpulsation is synchronized to the EKG or arterial waveforms
Increase coronary perfusion
Decrease left ventricular stroke work and myocardial oxygen requirements
Indications for its use include
Failure to wean from cardiopulmonary bypass
Cardiogenic shock after MI
Heart failure
Refractory ventricular arrhythmias with ongoing ischemia
In diastole, the balloon inflates to augment coronary perfusion
At the beginning of systole, the balloon deflates and blood is ejected from the left ventricle to increase cardiac output by as much as 40 percent

16. Impella Axial flow pumps Acute hemodynamic support
Miniaturized impellar pump in catheter
Helical catheter tip placed across aortic valve and left ventricle
Percutaneous or direct placement
Flow 4.5L/min
Bridge to recovery

18. E C M O
Matériel
Elles sont constituées d’un rotor mobile, électrique, qui propulse le sang soit par effet
vortex, soit par l’intermédiaire d’ailettes. Comme toute pompe non occlusive, leur
fonctionnement dépend directement de la précharge et de la post-charge. Elles peuvent
être associées à un oxygénateur permettant ainsi de réaliser un cœur-poumon artificiel
(ECMO ou ECLS [extra corporeal life support]) [2, 3]. Les canules d’entrée et de sortie de
la pompe sont implantées soit en intrathoracique par sternotomie, soit au niveau des
vaisseaux fémoraux, en utilisant la méthode Seldinger, après un abord a minima de la
face antérieure des vaisseaux (figures 1et 2). Dans ce cas, l’implantation peut être réalisée au lit du patient sous anesthésie locale. En fonction de la morphologie du patient,
le calibre des canules est de 18 à 20 F pour l’artère et de 25 à 30 F pour la veine. En cas
d’implantation périphérique, et afin d’éviter toute ischémie de membre inférieur, un
cathéter de perfusion de l’artère fémorale superficielle est branché en dérivation sur le
circuit artériel.
À côté de ces dispositifs de circulation extracorporelle, il faut signaler la mise à disposition
très récente de pompes miniaturisées, montées sur un cathéter, pouvant être insérées par
voie percutanée fémorale rétrograde jusque dans la cavité ventriculaire gauche (figure 3) et
générant un débit d’assistance de 2,5 à 5 l/min (Impella™). Ces dispositifs, encore en phase
d’évaluation clinique, ont un intérêt potentiel pour la prise en charge des chocs cardiogéniques, même si les résultats préliminaires incitent à la prudence.

19. Bridge to bridge: ECMO Immediately stabilize circulation
Improve end organ perfusion
Clinical indicators of poor outcome after ECMO: consider VAD implantation carefully
Elevated blood lactate levels
ECMO) is used for the resuscitation of patients in cardiogenic shock or after cardiopulmonary resuscitation (CPR) [1ñ 6]. Several investigators have demonstrated that patients who present with both postcardiotomy or intrinsic car- diogenic shock can be supported successfully with ECMO [1ñ 6]. Extracorporeal membrane oxygenation of- fers several advantages: (1) the percutaneous insertion of the cannulas into the femoral vessels is simple and can be performed even during CPR; (2) it provides both cardiac and pulmonary support for hypoxic patients; (3) it avoids a sternotomy incision; (4) it applies to patients in cardiac arrest; (5) it provides time to assess potential transplant candidates; and (6) it is less costly than other forms of mechanical circulatory supportWith the increasingly successful application of long- term implantable ventricular assist devices (VAD), the limitations of ECMO could be overcome by bridging patients to a long-term implantable VAD after initial ECMO resuscitation (bridge to bridge) [1, 2, 7]. In some patients suffering from myocarditis or postcardiotomy cardiogenic shock, weaning from VAD is possible (bridge to recovery). In all other patients, heart transplantation remains the only viable option (bridge to transplant). The objective of this study is to evaluate the outcome of the bridge to bridge concept and to identify risk factors indicating adverse outcome.
Pagani et al. Ann Thorac Surg 2000; 70:

20. Centrifugal pumps Acute hemodynamic support Continuous flow
Extracorporeal
LV, RV or biventricular support
Wide availability
Ease of use
Relatively low cost
Limited duration of support
Bridge to recovery
Bridge to decision
Wiebalck and associates [12] reported similar fidings with their use of the He- mopump, as well as a 58% survival and hospital dis- charge rate. Dreyfus [13] reported an overall survival rate of 40% with the Hemopump, and recommended its immediate use in the operating room as a fist step to treat postcardiotomy shock before a medical or intraaor- tic balloon pump failure. Our experience with the use of centrifugal pumps as a bridge to recovery for patients with postcardiotomy fail- ure has been favorable. Many patients in our series showed clinical improvement with circulatory support, were weaned successfully and discharged from the hos- pital, and have had satisfactory long-term survival. Cen- trifugal pumps are available, easy to use, relatively inex- pens i ve, and of t en have out comes equi val ent t o pneumatic devices. Our experience justifis their contin- ued use as a bridge to recovery for PCCS patients, despite the availability and the increasing use of more expensive devices.6..
Hoy et al. Ann Thorac Surg 2000; 70:

