Download Ventricular Assist Device

Ventricular Assist
Device
A/P Ong Biauw Chi
Dept of Anaesthesia and Surgical
Intensive Care
Singapore General Hospital
Beijing, Aug 2005
Introduction
The ventricular assist device is a
mechanical device to assist or support
the failing ventricle
 It can be used as a bridge to recovery in
acute reversible cardiac failure or as a
bridge to transplant in chronic terminal
heart failure
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Beijing, Aug 2005
Introduction
The assist devices are capable of left,
right or bi-ventricular support as
required
 The devices can be further grouped as
short, mid and long term device
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Beijing, Aug 2005
Device Available
Short-term devices include the IntraAortic Balloon pump, Extra-Corporeal
Membranous Oxygenator (ECMO) and
the ABIOMED BVS 5000
 These devices are designed to support
the patient for up to 2 weeks.
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Beijing, Aug 2005
External Device Available
The mid-term device available include
the Thoratec VAD that has been used
for up to 500 days
 Both the ABIOMED and Thoratec have
a right and left heart support capability
and are external devices.
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Implantable Device Available
The long-term device available include
the HeartMate VE LVAS pump
 This is a left ventricular assist device
that is implanted within the body
 The device is portable and the patient is
able to ambulate and return home.
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Implantable device
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Heart mate II which is smaller in size
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Beijing, Aug 2005
Implantable Device
The MicroMed DeBakey which is small
and works on an axial pump
 The Novocor
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Beijing, Aug 2005
Indications
Post cardiopulmonary bypass and
unable to wean off
 Acute cardiogenic shock after AMI
 Cardiogenic shock from
cardiomyopathies
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Contra-indications
Irreversible multi-organ failure
 Irreversible neurological injury
 Body surface area less than 1.5 for
heart mate implantation
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The Singapore General
Hospital Experience
Beijing, Aug 2005
Devices available
Abiomed
 Thoratec
 Heartmate VE LVAS
 MircoMed DeBakey
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Beijing, Aug 2005
Our experience
Heartmate LVAD 3 patients
 Thoratec Bi VAD 2 patients
 Abiomed LVAD 5 patients
 Abiomed RVAD 1 patient
 Abiomed Bi VAD 3 patients
 MicroMed DeBakey 2 patients
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Beijing, Aug 2005
Case History

Dilated cardiomyopathy after
pregnancy, idiopathic, ischeamic, post
viral myocarditis as the primary
diagnosis 8 patients of whom 5 died,
one was successfully explanted, one
went on to a transplant, one was a
foreigner were was transported back to
Berlin with the BiVAD and survived to a
transplant.
Beijing, Aug 2005
Case History
4 patients received assist device when
there was difficulty weaning off bypass
from emergent cardiac surgery, 3 were
elective surgery in poor risk patients
 In this group there were only 2 survivors
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First HeartMate
The first is Zarina who was a 37 year
old lady
 Post partum cardiomyopathy
 Implanted 11/07/2002 as a bridge to
transplant
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First HeartMate
Her myocardium appeared to improve
and was planned for assessment and
possible explantation on 22/07/2002 (1
year later)
 Unfortunately she died of pseudomonas
septicemia just a few days before this
(16/07/2002)
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Second HeartMate
LNP is a 42 year old man with idiopathic
dilated cardiomyopathy
 Implanted on 17/10/2001 as a bridge to
transplant
 He is awaiting a heart transplant
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First Thoratec

