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When Right Ventricular Failure may become a When Right Ventricular Failure may become a VAD FailureVAD Failure
When Right Ventricular Failure may become a When Right Ventricular Failure may become a VAD FailureVAD Failure
Dept. of Cardiothoracic Surgery
Medical University of Vienna
G. M. WieselthalerG. M. Wieselthaler
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
-- 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
Right Ventricular Failure and VAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation methods for native right ventricular function:
-- echocardiography
-- ECG gated MRI
-- vaso-active right heart catheterization
Right Ventricular Failure and VAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Echocardiography:
Pre LVAD
Post LVAD
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Echocardiography:
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Echocardiography:
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Echocardiography:
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Echocardiography:
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Echocardiography:
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Echocardiography:
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
MRI:
Z. F. 61 a, idiopath. CMP
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
MRI:
W.K., 56 a, isch. CMP + PH
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
MRI:
W. K., 56 a, isch. CMP + PH
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
Hemodynamic Testing before LVAD Implantation in 4 Patients
Baseline Nitro BolusAfter Simdax
2 hours
HR (b/min) 76 ± 11 72 ± 11 80 ± 12
MAP (mmHg) 81 ± 25 79 ± 21 79 ± 23
PAP (mmHg) 45 ± 7 35 ± 6 39 ± 5
PCWP (mmHg) 31 ± 6 17 ± 6 16 ± 1
CVP (mmHg) 17 ± 4 7 ± 2 10 ± 3
CO (L/min) 3,4 ± 0,7 4,3 ± 1,1 4,2 ± 1
SvO2 (%) 41 ± 12 65 ± 3 55 ± 8
Wood U 4,4 ± 1,2 4,5 ± 0,8 5,5 ± 1,5
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Patient 2: K. R. m, 66 a, 172 cm/92kg
Dg: isch CM since 2002, St.p. anterior wall infarct, St.p. AICD 5/2005Dg: isch CM since 2002, St.p. anterior wall infarct, St.p. AICD 5/2005 art. Hypertonie, COPDart. Hypertonie, COPD
repeted repeted Levosimendan-infusionsLevosimendan-infusions
Tx: Blopress 16 mg 1/2, Concor 5mg 1/2, Lasix 40 mg 1-1, Spirobene ,Restex, Tx: Blopress 16 mg 1/2, Concor 5mg 1/2, Lasix 40 mg 1-1, Spirobene ,Restex, Seretide, Berodual, MarcoumarSeretide, Berodual, Marcoumar
Lab: Crea 2.0 mg/dl, Bili 2.0 mg/dl, Lab: Crea 2.0 mg/dl, Bili 2.0 mg/dl, Lab preop: Crea 1,15 mg/dl, Bili 1,95 mg/dlLab preop: Crea 1,15 mg/dl, Bili 1,95 mg/dl Right heart catheter vom 29.12.2005:Right heart catheter vom 29.12.2005:
mPAP 52, PCWP 28, CO 5.2, Wood U 4,6mPAP 52, PCWP 28, CO 5.2, Wood U 4,6 Echo: highly reduced LVF EF 10%, EED 8.7 cmEcho: highly reduced LVF EF 10%, EED 8.7 cm
Evaluation of Right Ventricular Function
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
BaselinBaselin
Nach Nach PerlinganiPerlinganit Bolus t Bolus i.v.i.v.
