1. Mechanical circulatory support
Hitoshi Hirose, MD
Associate Professor of Surgery
Thomas Jefferson University
Nothing to disclose

2. Cardiogenic shock

4. Pharmacological therapy
Volume
Inotropes
Pressors
Still cardiogenic shock..

5. IABP

6. IABP Reduces afterload Increase diastolic coronary perfusion pressure
Modest increase coronary blood flow
Excellent safety profile
Easy to use
Stabilize pts with Cardiogenic shock, provides HD support for pts undergoing PCI
10k

7. IABP shock II trial 2012 NEJM
Back ground of study
IABP has been used almost half century.
USA: despite of class 1B ACC/AHA – only 35% of cardiogenic shock pt had IABP support.
Europe: despite of class 1C ESC– only 25% of cardiogenic shock pt had IABP support.
Why? No RCT, reviews and meta-analysis weak.

9. IABP-Shock-II Trial
Largest RCT ever in cardiogenic shock

11. IABP does not reduce mortality
Randomized multicenter trial in cardiogenic shock patients complicating myocardial infarction undergoing early revascularization, IABP support did not reduce 30 days mortality or one year mortality.

13. Impella

14. Impella 2.5 Percutaneously placed mini rotary pump.
Inserted from femoral artery.
Inlet at LV, outlet at ascending Ao.
Precise positioning.
No RV support.
Not good for arrhythmia.
Support only 2.5 Lpm.
50k

15. Impella 5.0 Centrally placed mini rotary pump.
Inserted from Asn Ao or Fem cut down.
Inlet at LV, outlet at ascending Ao.
Support up to 5 Lpm.
No RV support.
Not good for arrhythmia.
Need open sternum.
65k

16. Tandem Heart

17. Tandem heart Inlet at LA via atrial septum Outlet at iliac artery.
Requires catheterization technique.
Can be placed in OR (bet LA & Ao, bet RA and PA)
Support LV only unless placed in OR bet RA/PA.
Allow up to 4 Lpm.
65k

18. HMII LVAD

19. Implantable VAD Destination therapy or bridge to transplant.
Patient can go home with implantable VAD.
No other device can go home with it.
100k

20. Other implantable LVADs
Jarvik 2000 HearWare HVAD HMIII

21. HMII Long-term outcomes
Kirklin J. K. et al.; J Thorac Cardiovasc Surg 2012;144:

22. HMII improved survival for DT
Molina EJ et al. Semin Thrac Surg 2013;25:56-63

23. Timing of VAD implant
High mortality rate after VAD in INTERMACS 1 (crash burn).
VAD/TAH are not Emergent procedure.
Unknown
Liver
Kidney
Neuro
Profiles
Definition
INTERMACS 1
“Crash and burn”
INTERMACS 2
“Sliding on inotropes”
INTERMACS 3
“Dependent stability”
INTERMACS 4
“Frequent flyer”
INTERMACS 5
“Housebound”
INTERMACS 6
“Walking wounded”
INTERMACS 7
“Placeholder”

24. Implantable LVAD with external RVAD
RVAD support after LVAD
CetriMag, Rotaflow RVAD (bet RA & PA).
No oxygenation or resp support.
RVAD increase the risk after LVAD.
Try to avoid requirement of RVAD at the time of the LVAD placement.
12k

25. Syncardia TAH

26. Total artificial heart
Destination therapy or bridge to transplant.
Patient can go home with TAH.
Biventricular support.
No respiratory support.
500k

27. ECMO

28. ECMO device
20k

29. ECMO is life saving tool and Buy a time to make decision
Optimize and stabilize end-organ function.
Liver, Kidney, Lung, Brain
Pripheral cannulation (avoid sternotomy).
Decompress the Right side heart.
Improve congestion of the liver, kidney.
Easy to support a few weeks even a month.

30. VA ECMO

32. VV ECMO

34. VA vs. VV Any difference?

35. Yes there is a large difference
VA provide full cardiac and resp support.
Including cardiac stand-still, arrythymia (VT/VF)
VV require normal RV/LV to circulate.
Good for non-cardiac resp failure
Switching from VA to VV, or VV to VA is not simple.
Plan before placing on ECMO.