Newer Advances in Heart Failure Device Therapy

Newer advancements in heart
failure device therapy
» DR. GOPI KRISHNA

NEWER ADVANCES IN HEART FAILURE
DEVICE THERAPY

Introduction
• Heart failure prevalence is rising throughout the world.

• The reasons for this pandemic include
• the aging populations of both industrialized and
developing nations;
• a growing incidence of obesity, diabetes, and
hypertension .
• improved survival after myocardial infarction; and
success in preventing sudden cardiac death .
• Fortunately, therapies that have emerged during the
past few decades can greatly improve outcomes in
heart failure patients.
DEVICE THERAPY

Prevalence rates of heart
failure by gender and age in
the United States

Data from American Heart Association:
NEWER ADVANCES IN HEART FAILURE and Stroke Statistics
Heart Disease
DEVICE THERAPY

Stages of Heart Failure

DEVICE THERAPY

management

DEVICE THERAPY

• I.C.D
• C.R.T.-P/D.
• TEMPERORY SUPPORT DEVICES.
• PERMENENT SUPPORT DEVICES.
• OTHER SUPPORT DEVICES.

DEVICE THERAPY

I.C.D
SCD Rates in CHF Patients with LV Dysfunction
Total Mortality
30
Sudden Death
Control Group Mortality

20
20 19
17
15

11
10 9
8
7
6
4

0 CHF-STAT GESICA SOLVD V-HeFT I MERIT-HF CIBIS-II CARVEDILOL-US
45 months 13 months 41.4 months 27 months 12 months 16 months 6 months

Total Mortality ~15-40%; SCD accounts for ~50% of the total deaths.
DEVICE THERAPY

ICD

DEVICE THERAPY

Evolution of ICD Therapy:
1980 to Present 2000
2002
MADIT-II
ICDs
with
Cardiac 2004
1997/8 Resynch
SCD-HeFT
Number of Worldwide ICD Implants Per Year
Dual-Chamber
ICDs COMPANION
Size
Reduction
1980 1989 AVID
90,000 First Human CASH
•Transvenous Leads
80,000 Implant
1985 •Biphasic Waveform CIDS

70,000 FDA
Approval of
60,000 ICDs 1993
Smaller 1999
50,000 Devices
 AT Therapies
 MUSTT
40,000 1988

30,000 Tiered
Therapy
1996
 MADIT
20,000  Steroid-eluting Leads

10,000  Increased Diagnostic and
Memory Capacity
0
1980 1985 1990 1995
DEVICE THERAPY
2000 2005

DEVICE THERAPY

Cardiac resynchronistion therapy

DEVICE THERAPY

SCD in Heart Failure
100% QRS
Duration
(msec) • QRS duration is an
independent predictor
Cumulative Survival

90% <90
of mortality (>140 ms)
90-120
• Other factors are:
80%
120-170
age, creatinine, EF,
170-220 and HR
70%

>220
60%
0 60 120 180 240 300 360
Days
. NEWER ADVANCES IN HEART FAILURE
DEVICE THERAPY

Cardiac resynchronistion therapy

Right Atrial
Lead

Left Ventricular
Lead

Right Ventricular
Lead

DEVICE THERAPY

Achieving Cardiac
Resynchronization
Goal: Atrial synchronous
biventricular pacing Right Atrial
Lead
Transvenous approach for left
ventricular lead via coronary
sinus
Left Ventricular
Back-up epicardial approach Lead

Right Ventricular
Lead

Cumulative Enrollment in Cardiac
Resynchronization Randomized
Trials
4000
Cum ulat ive Pat ient s

CARE HF
MIRACLE ICD
3000 MIRACLE
MUSTIC AF MIRACLE ICD II
2000 MUSTIC SR
COMPANION

1000 PATH CHF
PATH CHF II
CONTAK CD
0
1999 2000 2001 2002 2003 2004 2005
Result s Present ed

NEWER ADVANCES IN HEART
FAILURE DEVICE THERAPY

Anatomical Challenges

• Enlarged right atrium
• Abnormal CS location
• Presence of valves in CS
• Altered CS angulation
• Acute branch take offs
• Tortuous vessel anatomy

DEVICE THERAPY

CRT Procedure and Device Related Risks
relative to CS placement

• CS lead dislogdement 8%
• CS dissection or perforation 5%
• Failure of lead placement 8%
• Phrenic nerve stimulation 2%

– ALL other risks associated with pacer or ICD implantation
and anesthesia in these patients.

DEVICE THERAPY

The 3 levels of asynchrony
1. Intraventricular asynchrony is best treated by
placing the LV lead in the best anatomic location-
usually the lateral or posterolateral (proven my
multiple studies). Get the LV working.
2. Interventricular asynchrony is dealt with by
adjusting the V-V interval. Get the RV and the LV to
work together.
3. A-V asynchrony is dealt with by adjusting the A-V
interval. Get the atria and the ventricles working
together.