Nach 3 Nach 3 Stunden Stunden PGEPGE22
Nach Nach Anästhesie Anästhesie EinleitungEinleitung
PostoperativPostoperativ15 Stunden 15 Stunden postoperativpostoperativ
HRHR 9090 8787 9292 6060 104104 104104
MAPMAP 7979 7171 7676 7575 7171 7878
mPAPmPAP 5050 3838 4747 4343 2323 2121
CVPCVP 1010 88 99 1212 1212 1111
PCWPPCWP 2929 1919 3535 2121 44 55
COCO 3,93,9 5,15,1 4,34,3 4,54,5 5,45,4 4,94,9
SvO2SvO2 4949 5757 4949 5555 6767 7272
PVRPVR 430430 298298 223223 391391 281281 261261
TPGTPG 2121 1919 1212 2222 1919 1616
Wood UWood U 5,4 3,7 2,8 4,94,9 3,53,5 3,23,2
Pro BNPPro BNP 40204020 64116411 43564356 40494049
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Evaluation of Right Ventricular Function
General exclusion criteria for VAD implantation:General exclusion criteria for VAD implantation:
absolute contraindications:absolute contraindications: - BUN > 100 mg / l or s-creatinine > 5,0 mg/dl- BUN > 100 mg / l or s-creatinine > 5,0 mg/dl - total bilirubin > 5 mg/ dl- total bilirubin > 5 mg/ dl - active infection- active infection - anamnestic coagulopathy- anamnestic coagulopathy - tumor anamnesis (bridge to transplant)- tumor anamnesis (bridge to transplant) - cerebrovascular disease- cerebrovascular disease - aortic disease- aortic disease
relative contraindications:relative contraindications:
- parenchymatous lung disease (Sarcoidosis)- parenchymatous lung disease (Sarcoidosis) - fixed pulmonary hypertension- fixed pulmonary hypertension - mechanical heart valve- mechanical heart valve - heparin intolerance (HIT)- heparin intolerance (HIT)
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
2007 in press
Mechanical Circulatory SupportMechanical Circulatory Support
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
fixed pulmonary hypertension and LVADfixed pulmonary hypertension and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
fixed pulmonary hypertension and LVADfixed pulmonary hypertension and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
10 Patients for LVAD Implantation
After Induction
After CPB
OR End postop6 hours postop
12 hours postop
24 hours postop
HR (b/min) 69 ± 24 105 ± 12 109 ± 10 114 ± 14 114 ± 12 110 ± 17 113 ± 14
MAP (mmHg) 68 ± 6 68 ± 7 65 ± 7 72 ± 5 76 ± 4 72 ± 5 68 ± 2
mPAP (mmHg) 37 ± 4 27 ± 5 27 ± 4 27 ± 4 25 ± 5 23 ± 3 28 ± 7
PCWP (mmHg) 24 ± 7 11 ± 4 10 ± 2 14 ± 5 8 ± 0,8 11 ± 3 11 ± 2
CVP (mmHg) 17 ± 5 10 ± 3 11 ± 3 10 ± 2 11 ± 1 12 ± 3 11 ± 3
CO (L/min) 3,7 ± 1 5,7 ± 0,7 5,6 ± 0,7 4,7 ± 0,7 5,4± 0,5 5,6 ± 0,1 4,8 ± 0,3
SvO2 (%) 58 ± 14 70 ± 3 68 ± 4 68 ± 4 66 ± 4 64 ± 8 66 ± 5
Wood U 3,6 ± 1,2 3 ± 1,2 3,1 ± 0,9 2,9 ± 0,9 3,2 ± 1,1 2,9 ± 0,3 3,3 ± 1,5
fixed pulmonary hypertension and LVADfixed pulmonary hypertension and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
After Induction
After CPB OP End postop6 hours postop
12 hours postop
24 hours postop
Dobutamin (µg/kg/min)
3,1 12 11,4 11,2 6,8 7,1 7,5
Levosimendan (µg/kg/min) 0,2 0,2 0,2 0,2 0,2 0,2 0,2
Norepinephrine (µg/kg/min)
0,07 0,14 0,22 0,26 0,03 0,05 0,04
Nitric Oxide (ppm) 10 10 10 10
10 Patients for LVAD Implantation
1 Patient additionally had Milrinone intraoperatively, 3 Patients postoperatively2 Patients needed Nitroglycerin postoperatively, 1 Patient was switched from to Nitro to Urapidil
fixed pulmonary hypertension and LVADfixed pulmonary hypertension and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
180 patients Heart Mate39% RHF14 Patiens RVAD
Right Heart Failure and LVADRight Heart Failure and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVADRight Heart Failure and LVAD
245 patients 9% RVAD (23 patients)
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
100 Patients Heart Mate LVAD
In 11 RVAD
Right Heart Failure and LVADRight Heart Failure and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Adverse EventAdverse EventDuraHeart DuraHeart (n=33)(n=33)
