Download INTERMACS LEVEL 1 - Scioto County Medical Society

QUEST FOR ULTIMATE CURE
“MODEL T” to “DREAM THERAPY”
Where is the MIRACLE BULLET?
Chittoor B. Sai Sudhakar, MD, FRCS
The Holy Grail !!!!!!!!
Treatment of Symptomatic CHF
5 classes of drug
ACE inhibitors
Beta blockers
Aldosterone antagonist
Nitrates and Hydralazine
Angiogenesis II receptor blockers
First Device as BTT
Designed by Dr. Domingo
Liotta, 1969
This heart was the first to be
implanted in a human being
as a bridge to transplant by
Dr. Denton A. Cooley.
The patient survived for
almost three days with the
artificial heart and 36 hours
more with a transplanted
heart.
Jarvik-7
Drs. Willem Kolff,
Donald Olsen, and
Robert Jarvik
First human implant
1982
– Destination Therapy
200 patients bridged
(Jarvik-7/Symbion)
Heartmate XV & XVE
Has been the workhorse for a long time
Does not need anti-coagulation
Bulky
Lasts for a 12-24 months
Our record is 32 months and going
REMATCH Trial
(Randomized Evaluation of Mechanical Assistance for the
Treatment of Congestive Heart failure)
Inclusion criteria resembled those for Heart TX
Class IV CHF
LVEF <25%
Peak oxygen consumption <12-14ml/kg/min
Inotrope dependent
Profiles of HF in different trials
REMATCH patients were much sicker
Group intermediate in severity between Status I & II
heart transplant candidates
Stevenson, L. W. et al. Circulation 2003;108:3059-3063
REMATCH Survival
Inotrope dependent at randomization – 91pts
6 mth
1 year
2year
LVAD
60%
49%
28%
OMM
39%
24%
11%
Not on inotrope at randomization – 38pts
LVAD
61%
57%
OMM
67%
40%
Heartmate II
VentrAssist
298 gms, 6 cms, size of a hockey puck
Single moving part – hemodynamically suspended impeller
Electromagnetic field rotates the impeller
HeartWare
Miniaturized centrifugal pump
Totally Intrapericardial
Single moving part and no mechanical bearings
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Long Term Support
60
50
40
30
20
2005
2006
2007
2008
2009
10
0
INTERMACS: Patient Selection
Patient Profile/ Status: INTERMACS Levels
1.
Critical cardiogenic shock
2.
Progressive decline
3.
Stable but inotrope dependent
4.
Recurrent advanced HF
5.
Exertion intolerant
6.
Exertion limited
7.
Advanced NYHA III
PROFILE-LEVEL
# Pts
Yr 1
Official Shorthand
General time frame
for support
INTERMACS
LEVEL 1
82
“Crash and burn”
Hours
INTERMACS
LEVEL 2
81
“Sliding fast”
Days to week
INTERMACS
LEVEL 3
18
Stable but
Dependent
Weeks
INTERMACS
LEVEL 4
9
“Frequent flyer”
Weeks to few
months, if baseline
restored
INTERMACS
LEVEL 5
4
“Housebound”
Weeks to months
INTERMACS
LEVEL 6
3
“Walking wounded”
Months, if nutrition
and activity
maintained
INTERMACS
LEVEL 7
4
Advanced Class III
Definition of heart failure populations with decreasing estimated
mortality
Stevenson, L. W. et al. Circulation 2003;108:3059-3063
Seattle Heart Failure Model
Right Heart Failure predictor
Elevated CVP is the single most important factor
Other factors:
PA pressures
RVSW
RVSWI
Degree of RV dysfunction
Tricuspid Annular Excursion
INTERMACS
Kirklin JK, et al. J Heart Lung Transplant ; 2008:1065-1072
Case Report
50 YO M ICM
Heartmate XVE placed 4/13/06
– Complicated by persistent Enterococcus
bacteremia
Replaced with Heartmate XVE 11/2/06
– Infection cleared, was doing well
Admitted 3 months later because high
power utilization and batteries burning out
M. Firstenberg
LVAD Thrombosis
M. Firstenberg
LVAD Thrombosis
M. Firstenberg
VAD endocarditis
M. Firstenberg
VAD Thrombosis
Migration
LOH 4 months
Post-op
Migration
GF 10days post-op
Lead Fractures : Multi-Institutional Experience
OSU, St. Vincent’s (Indiana), U of Minnesota
HIGH TECH PROBLEM!!!!!
Lead fracture in Ventrassist
LOW TECH SOLUTION
Other therapies – Immune Adsorption
Several antibodies against the cardiac proteins
IA removes these antibodies
Immune Adsorption
9 patients in each arm
High anti beta-1 adrenoceptor auto antibodies
IA for five courses followed by IgG substitution
Improvement in functional class at 3 months
In our lab at OSU
Ovine model of heart failure
Embolization technique
Beads
Aggregated platelets
LAD ligation
Picture 1. Fluoroscopy picture of left
circumflex artery cannulated with 6F
catheter and injected with 90um
polyester micro beads
Cytokine Expression
Cytokines
Thrombus
embolized
Bead embolized
LAD ligated
GFR alpha-3
5322
4764
1609
MIG
5092
2505
1739
IL-1 alpha
4983
4487
2815
TGF-beta 1
4681
2580
1282
IL-15
4661
3673
2536
IFN-gamma
4087
2302
1348
IL-3
4087
1572
1961
IL-13
3857
54
1622
GRO
3416
2262
1914
MCP-1
2988
2275
1821
IFN-alpha / beta R2
2878
2226
666
MCP-2
2689
1
342
Fas / TNFRSF6
2412
2388
1344
ICAM-1
2109
1
671
Epiregulin
2103
1826
483
Chandrakala
Our ongoing Investigation
Autoantibodies to CEC & ERP
Inhibit the homing mechanisms of BM derived EPC
Inhibition of Angiogenesis, Neovascularization and Repair
Are there any magic bullets for cure out there?
If there is one then we can sing praises:
Shot through the heart, you give VAD a bad name
Thank you