Bild 1

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SATS, Stockholm 2009 Lars H Lund Recovery and
Weaning from long-term LVADs
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ECMO and short-term VAD
Impella Recover Short-term Percutanoues Axial
flow 2.5-5 L/min
ECMO
Percutaneous IABP 0.5 L/min
TandemHeart pVAD Percutanoues Centrifugal axial
flow
Centrifugal axial flow extracorporeal Bidge 3M
Sarns Medtronic Bio-Medicus Levitronix Centrimag
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Pulsatile
TAH
Thoratec HeartMate I XVE Bridge Destination
(REMATCH)
Abiomed BVS 5000 and AB5000 Short-term. L- R- or
Bi-VAD. BB (BTx)
Thoratec VAD Bridge Post-cardiotomy
Novacor LVAS Bridge Destination trial (INTrEPID)
Abiomed Abiocor TAH Pulsatile
Axial flow
CardioWest TAH Pulsatile
Thoratec HeartMate II Bridge Destination
MicroMed DeBakey VAD Bridge Destination
Jarvik 2000 Bridge Destination
Ventracor VentrAssist Bridge trial
(DEVICE) Destination
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• Severe Heart Failure
• - Common
• - Deadly
• - Treatable
• In Sweden
• gt100,000 systolic heart failure 30-40 get
  ß-blockers and ACEI
• lt10 of indicated get CRT / ICD
• 10,000 NYHA IV
• 3000 benefit from transplant lt50 per year
• 500-2000 benefit from LVAD lt50 per year

OBS-CHF RiksSvikt Lund, Med Clin North Am
2004 Slaughter, ISHLT 2008 Stevenson, ISHLT
Monograph 2006
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• Cost effective?
• MCSD / LVAD improves quality of life and
  survival
• 2-yr survival destination therapy 50-70
• Cost 60,000 HMII
• 60,000 hospital care
• Cost per QALY 45,000
• yes
• Slaughter, ISHLT 2008
• Lund, Device Therapy for HF 2009

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Indicated? LVAD / MCS Guidelines -
ESC Bridge to Tx IIa C Dickstein, EHJ
2008 Destination IIb B - ACC/AHA Bridge
to Tx approved 2008 Hunt, Circ 2005 /
2009 Destination IIa B - Swedish
Socialstyrelsen Bridge to Tx 6/10 Destinatio
n FoU Nationella riktlinjer för hjärtsjukvården
Beslutsstöd, 2008 yes and becoming stronger
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Improved outcomes 1 Technology REMATCH vs. HM II
79
77
42
36
19
2
1
HM II investigators, NEJM 2007
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Improved outcomes 2 ExperienceREMATCH Learning
Curve Early vs. Late Survival in LVAD Arm
Legend
21st Century
20th Century
(12)
(4)
P.0338
(9)
(0)
12/29/02 DatasetMoskowitz
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Improved outcomes 3 Selection REMATCH survival
according to pre-op risk
K. Lietz et al. Circulation 2007
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Lund, Device Therapy for HF 2009 Lietz, in
press Potapov JHLT 2008 Ochiai Circ 02 Dang JHLT
06 Scalia J Am soc Echo 00 Puwanant JHLT
2008 Matthews JACC 2008 Lietz, Miller,
Circulation 2007
RVEDD PSAX gt35 mm RVFAC lt30 RA gt50 mm RVSWI
lt250-300-400 / lt4 RV ischemia low sPAP and mPAP
(lt25) low PVR SBP lt96 high CVP (gt15) low CI
(lt1,8-2.3) high PCWP low mixed venous
saturation transfusions female gender low
BSA non-ischemic etiology myocarditis pre-op
MCS previous cardiac surgery pulmonary
edema emergent implantation albumin
lt3.3 spontaneous INRgt1.3, PTT gt15 Hematocrit
lt34 Platelets lt150 WBC gt10 organ failure
features mechanical ventilation ascites
bili 2 crea 2.3 AST 50-80 vasopressors
Y
STOP
Contraindication AI (close valve) LV
thrombus permanent HD cirrhos och port
HT (HIT) spont INRgt2,5 sepsis recent
stroke Unclear neuro status
N
MOF most or all of ascites bili 2 creat
2.3 AST 80 mechanical ventilation
vasopressors
3-4/4 TR RV S/L gt0.6 TAPSE lt7.5
N
N
many
Y
Y
few
Lund, version 6, 20-april-2009
LVAD
BiVAD / TAH
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• Indications long-term LVAD
• - Bridge to Tx EFlt25 and
• NYHA IV and
• PCWP gt20 and
• SBP lt90 or CI lt2
• PVRgt5 or
• GFR lt25-30
• From short-term MCS
• Destination EFlt25 and
• chronic inotropes or pVO2lt12
• Bridge to recovery? 1. Potential for recovery
• 2.Transplant or destination contraindicated or
  unwanted?
• 3. Improvement but incomplete recovery?

