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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.

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6/22/2013 1

Mechanical Support of the Right Ventricle in Children with Pulmonary Hypertensive Vascular Disease

6th 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

SLIDE 2

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LVAD Support as a Bridge to Transplant in Patients with Heart Failure Complicated by Pulmonary Hypertension

Heart transplant listing criteria Heart transplant listing criteria

Mortality vs Pulmonary Vascular Resistance

Transplant Mortality

PVR (WU.M2)

Transpulmonary Gradient (TPG)

Low risk

< 5% < 4 < 10

Medium Risk

10% 4 - 6 10 - 15

High risk

20% > 6 > 15

LVAD Support as a Bridge to Transplant in Patients with Heart Failure Complicated by Pulmonary Hypertension

“ Unloading of the LV via LVAD support can improve pulmonary hemodynamics and improve candidacy for transplantation “ “ Unloading of the LV via LVAD support can improve pulmonary hemodynamics and improve candidacy for transplantation “

Basic Premise Basic Premise

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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 for Pulmonary Hypertension Mechanical Circulatory Support Options 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)

SLIDE 4

6/22/2013 4 Pediatric Mechanical Circulatory Support Pediatric Mechanical Circulatory Support

Emergency support

(ECMO)

Short-term support

(“Bridge to Decision device”)

Long-term support

(Implantable VAD)

Short-term VAD vs ImplantableVAD Short-term VAD vs ImplantableVAD

CentriMag $5,000.00 CentriMag $5,000.00 HeartWare $100,000.00 HeartWare $100,000.00

Mechanical Circulatory Support Options for Pulmonary Hypertension Mechanical Circulatory Support Options 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)

Extra Corporeal Membrane Oxygenation (ECMO) Extra Corporeal Membrane Oxygenation (ECMO)

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ECMO Complications ECMO Complications

Bleeding, Bleeding, Bleeding
Neurological injury
Lung / liver / renal dysfunction
LV not decompressed

Mechanical Circulatory Support Options for Pulmonary Hypertension Mechanical Circulatory Support Options 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)

RVAD / LVAD Support RVAD / LVAD Support

RVAD

Inflow - RA Outflow - PA

LVAD

Inflow - LA Outflow - Aorta

Mechanical Circulatory Support Options for Pulmonary Hypertension Mechanical Circulatory Support Options 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)

SLIDE 6

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Mechanical Circulatory Support Options for Pulmonary Hypertension Mechanical Circulatory Support Options 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 Novalung Assist PA - LA Novalung Assist Novalung vs Quadrox Novalung vs Quadrox

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

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Mechanical Circulatory Support Options for Pulmonary Hypertension Mechanical Circulatory Support Options 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)

RVAD / LVAD Support RVAD / LVAD Support

RVAD

Inflow - RA Outflow - PA

LVAD

Inflow - LA Outflow - Aorta

PA – LA cannulation (with Novalung) PA – LA cannulation (with Novalung)

Pros

better RV unloading
simpler circuit (no pump)

Cons

thromboembolism risk (especially in children)
requires good RV / LV function
flow not adjustable

SLIDE 8

6/22/2013 8 RA – Aortic cannulation (with pump and oxygenator) RA – Aortic cannulation (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

Berlin Heart cannulae Goretex graft to aorta Gelweave graft to left atrial cuff Goretex graft to aorta

Salvage Cardiectomy Salvage Cardiectomy

Aortic cannula Atrial cannula

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Salvage Cardiectomy Salvage Cardiectomy

Saline bag filler Aortic cannula Atrial cannula