STATE OF THE ART IN THE

TREATMENT OF PATIENTS

WITH ACUTE HEART FAILURE

MARKO TURINA University Hospital

Zurich

Switzerland

LVAD with atomic drive, built by the US Atomic

Energy Commission (1971)

Steam Engine (!) for LVAD

AEC, cca 1971

Implanted Atomic LVAF

AEC, 1971

First Clinical Application of LVAD

DeBakey 1966

Zurich paracorporeal assist system, 1976

Zürcher Kreislaufassistenz System im klinischen Einsatz, 1976

First total artificial heart implantation (DeVries & Jarvik, 1982)

MECHANICAL CIRCULATORY ASSISTANCE:

MAIN APPLICATIONS

• Short term (<2 weeks) postoperative or post

interventional support: IABP, Abiomed 5000

• Bridge to transplant or bridge to recovery:

Thoratec, Heartmate II, Micromed, Jarvik 7,

CorAid, Berlin Heart, etc.

• Permanent Implantation (“Destination

Therapy”): Abiomed, CardioWest, Lionheart

ECMO (Extracorporeal membrane oxygenation): obvious

first step in postoperative low output and urgent assist

Diastolic Augmentation

Coronary Perfusion

Assisted Aortic End-

Diastolic Pressure

MVO2 Demand

Assisted

Systole

Unassisted

Systole

Balloon

Inflation

Unassisted Aortic

End-Diastolic

Pressure

140

120

100

80

60

mm

Hg

IABP: FIRST STEP IN

PREOPERATIVE STABILIZATION

OF ACUTE CORONARY

SYNDROMS, URGENT CABG, AND

POSTOP. LOS

Fast Archimedic pumps (e.g.

Impella): very efficient for a

short period (24 hours?),

multiple contraindications

(aortoiliac disease, aortic

prosthesis or AI, more difficult

in right assist)

Tandem Heart for

percutaneous

transseptal use

Left-heart bypass with

Carlens-Dennis cannula

(1960/61)

Abiomed BVS-5000: pneumatic pumping

and filling chamber (artificial atrium)

MECHANICAL

CIRCULATORY ASSISTANCE Abiomed BVS-5000: drive console

ORTHOTOPIC ARTIFICIAL HEARTS

FROM THE SEVENTIES

ORTHOTOPIC ARTIFICIAL HEART

”Most promising” development of the eighties

Present clinical experience

Orthotopic total artificial heart

• Still excessive complication rate:

Thromboembolism und complex anticoagulation

infections und mechanical defects.

• Minimal support from the industry (e.g. Elimination

of Lionheart by Arrow).

• Totally implantable systems still have major

problems: transcutaneous energy transfer, volume

compensation chamber, auto regulation

• Presently TAH can be used only in major,

specialized centers

“Lionheart”, First totally implantable LV assist

system with compliance chamber

Compliance Chamber is essential in totally

implantable systems

Implantiertes Atomherz (AEC, 1971)

In the field of mechanical circulatory assistance,

companies frequently change names, owners

and direction of development.

Abiocor totally implantable

artificial heart: transcutaneous

energy transfer, does not need

volume compensation chamber

(reciprocal ventricular action )

Volume compensation chamber is not necessary

in pumps with reciprocal ventricular action

(Abiocor)

Syncardia

Cardiowest

Kunstherz

Copeland, J. G. et al. N Engl J Med 2004;351:859-867

Overall Survival Rate from the Time of Study Entry to the Termination of the Study among the Patients Who Received a Total Artificial Heart According to Protocol and the Controls

What did we learn in recent years?

Long-term circulatory assistance

Totally implantable biventricular artificial heart is

rarely used: difficult anticoagulation, mechanical

defects, infection, embolization, limited mobility

There is a widespread use of LVADs (Left Ventricular

Assist Device), as „Bridge to Transplant“, and

emerging as permanent solution (“Destination

Therapy”)

NOVACOR “Dual pusher plate

system”

NOVACOR “Dual pusher plate

system”

NOVACOR “Dual pusher plate

system”

Heart Mate XVE Device

Components

Heart Mate Device

HEARTMATE II AXIAL FLOW PUMP

THE NASA DE BAKEY LVADTM

OUTFLOW

GRAFT

LVAD

MICROMED LVAD ACTION

LVAD unloads the left ventricle; aortic valve remains

closed, and still there is pulsatile pressure curve

in the aorta

LVADs are not created equal: Micromed DeBakey is a

minimal pump, and a LionHeart is much bigger device!

Axial flow

pump

Transit-time

flowmeter

Aortic graft

19 year old patient with

muscular dystrophy and

cardiomyopathy, LVAD

implant in profound

cardiogenic shock; fully

recovered and mobile 2

weeks after surgery.

Successful heart

transplant 4 months

later.

Special devices for pediatric use: Berlin Heart

Trend towards smaller pumps: Coraid

Device

ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by VAD usage (Transplants: 1/1999-6/2003)

50

60

70

80

90

100

0 1 2 3 4 5

Years

Su

rviv

al (%

)

Heartmate/Novacor (N=1,055) No LVAD (N=7,000)

p = 0.022

ISHLT 2005

Note: Only 32 transplants involving

continuous flow devices and 33 with

ECMO; too few to analyze.

J Heart Lung Transplant 2005;24: 945-982

Physical exercise in patients with

DeBakey LVAD (Zurich Experience)

• No pump manipulation necessary

• Flow increase up to 50% above

resting values regularly observed

during exercise.

• Prior to TX all patients reached

normal level of activity (NYHA I - II)

• Ambulatory treatment possible:

patients can leave the hospital

NEW GENERATION OF AXIAL-

FLOW PUMPS Recent insights

• It is not necessary to replace the whole

heart: most patients recover with an efficient

left heart bypass device alone.

• High PVR normalizes with prolonged

pumping

• Small size of the device is essential.

• High-speed (8’000-10’000 RPM) axial-flow

pumps are not necessarily hemolytic.

• Early ambulation and full mobility greatly

accelerate patient’s recovery.

Copyright ©2004 The Society of Thoracic Surgeons

Dembitsky, W. P. et al.; Ann Thorac Surg 2004;78:2123-2130

Freedom from left ventricular assist device (LVAD) failure

Clinical requirements for a widely

usable LVAD

• Reliability (safe operation ~ 2 years)

• Small size

• Needs only a low-degree anticoagulation (INR 2.0 –

2.5)

• Transcutaneous energy transfer (no wires exiting

the body)

• Several sizes of the device (children, small females,

etc.)

• Self-regulation (exercise, sleep)

• Quiet operation

• Affordable price (50 – 100 K€)

Presently, such a device does not exist!

Time between overhaul (TBO) in some well known objects

Robinson helicopter: 2’200

hours (92 days)

Piston aeroplane engine:

1’600 hours (67 days)

Jet engine: 5’000 – 8’000

hours (208 - 333 days); but

time between engine

maintenance 80-100 hours

(3-4 days)

Present state of the art in the field of

assisted circulation Summary

• LVADs belong to clinical routine in a well equipped

center.

• Best results are obtained as the bridge to transplant.

• Total orthotopic artifical heart still has too many

complications and cannot be recommended for

everyday use.

• Mechanical circulatory assistance is a cost- and

resources-intensive treatment.

• Such therapy remains reserved for a few

specialized, supraregional centers.