6/22/2013 Mechanical Support of the Right Ventricle in Children with Pulmonary Hypertensive Vascular Disease 6 th International Conference Neonatal & Childhood Pulmonary Vascular Disease San Francisco, California June 21-22, 2013 Ivan M. Rebeyka, M.D. University of Alberta & Stollery Childrens Hospitals Edmonton, Alberta, Canada Disclosures Disclosures No conflicts to disclose 1
6/22/2013 LVAD Support as a Bridge to Transplant in Patients with Heart Failure Complicated by Pulmonary Hypertension Heart transplant listing criteria Heart transplant listing criteria LVAD Support as a Bridge to Transplant in Patients with Heart Failure Complicated by Pulmonary Hypertension Mortality vs Pulmonary Vascular Resistance PVR Transplant Transpulmonary Basic Premise Basic Premise Mortality (WU.M 2 ) Gradient (TPG) < 5% < 4 < 10 Low risk “ Unloading of the LV via LVAD support can “ Unloading of the LV via LVAD support can 10% 4 - 6 10 - 15 improve pulmonary hemodynamics and improve pulmonary hemodynamics and Medium Risk improve candidacy for transplantation “ improve candidacy for transplantation “ 20% > 6 > 15 High risk 2
6/22/2013 LVAD support in patients with end-stage heart failure and pulmonary hypertension - Improves pulmonary hemodynamics - Improvement in PVR/TPG usually occurs early and is sustained - Is associated with acceptable risk - Independent of device type - ?? Should be considered in all cardiac transplant candidates previously considered to have irreversible pulmonary hypertension Mechanical Circulatory Support Options Mechanical Circulatory Support Options for Pulmonary Hypertension for Pulmonary Hypertension 1. Extracorporeal Membrane Oxygenation (ECMO) 2. Right Atrium to Pulmonary Artery (classical RVAD) 3. Pulmonary Artery to Left atrium (with Novalung) 4. Right Atrium to Aorta (with pump and oxygenator) 3
6/22/2013 Short-term VAD vs ImplantableVAD Short-term VAD vs ImplantableVAD Pediatric Mechanical Circulatory Support Pediatric Mechanical Circulatory Support Emergency support (ECMO) Short-term support (“Bridge to Decision device”) CentriMag CentriMag Long-term support HeartWare HeartWare $5,000.00 $5,000.00 $100,000.00 $100,000.00 (Implantable VAD) Mechanical Circulatory Support Options Mechanical Circulatory Support Options Extra Corporeal Membrane Oxygenation Extra Corporeal Membrane Oxygenation for Pulmonary Hypertension for Pulmonary Hypertension (ECMO) (ECMO) 1. Extracorporeal Membrane Oxygenation (ECMO) 2. Right Atrium to Pulmonary Artery (classical RVAD) 3. Pulmonary Artery to Left atrium (with Novalung) 4. Right Atrium to Aorta (with pump and oxygenator) 4
6/22/2013 ECMO Complications ECMO Complications Mechanical Circulatory Support Options Mechanical Circulatory Support Options for Pulmonary Hypertension for Pulmonary Hypertension 1. Extracorporeal Membrane Oxygenation • Bleeding, Bleeding, Bleeding (ECMO) • Neurological injury 2. Right Atrium to Pulmonary Artery (classical RVAD) • Lung / liver / renal dysfunction 3. Pulmonary Artery to Left atrium • LV not decompressed (with Novalung) 4. Right Atrium to Aorta (with pump and oxygenator) RVAD / LVAD Support RVAD / LVAD Support Mechanical Circulatory Support Options Mechanical Circulatory Support Options for Pulmonary Hypertension for Pulmonary Hypertension LVAD RVAD 1. Extracorporeal Membrane Oxygenation (ECMO) Inflow - LA Inflow - RA 2. Right Atrium to Pulmonary Artery Outflow - Aorta Outflow - PA (classical RVAD) 3. Pulmonary Artery to Left atrium (with Novalung) 4. Right Atrium to Aorta (with pump and oxygenator) 5
6/22/2013 Mechanical Circulatory Support Options Mechanical Circulatory Support Options for Pulmonary Hypertension for Pulmonary Hypertension 1. Extracorporeal Membrane Oxygenation (ECMO) 2. Right Atrium to Pulmonary Artery (classical RVAD) 3. Pulmonary Artery to Left atrium (with Novalung) 4. Right Atrium to Aorta (with pump and oxygenator) Novalung vs Quadrox Novalung vs Quadrox PA - LA Novalung Assist PA - LA Novalung Assist Novalung Quadrox Polymethylpentine (PMP) Polymethylpentine (PMP) Low resistance High resistance No pump needed Pump required Good CO2 clearance Good CO2 clearance Poor oxygen transfer Good oxygen transfer 6
6/22/2013 Mechanical Circulatory Support Options Mechanical Circulatory Support Options for Pulmonary Hypertension for Pulmonary Hypertension 1. Extracorporeal Membrane Oxygenation (ECMO) 2. Right Atrium to Pulmonary Artery (classical RVAD) 3. Pulmonary Artery to Left atrium (with Novalung) 4. Right Atrium to Aorta (with pump and oxygenator) PA – LA cannulation PA – LA cannulation RVAD / LVAD Support RVAD / LVAD Support (with Novalung) (with Novalung) LVAD RVAD Pros - better RV unloading Inflow - LA Inflow - RA - simpler circuit (no pump) Outflow - Aorta Outflow - PA Cons - thromboembolism risk (especially in children) - requires good RV / LV function - flow not adjustable 7
6/22/2013 RA – Aortic cannulation RA – Aortic cannulation (with pump and oxygenator) (with pump and oxygenator) Pros - not dependent on RV / LV function - flow adjustable (CentriMag) - better oxygenation (Quadrox) - stable cannulae for patient mobilization Cons - less RV unloading Salvage Cardiectomy Salvage Cardiectomy Salvage Cardiectomy Salvage Cardiectomy Atrial cannula Goretex graft Goretex graft Gelweave graft to aorta to aorta to left atrial cuff Aortic cannula Berlin Heart cannulae 8
6/22/2013 CentriMag support CentriMag support Salvage Cardiectomy Salvage Cardiectomy following total excision of heart following total excision of heart Atrial cannula Aortic cannula Saline bag filler Thank you for your attention Thank you for your attention 9
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