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QUEST FOR ULTIMATE CURE “MODEL T” to “DREAM THERAPY” Where is the MIRACLE BULLET?

QUEST FOR ULTIMATE CURE “MODEL T” to “DREAM THERAPY” Where is the MIRACLE BULLET?. Chittoor B. Sai Sudhakar, MD, FRCS. The Holy Grail !!!!!!!!. Treatment of Symptomatic CHF. 5 classes of drug ACE inhibitors Beta blockers Aldosterone antagonist Nitrates and Hydralazine

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QUEST FOR ULTIMATE CURE “MODEL T” to “DREAM THERAPY” Where is the MIRACLE BULLET?

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  1. QUEST FOR ULTIMATE CURE “MODEL T” to “DREAM THERAPY” Where is the MIRACLE BULLET? Chittoor B. Sai Sudhakar, MD, FRCS

  2. The Holy Grail !!!!!!!!

  3. Treatment of Symptomatic CHF 5 classes of drug ACE inhibitors Beta blockers Aldosterone antagonist Nitrates and Hydralazine Angiogenesis II receptor blockers

  4. First Device as BTT • Designed by Dr. Domingo Liotta, 1969 • This heart was the first to be implanted in a human being as a bridge to transplant by Dr. Denton A. Cooley. • The patient survived for almost three days with the artificial heart and 36 hours more with a transplanted heart.

  5. Jarvik-7 • Drs. Willem Kolff, Donald Olsen, and Robert Jarvik • First human implant 1982 • Destination Therapy • 200 patients bridged (Jarvik-7/Symbion)

  6. Heartmate XV & XVE Has been the workhorse for a long time Does not need anti-coagulation Bulky Lasts for a 12-24 months Our record is 32 months and going

  7. REMATCH Trial (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart failure) Inclusion criteria resembled those for Heart TX Class IV CHF LVEF <25% Peak oxygen consumption <12-14ml/kg/min Inotrope dependent

  8. Profiles of HF in different trials REMATCH patients were much sicker Group intermediate in severity between Status I & II heart transplant candidates Stevenson, L. W. et al. Circulation 2003;108:3059-3063

  9. REMATCH Survival Inotrope dependent at randomization – 91pts 6 mth 1 year 2year LVAD 60% 49% 28% OMM 39% 24% 11% Not on inotrope at randomization – 38pts LVAD 61% 57% OMM 67% 40%

  10. Heartmate II

  11. VentrAssist 298 gms, 6 cms, size of a hockey puck Single moving part – hemodynamically suspended impeller Electromagnetic field rotates the impeller

  12. HeartWare Miniaturized centrifugal pump Totally Intrapericardial Single moving part and no mechanical bearings

  13. Long Term Support

  14. The difficult part is the selection

  15. 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

  16. Definition of heart failure populations with decreasing estimated mortality Stevenson, L. W. et al. Circulation 2003;108:3059-3063

  17. Seattle Heart Failure Model

  18. Right Heart Failure predictor Elevated CVP is the single most important factor Other factors: PA pressures RVSW RVSWI Degree of RV dysfunction Tricuspid Annular Excursion

  19. Even more difficult : post-op management

  20. INTERMACS Kirklin JK, et al. J Heart Lung Transplant; 2008:1065-1072

  21. Case Report • 50 YO M ICM • Heartmate XVE placed 4/13/06 • Complicated by persistent Enterococcus bacteremia • Replaced with Heartmate XVE 11/2/06 • Infection cleared, was doing well • Admitted 3 months later because high power utilization and batteries burning out M. Firstenberg

  22. LVAD Thrombosis M. Firstenberg

  23. LVAD Thrombosis M. Firstenberg

  24. VAD endocarditis M. Firstenberg

  25. VAD Thrombosis

  26. Migration LOH 4 months Post-op

  27. Migration GF 10days post-op

  28. Lead Fractures : Multi-Institutional Experience OSU, St. Vincent’s (Indiana), U of Minnesota

  29. HIGH TECH PROBLEM!!!!! Lead fracture in Ventrassist

  30. LOW TECH SOLUTION

  31. Other therapies – Immune Adsorption Several antibodies against the cardiac proteins IA removes these antibodies

  32. Immune Adsorption 9 patients in each arm High anti beta-1 adrenoceptor auto antibodies IA for five courses followed by IgG substitution Improvement in functional class at 3 months

  33. In our lab at OSU Ovine model of heart failure Embolization technique Beads Aggregated platelets LAD ligation

  34. Picture 1. Fluoroscopy picture of left circumflex artery cannulated with 6F catheter and injected with 90um polyester micro beads

  35. Cytokine Expression Chandrakala

  36. Our ongoing Investigation Autoantibodies to CEC & ERP Inhibit the homing mechanisms of BM derived EPC Inhibition of Angiogenesis, Neovascularization and Repair

  37. Are there any magic bullets for cure out there?

  38. If there is one then we can sing praises: Shot through the heart, you give VAD a bad name

  39. Thank you

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