DEVICE THERAPY

Extending indications to class II
• REVERSE.
• MADIT-CRT.
• RAFT

DEVICE THERAPY

The HF clinical composite response.

Linde C Europace 2009;11:v72-v76

Published on behalf of the European Society of Cardiology. All rights reserved. © The AuthorHEART
NEWER ADVANCES IN FAILURE
2009. For permissions please email: journals.permissions@oxfordjournals.org. DEVICE THERAPY

Mean LVESVi, LVEDVi, and LVEF at baseline and 12-month follow-up in the CRT-OFF and
CRT-ON groups.


DEVICE THERAPY

Time to first HF hospitalization or death in the 18-month follow-up period in the CRT-OFF and
CRT-ON groups.


DEVICE THERAPY

Other trials

• rethinQ
• PROSPECT trial.

DEVICE THERAPY

Assist devices
• Percutaneous.
• Implanted.

DEVICE THERAPY

I.A.B.P balloon

DEVICE THERAPY

I.A.B.P

DEVICE THERAPY

Indications for Intraaortic Balloon Pump
Counterpulsation

DEVICE THERAPY

complications
• vascular compromise
• aortic dissection,
• aortoiliac laceration,
• femoral artery pseudoaneurysm
• retroperitoneal hemorrhage,
• renal ischemia from malposition,
• myocardial ischemia from poor timing of balloon
augmentation,
• deep wound infection requiring operative débridement

DEVICE THERAPY

TANDEM HEART

DEVICE THERAPY

IMPELLA LP2.5 SYSTEM

DEVICE THERAPY

Effect of IABP and Impella 2.5 device on
important hemodynamic parameters

DEVICE THERAPY

Contraindications
• 1. Mural thrombus in the left ventricle
• 2. The presence of a mechanical aortic valve device
• 3. Moderate aortic stenosis or moderate to severe aortic
insufficiency
• 4. Abnormalities of the aorta that would preclude surgery,
including aneurysms and extreme tortuosity or
calcifications.
• 5. Renal failure (creatinine>4 mg/dL)
• 6. Liver dysfunction or markedly abnormal coagulation
parameters.
• 7. Recent (within 3 months) stroke or transient
ischemic attack

DEVICE THERAPY

THE REITAN CATHETER PUMP

PUMP IMPLANTATION HEMODYNAMIC EFFECTS

DEVICE THERAPY

Algorithm for device selection.

DEVICE THERAPY

PERMENENT V.A.D.

DEVICE THERAPY

History of lvad

DEVICE THERAPY

Mechanical Circulatory Support

DEVICE THERAPY

Mechanical Circulatory Support
INDICATION NOMENCLATURE DEFINITION
Bridge to transplantation Patient is listed for heart transplantation

Patient initially deemed ineligible for heart
transplantation because of comorbidity
Bridge to candidacy (cardiorenal syndrome or pulmonary
hypertension), which improves during
mechanical support

Patient with a potentially reversible cause
of cardiac decompensation (acute
Bridge to recovery
myocarditis, postcardiotomy syndrome,
peripartum cardiomyopathy)
Patient in whom the potential for
Bridge to decision
transplantation or recovery is yet unclear
Patient in whom recovery or
Destination therapy
transplantation is not feasible
DEVICE THERAPY

First generation Second generation

Third generation
DEVICE THERAPY

1st generation

2nd generation

NEWER rd
3 ADVANCES IN HEART FAILURE
generation
DEVICE THERAPY

FIRST GENERATION DEVICES
FEATURES The Abiomed BVS 5000i
• is a short-term uni- or
biventricular support
system .
• comprised of two 100 mL
polyurethane blood sacs.
• the inlet and outlet
portions of which are
guarded by polyurethane
valves

DEVICE THERAPY

Pulsatile Devices

• has a titanium-alloy external
housing, with inflow and
outflow conduits that use
porcine xenograft valves.

• Internal blood-contacting
surface is made of textured
titanium that results in the
development of a pseudo-
neointima on which thrombus
formation is greatly reduced,
thereby decreasing the need
for anticoagulation.

DEVICE THERAPY

Thoratec paracorporeal VAD
Para carporial
• actual pump chamber is
outside of the body.
• this device can be used on
patients with body sizes too
small to house the HeartMate
or Novacor devices (i.e., <1.5
m2).
• Pneumatic drivers provide
alternating air pressure to fill
and empty the blood pump.
• Anticoagulation with warfarin
is necessary, as for patients
with mechanical valves.

