Recent Trials With Durable LVADs: Is There a Superior
Device?
Francis D. Pagani MD PhDOtto Gago MD Endowed Professor of Cardiac Surgery
Michigan Medicine
HeartMate 3 HeartMate II HVADApproved “Short Term” 2017 Approved BTT 2008 Approved BTT 2012
Approved DT 2010 Approved DT 2017
Current Device Landscape 2018
Recent IDE Clinical Trials in MCS
•HeartMate II Pivotal Trial for Bridge to Transplant (2008) and Destination Therapy (2010)
•ADVANCE- Pivotal Trial for HVAD for Bridge to Transplant Indication
(2012)•ENDURANCE I and ENDURANCE Supplemental Trial
- Pivotal Trial for HVAD for Destination Therapy (2017)•MOMENTUM 3
- Pivotal Trial for HeartMate 3 for Short Term and Long Term Use (2017)
HeartMate II HVADversus
5
Primary endpoint:
• Survival free of disabling stroke (mRS < 4 at 24 weeks post stroke) on the originally implanted device or transplanted or explanted due to myocardial recovery
ENDURANCE TRIAL
ENDURANCE TRIAL Primary Endpoint Overall Survival
Stroke Risk Factor Multivariable Analysis (HVAD)
8
-10 0 10 20 30 40 50 60
MAP (> 90 mmHg)
INR (≤ 2)
ASA (≤ 81 mg)
Odds Ratio P-value14.1 <0.0001
3.0 0.002
2.2 0.034
Statistically significantly more HVAD patients (7.3%, 0.07 EPPY) had a sub-therapeutic INR <2.0 compared to control patients (2.2%, 0.02 EPPY), P=0.004.
Endurance Supplemental Trial• The primary endpoint was the
incidence of neurologic injury (defined as any stroke with an MRS >0 at 24-weeks post-stroke or any transient ischemic attack (TIA) or spinal cord infarct) at 12 months, including only time on the originally implanted LVAD.
• Strokes with MRS = 0 at 24 weeks (n=13 for HVAD, n=5 for control) were not included in the primary endpoint of neurological injury
• Intervention: BP Management for the HVAD arm
Milano et al. ISHLT April 2017versus
76%87%
70% 66% 72%79% 83%
53% 54% 54%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
ent o
f Sub
ject
s
B.
>100
96-100
91-95
86-90
<=85
HeartWare HVAD Control LVAD
Endurance Supplemental Trial
Milano et al. ISHLT April 2017versus
65
70
75
80
85
90
Baseline Discharge 3 Months 6 Months 12 Months
Aver
age
MAP
(mm
Hg)
A.
ENDURANCE HeartWare HVAD
ENDURANCE Control LVAD
ENDURANCE Supplemental HeartWare HVAD
ENDURANCE Supplemental Control LVAD
p = 0.0003
p = 0.0001 p = 0.0001 p = 0.0001
Endurance Supplemental Trial
Milano et al. ISHLT April 2017
Endurance Supplemental Trial
Milano et al. ISHLT April 2017
Adverse Event
Study DeviceN=308
Control DeviceN=157
P valuePatients with
eventn (%)
No. of eventsPatients with event n (%)
No. of events
Device Malfunction/Failure 74 (24.0%) 107 38 (24.2%) 47 >0.99
Hemolysis 4 (1.3%) 5 9 (5.7%) 9 0.01
StrokeIschemic Cerebrovascular EventHemorrhagic Cerebrovascular Event
TIA
52 (16.9%)40 (13.0%)16 (5.2%)13 (4.2%)
75581713
23 (14.6%)12 (7.6%)11 (7.0%)1 (0.6%)
2514111
0.600.090.530.04
Pump replacementExchange for pump thrombosis
16 (5.2%)14 (4.5%)
NA18 (11.5%)16 (10.2%)
NA0.020.03
Endurance Supplemental Trial Secondary Endpoint:(Stroke-free survival (Modified Rankin Score <4 at 24-weeks post-stroke) at two years, defined as
alive on the originally implanted device, transplanted or explanted due to patient recovery)
Milano et al. ISHLT April 2017
HeartMate II HeartMate 3versus
HeartMate 3 Engineering
MOMENTUM 3 TRIAL•The primary end point was a composite of survival free of
disabling stroke (Modified Rankin Score < 4) or survival free of reoperation to replace or remove the device (for reasons other than recovery or transplant) at 6 months after implantation.
PRIMARY OUTCOME
HeartMate 3: US MOMENTUM TRIALShort Term Cohort: 6 Months
Primary Endpoint Overall Survival
Circulation. 2017;135:00–00. DOI: 10.1161/CIRCULATIONAHA.117.028303
Circulation. 2017;135:00–00. DOI: 10.1161/CIRCULATIONAHA.117.028303
HeartMate 3 HVADApproved “Short Term” 2017 Approved BTT 2012
Approved DT 2017
versus
Important Challenges
• Stroke-Technology goal < 5%
• Device-related infection• Device thrombosis
Summary• 2017 was a progressive year for durable VAD therapy
-Optimism stemming from continued improvements in technology
-The importance of new technology significantly reducing pump thrombosis can not be understated
-Important understanding of how management practices can influence outcomes (i.e., BP control)
• Centrifugal pumps will dominate clinical use• Continued dissemination/diffusion of the therapy• Stroke and device-related infections remain important
barriers into the less ill population
Role: SpeakerDate: Thursday, March 8, 2108Session: Plenary Session: Hot Topics in Mechanical Circulatory Support for Heart and LungTitle: Recent Trials With Durable LVADs: Is There a Superior Device?Time: 8:10 a.m. - 8:30 a.m.
Dear Dr. Pagani,
We look forward to your participation in the AATS Mechanical Circulatory Support Symposium: 21st Century State of the Art Treatment of Heart and Lung Failure, taking place March 8 - 9, 2018 at the Marriott Marquis Houston in Houston, Texas.
Attached is a copy of the program agenda listing your presentation(s) date(s), time(s) and title(s). Your role for each is listed below.
Role: SpeakerDate: Thursday, March 8, 2108Session: Plenary Session: Hot Topics in Mechanical Circualtory Support for Heart and LungTitle: Recent Trials With Durable LVADs: Is There a Superior Device?Time: 8:10 a.m. - 8:30 a.m.
Role: ModeratorDate: Thursday, March 8, 2108Session: Concurrent Session IIIa: Patient Selection and Optimization for Durable MCS DevicesTime: 1:30 p.m. - 3:00 p.m.
Role: ModeratorDate: Friday, March 9, 2018Session: Concurrent Session VIIa: Debates on Controversial SubjectsTime: 9:45 a.m. - 10:45 a.m.
As you prepare your presentation slides, please keep in mind the following:•All Relevant Financial Relationships must be disclosed to learners prior to the start of the live activity. A Disclosure Statement slide must be included as the second slide for all presentations.•AATS will be using 16:9 Wide Screens. Instructions for formatting slides wide screen are attached.•You will NOT have access to “speaker notes” view in your session room – please bring a hardcopy of your notes, if needed.•Laptops are NOT allowed to be connected to the podium monitor- please bring a copy of your presentation on a USB drive.
Presentation Check In: