ECHO 2013 / Echocardiography in Advanced Heart Failure Mechanical Support
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Echocardiography in Advanced Heart Failure:
Mechanical Support
Michael H. Picard
Massachusetts General Hospital
Harvard Medical School
No disclosures
Role of echocardiography in heart failure
•Define cardiac structure
–Are symptoms due to systolic dysfunction, diastolic dysfunction, valvular disease, other cardiac things or non-cardiac etiologies
•Prognosis
•Eligibility for advanced therapies
•Monitor response to therapy
•Identify complications
Treatments for advanced heart failure when medical therapy is not enough
•Revascularization
•Valve repair/replacement
–Don’t forget the TV
•Cardiac resynchronization therapy
•Cardiac transplantation
•Mechanical support (LVAD, etc)
•Experimental surgical procedures
–LV remodeling
LVAD Mechanical support principles
•Blood removed from heart
–Inlet cannula (LV apex)
•Pump generates flow and pressure
–Continuous flow
–Pump flow is partially preload dependent
–Creates a degree of pulsatility in outflow
• Blood delivered to ascending aorta www.Thoratec.com
– Outlet cannula
• LV can contribute some flow
Ventricular Assist Devices
•LV assist devices used in end stage heart failure as
–Bridge to heart transplant (BHT)
•REMATCH study
–“Destination” therapy (DT)
•Permanent support for those not eligible for transplant
•Smaller devices now available
–Small implantable pump
–External battery pack + system driver that are worn
–Allows patients to be mobile
•not tethered to large control module
LVAD – impact on survival
Rose et al, NEJM 2001;345;1435-43 |
Stevenson et al, Circ 2004;110;975-981 |
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Multicenter trials have shown morbidity and mortality benefits of mechanical assist devices over medical tx for BHT and DT
Other devices for shorter term LV support
•Intra-aortic balloon pump (IABP)
•Veno-arterial Extra Corporeal Membrane Oxygenator (VA ECMO)
•Percutaneous LVADs
–High risk PCI
–Cardiogenic shock where etiology thought to be quickly reversible
types of mechanical support
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Remove blood |
Inject blood into: |
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from: |
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IABP |
Aorta |
aorta |
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ECMO |
RA |
Descending |
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aorta |
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Tandem Heart |
LA |
Descending |
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aorta |
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Impella |
LVOT |
Ascending |
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aorta |
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LVAD |
LV apex or LA |
Ascending Ao |
RVAD |
RV |
Pulm artery |
BiVAD |
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Impella Recover device
cannula placed across aortic valve, pump aspirates blood from the LV cavity and expels it in the ascending aorta
Catena et al, JASE 2004;17:470-3
Meyns et al, JACC |
Lee + Makkar, Cardiol Clinics |
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2003;41:1087-95 |
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2006;24:265-275 |
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Tandem Heart device
cannula placed across interatrial septum, blood aspirated from the LA, pumped into the femoral artery
Lee + Makkar, Cardiol Clinics 2006;24:265-275