DEVICE THERAPY

2 generation
nd

DEVICE THERAPY

The Jarvik 2000 implanted in the apex of the left ventricle
outflow graft anastomosed to the
descending aorta.

DEVICE THERAPY

• BI VENTRICULAR SUPPORT

DEVICE THERAPY

• A Jarvik 2000-C removed for
transplant after 3 months
with no thrombus present
on the cone bearings.

DEVICE THERAPY

• The junction of the
microsphere coating with
• the myocardial tissue at the
apex is well healed by 2
• months, and free of
thrombus.
• A healthy adherent
neointema is seen growing
into the porous
microsphere surface.
DEVICE THERAPY

Miniature Ventricular Assist Device

DEVICE THERAPY

CircuLite Synergy Pocket Micropump

DEVICE THERAPY

• RV dysfunction is an important source
of morbidity and mortality after LVAD
insertion.
• Recent data demonstrates that early planned
institution of RV support can mitigate the
potential adverse consequences of RV
dysfunction after LVAD placement.

DEVICE THERAPY

Parameters identified as risk factors for RV
failure after LVAD placement

DEVICE THERAPY

INTERMACS: profiles for patient
selection

DEVICE THERAPY

The C-Pulse ( implantable, extra-aortic counterpulsation
device)

DEVICE THERAPY

Symphony Counterpulsation Device

DEVICE THERAPY

TOTAL ARTIFICIAL HEART

DEVICE THERAPY

Effects of Chronic Hemodynamic Unloading with Ventricular
Assist Devices

Structural
• Regression of myocyte
hypertrophy.
• Reduction in
neurohormonal activation
• Normalization in expression
of contractile proteins .
• Enhanced electron
transport chain respiratory
function
• Decreased apoptosis and
cellular stress markers DEVICE THERAPY

• Functional
• Improvement in left ventricular ejection
fraction and diastolic and systolic dimension
• Recovery from spherical to more elliptical left
ventricular shape
• Improvement in heart failure–specific indices
of quality of life
• Improvement in peak aerobic capacity
DEVICE THERAPY

complications
• Anticoagulation.
• Drive line infections .
• Noise.
• Durability.
• Activation of immune system.

DEVICE THERAPY

epicardial pads secured and used to
tighten the device.
DEVICE THERAPY

The CorCap device

DEVICE THERAPY

Percutaneous Leaflet Repair and Annuloplasty for Mitral
Regurgitation

DEVICE THERAPY

EVEREST II Randomized Clinical Trial
Key Inclusion/Exclusion Criteria

Inclusion Exclusion
– Candidate for MV Surgery – AMI within 12 weeks
– Moderate to severe (3+) or – Need for other cardiac surgery
severe (4+) MR – Renal insufficiency
• Symptomatic • Creatinine >2.5mg/dl
– >25% EF & LVESD ≤55mm – Endocarditis
• Asymptomatic with one or more – Rheumatic heart disease
of the following
– LVEF 25-60%
– MV anatomical exclusions
– LVESD ≥40mm • Mitral valve area <4.0cm2
– New onset atrial fibrillation • Leaflet flail width (≥15mm) and
– Pulmonary hypertension gap (≥10mm)
• Leaflet tethering/coaptation
ACC/AHA Guidelines JACC depth (>11mm) and length
52:e1-e142, 2008
(<2mm)

Investigational Device only in the US;
90
Not available for sale in the US

Figure 6. Core laboratory tracings of the mitral annulus and leaflet line of coaptation from 3D
echo data sets recorded at preprocedure baseline and follow-up time points noted from
patients with PTMA implants still observed by x-ray to be in place.

Sack S et al. Circ Cardiovasc Interv 2009;2:277-284

Copyright © American Heart Association

From: Percutaneous Leaflet Repair and Annuloplasty for Mitral Regurgitation

J Am Coll Cardiol. 2011;57(5):529-537. doi:10.1016/j.jacc.2010.10.012

Figure Legend:
Direct Annuloplasty

The Guided Delivery Systems Accucinch device is delivered through
retrograde catheterization of the left ventricle. (Left) Anchors are placed in the
Date of download:mitral annulus and (right) connected with a “drawstring” to cinch the
posterior Copyright © The American College of Cardiology.
11/6/2012 All rights reserved.
annular circumference.

nk you
•T ha

DEVICE THERAPY

Newer Advances in Heart Failure Device Therapy

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

Similaire à Newer Advances in Heart Failure Device Therapy

Similaire à Newer Advances in Heart Failure Device Therapy (11)

Plus de Gopi Krishna Rayidi

Plus de Gopi Krishna Rayidi (15)

Newer Advances in Heart Failure Device Therapy

Notes de l'éditeur