WCH was a 46 year old man with ischemic
cardiomyopathy, LVEF of 15% and AF
 Elective CABG and radiofrequency ablation
 On the 3rd POD the BiVAD Thoratec was
implanted emergently because of heart failure
 He died 5 days later from sepsis, renal and
liver failure
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Second Thoratec
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TLH is a 41 year old lady
Post viral myocarditis a week after a viral
fever
Her cardiac index was 1 and venous
saturation 50%
BiVAD Thoratec was implanted on 2/6/2002
as a bridge to recovery/transplant
She is waiting for a transplant
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First Abiomed
Steven is a 64 year old man who had 2
previous CABG and had a heart
transplant on 28/06/2002
 He could not be weaned off bypass and
a BiVAD Abiomed was implanted
 This was explanted a week later when a
second heart transplant was performed
 He is awaiting neurological recovery
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Second Abiomed
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Mr Singh is a 59 year old man who came in
with AMI, MR and pulmonary edema
 He had an emergency CABG and MVR
 Could not wean off bypass and a LVAD
Thoratec was implanted 27/7/2002 as a
bridge to recovery
 He was explanted on 1/8/2002 and is
recovering well
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MicroMed DeBakey
Our first patient had idiopathic
cardiomyopathy with EF of 10-15%.
Unfortunately he died of an intracranial
bleed at 34 days. This device needs
anticoagulation.
 The 2nd patient had ischeamic
cardiomyopathy. At the time of implant
he was on treatment for pneumonia and
died 6 days later from fulminant sepsis.
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Coagulation
The Thoratec, Abiomed and MicroMed
DeBakey require anticoagulation
 The HeartMate has a coated surface
and only needs aspirin post-operatively
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Cost of Device
HeartMate and MicroMed Debakey:
$190,000
 Thoratec: each $49,000-$60,000
 Abiomed: each $14,000
 Surgical and ICU cost: about $130,000
for the first month
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Anaesthesia
Large bore IV and swan sheath for
transfusion
 Rapid infusor
 PA line (continuous)
 Echo machine for TEE (exclude PFO)
 Nitric oxide
 Blood and products
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Beijing, Aug 2005
Anaesthesia
Careful aseptic technique
 Prophylactic antibiotic regime
 Heparin
 Protamine
 Aprotinin may be required
 May be required to draw blood for
spinning to coat the graft
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Lessons Learnt (Anaesthesia)
Anaesthesia: the SVR is usually very
low after the insertion of the device.
Therefore be prepared for this and I
personally do not use propofol infusion
while on the pump
 Prepare Noradrenaline in readiness
before the device takes over the flow
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Lessons Learnt (Anaesthesia)
Arterial line may be extremely difficult to
insert
 The preparation takes a long time
 It may be good to set lines the day
before and optimise the patient on
drugs like milrinone
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Lessons Learnt (Patients)
The selection of patient is important but
difficult
 In elective cases the patient must be
motivated and able to share the care
and understand the care (our first 2
patients)
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Lessons Learnt (Patients)
In general those who come in and
require emergent implantation do not do
well
 Family support is important since they
may stay in the hospital for months
before discharge
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Lessons Learnt (Patients)
When used to support inability to wean
off pump the ones who do well are
those where the possible plan of a
device implantation is planned before
the surgery
 Not every patient who does not wean off
pump will benefit from “resting the
heart”
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Lessons Learnt (Patients)
The timing is crucial for elective
insertions
 Too early it may be a waste of the
device and also expose the patient to
risk
 Too late and the patient may be infected
and unable to be ready for the
implantation like our last patient
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Beijing, Aug 2005
Lessons Learnt (Team)

This is not a situation where the cardiologists
refers the patient, the surgeon decides and
the anaesthetist only knows about the case
the day before
 We come together as a team to discuss the
patients echo, interact with the patient to
understand the family support, the personality
and his fears and problems
Beijing, Aug 2005
Lessons Learnt (Team)
The team includes the post-op care
nurses, physiotherapy and support staff
to see the patient home
 They are also prepared as for a bridge
to transplant or recovery
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Beijing, Aug 2005
Conclusion
Expensive program which require
support and commitment from all
involved
 A necessary program if the basic
cardiac program is well established and
there is a heart transplant program
 Exciting new frontier where new
development is still ongoing
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Beijing, Aug 2005