21. Tandem hearts Acute hemodynamic support Centrifugal pump
Percutaneous placement
LV support via transseptal cannula
Used in high risk cardiac catheterization procedures
Risk of vascular injuries due to cannula size

22. Abiomed 5000 Extracorporeal Pneumatic pulsatile pumps
Uni- or biventricular support
Bridge to transplant
Easy to insert and operate so used in community hospitals
Flows 6L/min
The ABIOMED BVS 5000™ is used worldwide for temporary left, right, or biventricular (both ventricles) support in patients with potentially reversible heart failure. The BVS 5000 underwent preclinical studies at the Texas Heart Institute (THI) from 1986 to 1988 and was introduced for use in patients at THI in It was the first heart assist device approved by the US Food and Drug Administration for the support of post-cardiotomy patients (those who have developed heart failure as a result of heart surgery). Since that time, hundreds of patients have been sustained by the BVS 5000.
In addition to post-cardiotomy support, the BVS 5000 may also be used in the following cases:
. Donor heart dysfunction or donor heart failure after heart transplantation.
. Right-sided heart failure after placement of a left ventricular assist device.
. Acute heart attack.
. Acute heart disorders, such as viral myocarditis.
. Trauma to the heart.
. Disease of the heart muscle (cardiomyopathy).
. In patients whose hearts have not recovered after temporary support, the BVS 5000 may  be used as a bridge to another device or as a bridge to heart transplantation.
This air-driven blood pump is placed outside the body (extracorporeally). A unique feature of this system is its dualchamber design, which is similar to the natural heart. This design provides support for either the left or right ventricle, or both.
The Pump
The pump houses two polyurethane chambers: an atrial chamber that fills with blood through gravitational force and a ventricular chamber  that pumps blood by air-driven power. The atrial chamber is vented outside the patient. The ventricular chamber is connected to the power console by a 0.25-inch pneumatic (air) line. Two trileaflet valves separate the atrial and ventricular chambers. The pump can produce blood flow of up to 5 liters per minute. Cannulas of various designs (for blood drainage and return) are available to accommodate individual patient anatomy.
The Console
The BVS 5000 console can support one or two blood pumps. It is fully automatic and compensates for changes both in preload and afterload. The left and right  sides are triggered independently of each other. A backup battery provides 1 hour of support, and an alarm will sound when only 10 minutes of power remain. A foot  pump can also serve as a backup power source. By using the console to limit blood flow, patients can be slowly weaned
Circulation. 2005;112:

23. Abiomed 5000 Minimal bedside monitoring
Supports large children and adults
Maximum use….1 week
Patients are not mobile
High cost

24. Short term Device options

25. Long term Device options
Heartmate II
Heartmate XVE
Bridge to transplant
Thoratec
Blue: general shade
Centrifugal: light blue
Teal:
Axial: purple
Pneumatic: green
Jarvik 2000
CardioWest TAH
Circulation 112 (3): 438

27. Thoratec Pneumatic pump LVAD, RVAD or biventricular support Durable
Can be used in smaller patients
Flows 7L/min
Bridge to recovery
Bridge to transplant
Circulation. 2005;112:

29. Heartmate XVE Pneumatic or vented electric plates
Textured internal surfaces
Only left-sided support
Flows 10L/min
Bridge to transplant
First device to be approved for destination therapy
Need BSA>1.5
Limited durability: half life 18 months
Infection risk with percutaneous drive line
Circulation. 2005;112:

30. Heartmate II Axial flow LV support Flows 10L/min Long term durability
Bridge to transplant
Approved January 2010 for destination therapy
Over 4000 devices implanted to date

31. CardioWest The TAH is used to bridge the time to a heart transplant.
SynCardia CardioWest TAH

32. Total Artificial Heart
CardioWest ( C-70 ) Pneumatic total artificial heart
C.O. is approximately 7.0 L/M
BSA>1.7
Need CPB for implant
Native heart not excised
Need Anti-coagulation
Patient in-house but mobile

33. Total Artificial Heart
Abiomed’s total artificial heart
Still in clinical trials
First patient lasted several months on device
If successful, will save hundreds of thousands of live because there will be no waiting like the transplant list

35. Transplantation versus assistance circulatoire de longue durée : quelle stratégie pour les patients présentant une insuffisance cardiaque terminale décompensée ?

37. Specificity in children
Child’s size > miniaturisation du dispositif
The pathophysiology of HF in children is different than in adult patient
short duration:
ECMO
Centrifugal pump
Long duration :
Berlin heart : pneumatic assistance
Pediatric Jarvik 2000 : turbine
MEDOS

38. Device complications Early Late Bleeding Right sided heart failure
Progressive multiorgan system failure
Late
Infection
Nosocomial
Device related
Thromboembolism
Failure of device

39. Next generation of VADs
Miniaturized
Improved durability
Bearing-less technology
Blood compatible surfaces
Nonthrombogenic
Transcutaneous
Drive line
Power sources
Future for ESHD lies in cell therapy: reverse myocardium remodeling or regrow new myocardium

40. Conclusion
Domain still area for research Save lives but $$$$ Should be used efficiently in our institution