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When Right Ventricular Failure may become a VAD Failure

When Right Ventricular Failure may become a VAD Failure. Dept. of Cardiothoracic Surgery Medical University of Vienna. G. M. Wieselthaler. Right Ventricular Failure and VAD. -- VAD is established therapy for terminal heart failure -- 85% of implanted pumps are LVADs

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When Right Ventricular Failure may become a VAD Failure

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  1. When Right Ventricular Failure may become a VAD Failure Dept. of Cardiothoracic Surgery Medical University of Vienna G. M. Wieselthaler

  2. Right Ventricular Failure and VAD -- 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

  3. Right Ventricular Failure and VAD Evaluation methods for native right ventricular function: -- echocardiography -- ECG gated MRI -- vaso-active right heart catheterization

  4. Evaluation of Right Ventricular Function Echocardiography: Pre LVAD Post LVAD

  5. Evaluation of Right Ventricular Function Echocardiography:

  6. Evaluation of Right Ventricular Function Echocardiography:

  7. Evaluation of Right Ventricular Function Echocardiography:

  8. Evaluation of Right Ventricular Function Echocardiography:

  9. Evaluation of Right Ventricular Function Echocardiography:

  10. Evaluation of Right Ventricular Function Echocardiography:

  11. Evaluation of Right Ventricular Function MRI: Z. F. 61 a, idiopath. CMP

  12. Evaluation of Right Ventricular Function MRI: W.K., 56 a, isch. CMP + PH

  13. Evaluation of Right Ventricular Function MRI: W. K., 56 a, isch. CMP + PH

  14. Evaluation of Right Ventricular Function Hemodynamic Testing before LVAD Implantation in 4 Patients

  15. Patient 2: K. R. m, 66 a, 172 cm/92kg Evaluation of Right Ventricular Function • Dg: isch CM since 2002, St.p. anterior wall infarct, St.p. AICD 5/2005 • art. Hypertonie, COPD • repeted Levosimendan-infusions • Tx: Blopress 16 mg 1/2, Concor 5mg 1/2, Lasix 40 mg 1-1, Spirobene ,Restex, Seretide, Berodual, Marcoumar • Lab: Crea 2.0 mg/dl, Bili 2.0 mg/dl, • Lab preop: Crea 1,15 mg/dl, Bili 1,95 mg/dl • Right heart catheter vom 29.12.2005: • mPAP 52, PCWP 28, CO 5.2, Wood U 4,6 • Echo: highly reduced LVF EF 10%, EED 8.7 cm

  16. Evaluation of Right Ventricular Function

  17. Evaluation of Right Ventricular Function General exclusion criteria for VAD implantation: absolute contraindications: - BUN > 100 mg / l or s-creatinine > 5,0 mg/dl - total bilirubin > 5 mg/ dl - active infection - anamnestic coagulopathy - tumor anamnesis (bridge to transplant) - cerebrovascular disease - aortic disease relative contraindications: - parenchymatous lung disease (Sarcoidosis) - fixed pulmonary hypertension - mechanical heart valve - heparin intolerance (HIT)

  18. Mechanical Circulatory Support 2007 in press

  19. fixed pulmonary hypertension and LVAD

  20. fixed pulmonary hypertension and LVAD

  21. fixed pulmonary hypertension and LVAD 10 Patients for LVAD Implantation

  22. fixed pulmonary hypertension and LVAD 10 Patients for LVAD Implantation 1 Patient additionally had Milrinone intraoperatively, 3 Patients postoperatively 2 Patients needed Nitroglycerin postoperatively, 1 Patient was switched from to Nitro to Urapidil

  23. Right Heart Failure and LVAD 180 patients Heart Mate 39% RHF 14 Patiens RVAD

  24. Right Heart Failure and LVAD 245 patients 9% RVAD (23 patients)

  25. Right Heart Failure and LVAD 100 Patients Heart Mate LVAD In 11 RVAD

  26. Comparison of Adverse Event Rates (per pt-yr) DuraHeart vs. HM VE vs. HM II As of June 15, 2007 *Event rate after implementing less intensive anticoagulation (n=22, 13 pt-yrs) • Frazier OH, et al. J Thoracic Cardiovasc Surg 2001;122:1186-95. • Miller LW, et al. NEJM 2007;357:885-96.

  27. Complication Patients Events Event Rate n n per pt yr Infections (exit site) 3 3 0.28 Bleeding (requiring re-operation) 3 4 0.37 Respiratory Dysfunction 4 4 0.37 Renal Dysfunction 3 3 0.28 Right Heart Failure 1 1 0.09 HeartWare HVAD multi-institutional trial adverse events in first 23 implants: At 180 days G.M.Wieselthaler et al, JHLT 2009 submitted

  28. Right Heart Failure and LVAD Continuous unloading of left ventricle can cause shift of thined, free lateral ventricular wall and results in reduced pump-flows & can provoke suction

  29. Right Heart Failure and LVAD thin & flexing interventricular septum in a patient with dilative CMP

  30. Right Heart Failure and LVAD -- in a patient with a thin & flexing interventricular septum -- leads to shift of interventricular septum to the left side & increased TI with consecutive right ventricular failure

  31. Right Heart Failure and LVAD

  32. Right Heart Failure and LVAD LVAD vs. BiVAD: -- extended infarct areas (RCA) -- consider BiVAD -- patients with malignant arrythmias benefit from BiVAD -- patients in prolonged cardiogenic shock always BiVAD -- Patients with two- or multi-organ failure always BiVAD

  33. Right Heart Failure and LVAD 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

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