1. BME 301 Lecture Nineteen

2. Progression of Heart Disease High Blood Pressure High Cholesterol Levels Atherosclerosis Ischemia Heart Attack Heart Failure

3. Review of Last Time What is heart failure? Occurs when left or right ventricle loses the ability to keep up with amount of blood flow http://www.kumc.edu/kumcpeds/cardiology/movies/s ssmovies/dilcardiomyopsss.html http://www.kumc.edu/kumcpeds/cardiology/movies/s ssmovies/dilcardiomyopsss.html How do we treat heart failure? Heart transplant Rejection, inadequate supply of donor hearts LVAD Can delay progression of heart failure Artificial heart

4. Which one is a healthy heart?

5. Heart Failure

6. Which one is a healthy heart? Heart Failure

7. Which one is a healthy heart? Heart Failure Atrial Fibrillation Healthy Heart

8. Artificial Heart - History First artificial heart implanted in 1969 No more human trials until the 1980s…

9. History of Artificial Heart http://www.cbsnews. com/stories/2004/05/ 27/earlyshow/contrib utors/emilysenay/mai n620068.shtml http://www.cbsnews. com/stories/2004/05/ 27/earlyshow/contrib utors/emilysenay/mai n620068.shtml June 2001 http://discover.npr.org/feat ures/feature.jhtml?wfId=11 23833 http://discover.npr.org/feat ures/feature.jhtml?wfId=11 23833 August 2001 http://discover.npr.org/feat ures/feature.jhtml?wfId=11 27758 http://discover.npr.org/feat ures/feature.jhtml?wfId=11 27758 November 2001 http://discover.npr.org/feat ures/feature.jhtml?wfId=11 33260 http://discover.npr.org/feat ures/feature.jhtml?wfId=11 33260 http://images.usatoday.com/news/_photos/2001-11-30-heartguy.jpg

10. History of Artificial Heart 1958: Designed by Drs. Willem Kolff and Tetsuzo Akutsu Polyvinyl chloride device Sustained a dog for 90 minutes 1965: Dr. Willem Kolff Silicone rubber heart Tested in a calf http://www.a ccessexcellen ce.org/WN/gr aphics/jarvik.j pg http://www.abiomed.com/images/prodtec h/kolff65.jpg

11. History of Artificial Heart 1969: Dr. Domingo Liotta First to be implanted in human as bridge to transplant Patient survived for 3 days with artificial heart and 36 hours more with transplanted heart 1982: Drs. Willem Kolff, Donald Olsen, and Robert Jarvik, Jarvik-7 First to be implanted in a human as destination therapy http://www.abi omed.com/ima ges/prodtech/li otta.jpg

12. http://static.howstuffworks.com/gif/artificial-heart-abiocor-diagram.gif http://www.ps-lk3.de/images/ABIOCOR.JPG

13. AbioCor Artificial Heart http://www.heartpion eers.com/newsimages.html# http://www.heartpion eers.com/newsimages.html# Cost: $70-100k http://www.cardiocaribe.com/newsite/images/articulos/feb02/abiocor_hand.jpg

14. Surgical Procedure Surgeons implant energy-transfer coil in the abdomen The chest is opened and patient is placed on a heart- lung machine Surgeons remove the right and left ventricles of native heart. This part of the surgery takes two to three hours Atrial cuffs are sewn to native heart's right and left atria A plastic model is placed in the chest to determine the proper placement and fit of the heart in the patient Grafts are cut to an appropriate length and sewn to the aorta and pulmonary artery The AbioCor is placed in the chest. Surgeons use "quick connects" -- sort of like little snaps -- to connect heart to the pulmonary artery, aorta and left and right atria. All of the air in the device is removed The patient is taken off the heart-lung machine

15. http://www.pbs.org/wgbh/nova/eheart/transplantwave.htmlhttp://www.pbs.org/wgbh/nova/eheart/transplantwave.html ` http://www.louisville.edu/hsc/medmag/ss01/images/ abio-prep.gif http://www.heartpioneers.com/images/news/impla nt_thumb.jpg

16. Clinical Trial of AbioCor Goals of Initial Clinical Trial Determine whether AbioCor™ can extend life with acceptable quality for patients with less than 30 days to live and no other therapeutic alternative To learn what we need to know to deliver the next generation of AbioCor, to treat a broader patient population for longer life and improving quality of life.

17. Clinical Trial of AbioCor Patient Inclusion Criteria (highlights) Bi-ventricular heart failure Greater than eighteen years old High likelihood of dying within the next thirty days Unresponsive to maximum existing therapies Ineligible for cardiac transplantation Successful AbioFit™ analysis Patient Exclusion Criteria (highlights) Heart failure with significant potential for reversibility Life expectancy >30 days Serious non-cardiac disease Pregnancy Psychiatric illness (including drug or alcohol abuse) Inadequate social support system

18. Clinical Trial of AbioCor Clinical Trial Endpoints All-cause mortality through sixty days Quality of Life measurements Repeat QOL assessments at 30-day intervals until death Number of patients Initial authorization for five (5) implants Expands to fifteen (15) patients in increments of five (5) if 60-day experience is satisfactory to FDA

19. Consent Form http://www.abiomed.com/Fabiocor.html http://www.awpagesociety.com/public/cas es/ABIOMED_1-Case.pdf http://www.awpagesociety.com/public/cas es/ABIOMED_1-Case.pdf

20. Planning a Clinical Trial Two arms: Treatment group Control group Outcome: Primary outcome Secondary outcomes Sample size: Want to ensure that any differences between treatment and control group are real Must consider $$ available

21. Example – Planning a Clinical Trial New drug eluting stent Treatment group: Control group: Primary Outcome: Secondary Outcomes:

22. Sample Size Calculation There will be some statistical uncertainty associated with the measured restenosis rate Goal: Uncertainty << Difference in primary outcome between control & treatment group Choose our sample size so that this is true

23. Types of Errors in Clinical Trial Type I Error: We mistakenly conclude that there is a difference between the two groups, when in reality there is no difference Type II Error: We mistakenly conclude that there is not a difference between the two, when in reality there is a difference Choose our sample size: Acceptable likelihood of Type I or II error Enough $$ to carry out the trial

24. Types of Errors in Clinical Trial Type I Error: We mistakenly conclude that there IS a difference between the two groups p-value – probability of making a Type I error Usually set p = 1% - 5% Type II Error: We mistakenly conclude that there IS NOT a difference between the two Beta – probability of making a Type II error Power = 1 – beta = 1 – probability of making a Type II error Usually set beta = 10 - 20%

25. How do we calculate n? Select primary outcome Estimate expected rate of primary outcome in: Treatment group Control group Set acceptable levels of Type I and II error Choose p-value Choose beta Use sample size calculator HW14

26. Drug Eluting Stent – Sample Size Treatment group: Receive stent Control group: Get angioplasty Primary Outcome: 1 year restenosis rate Expected Outcomes: Stent: 10% Angioplasty: 45% Error rates: p =.05 Beta = 0.2 55 patients required

27. Assignments Due Next Time HW14 Project 6 Exam Three: April 11 th Take Home Exam