18 pt-yrs18 pt-yrs(mean:197 days)(mean:197 days)
HM VEHM VE1 1 (n=280)(n=280)
86 pt-yrs86 pt-yrs(mean:112 days)(mean:112 days)
HM IIHM II2 2 (n=133)(n=133)
62 pt-yrs62 pt-yrs(mean:168 days)(mean:168 days)
Bleeding requiring surgeryBleeding requiring surgery 0.220.22 1.471.47 0.780.78
Driveline/pocket infectionDriveline/pocket infection 0.400.40 3.493.49 0.370.37
StrokeStroke 0.28 0.28 0*0* 0.440.44 0.190.19
Non-stroke neurologicNon-stroke neurologic 0.280.28 0.23*0.23* 0.670.67 0.260.26
RHF requiring RVADRHF requiring RVAD 0.060.06 0.30.3 0.080.08
Device thrombosisDevice thrombosis 00 NANA 0.030.03
Pump mechanical failurePump mechanical failure 00 0.030.03 00
HemolysisHemolysis 00 00 0.060.06
1.1. Frazier OH, et al. J Thoracic Cardiovasc Surg 2001;122:1186-95.Frazier OH, et al. J Thoracic Cardiovasc Surg 2001;122:1186-95.2.2. Miller LW, et al. NEJM 2007;357:885-96.Miller LW, et al. NEJM 2007;357:885-96.
Comparison of Adverse Event Rates (per pt-yr) Comparison of Adverse Event Rates (per pt-yr) DuraHeart vs. HM VE vs. HM IIDuraHeart vs. HM VE vs. HM II
As of June 15, 2007
**Event rate after implementing less intensive anticoagulation (n=22, 13 pt-yrs)Event rate after implementing less intensive anticoagulation (n=22, 13 pt-yrs)
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
HeartWare HVAD multi-institutional trial
ComplicationComplication Patients Patients Events Event Events Event RateRate
n n n n per pt yr per pt yr
Infections (exit site) Infections (exit site) 3 3 3 3 0.28 0.28
Bleeding (requiring re-operation) 3 Bleeding (requiring re-operation) 3 4 4 0.37 0.37
Respiratory DysfunctionRespiratory Dysfunction 4 4 4 4 0.37 0.37
Renal DysfunctionRenal Dysfunction 3 3 3 3 0.28 0.28
Right Heart FailureRight Heart Failure 1 1 1 1 0.09 0.09
At 180 daysadverse events in first 23 implants:
G.M.Wieselthaler et al, JHLT 2009 submitted
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Continuous unloading of left ventricle can cause shift of thined, free lateral ventricularContinuous unloading of left ventricle can cause shift of thined, free lateral ventricular
wall and results in reduced pump-flows & can provoke suctionwall and results in reduced pump-flows & can provoke suction
Right Heart Failure and LVADRight Heart Failure and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
thin & flexing interventricular septum in a patient with dilative CMPthin & flexing interventricular septum in a patient with dilative CMP
Right Heart Failure and LVADRight Heart Failure and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
-- in a patient with a thin & flexing interventricular septum-- in a patient with a thin & flexing interventricular septum
-- leads to shift of interventricular septum to the left side & increased TI with -- leads to shift of interventricular septum to the left side & increased TI with consecutive right ventricular failureconsecutive right ventricular failure
Right Heart Failure and LVADRight Heart Failure and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVADRight Heart Failure and LVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVADRight Heart Failure and LVAD
LVAD vs. BiVAD:
-- extended infarct areas (RCA) -- consider BiVAD -- extended infarct areas (RCA) -- consider BiVAD
-- patients with malignant arrythmias benefit from BiVAD-- patients with malignant arrythmias benefit from BiVAD
-- patients in prolonged cardiogenic shock always BiVAD-- patients in prolonged cardiogenic shock always BiVAD
-- Patients with two- or multi-organ failure always BiVAD-- Patients with two- or multi-organ failure always BiVAD
G.M.Wieselthaler, Univ. of Vienna 04/2009G.M.Wieselthaler, Univ. of Vienna 04/2009
Right Heart Failure and LVADRight 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