restoration
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Recovery? Remodelling Reverse
Remodelling Lund, Device
Therapy for HF 2009
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Frank-Starling
C
A normal rest B initial insult ??CO C RAAS
? ?filling pressure catecholamines ?
?contractility
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LVAD ? Reverse remodeling
Geometric Normalize LV geometry
restoration ? EF ? LVEDD Hemodynamic ?pVO2 ?CO
?PCWP Neurohormonal ? B1-receptor (at protein
but not mRNA level) ? B2-receptors ? response to
B1 stimulation Cellular ? hypertrophy Extracell
ular ? fibrosis ?? ? cytoskeletal dystrophin
structure Ca2 handling (molecular) ? mRNA for
SERCA2a, RyR2, Na/Ca2 exchanger ? protein for
SERCA2a ? phosphorylation of RyR2 (PBMC)
Vatta Lancet 2002, Marx Cell 2000, Heerdt Circ
2000, Bruckner JHLT 2001, Ogletree-Hughes Circ
2001, Milting ISHLT 2008
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Remodelling in Heart Failure and mechanisms of
MCS recovery
Marks, J Clin Invest. 2003 Mar111(5)617-25.
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Molecular recovery 2000 Unloading ?
?phosphorylation of RyR

Marx, Reiken et al, Cell 101265
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Reproducible clinical recovery 2006

• 15 patients idiopathic DCM
• LVAD
• 2x lisinopril (Zestril) 40 x 1
• 2x carvedilol 50 x 2
• 1x spironolactone 25 x 1
• 2x losartan (Cozaar) 100 x 1
• Clenbuterol
• Most important high-dose ß-blocker

11/15 explant at 320 days 9 lived 1 year, 8
lived 4 years EF 64 Peak VO2 26
ml/kg/min MLHFQ near-normal
?
But other studies 1-40 recovery
N Engl J Med 2006 3551873-1884, Nov 2, 2006.
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How evaluate Recovery ? Harefield Recovery
Protocol, George JHLT 2007
No a priori predictors No predictors device
on EF and BP predictors device off
Also need exercise test?
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Harefield Recovery Protocol Study for Patients
With Refractory Chronic Heart Failure HARPS T
reatment clenbuterol Georgetown Montefiore Nort
hwestern Ohio state Texas Heart Minnesota Pennsylv
ania Criteria for explant at 6000 rpm (4500
rpm or 3600) LVEDD lt 6 cm LVESD lt 5 cm LVEF gt
45 PCWP lt 12 mmHg Cardiac Index gt 2.8
L/min/m2 Peak VO2 gt 16 ml/kg/min VE/VCO2 lt 34
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Weaning protocol axial flow
Aaronson, Michigan Mancini, Columbia Dandel,
Hetzer, D Herz El Banayoysi, Bad Oeyn.
Echo pump on EF lt 45 LVEDD gt 55mm Mod-sev TI
or MI
Ischemic HF gt 5 years Non-sinus rhythm Age gt
65 High NT-proBNP
N
off heparin 300E/kg bolus, ACTgt400, rpm down
for max 15 min
N approach 1
VO2 gt14 pump on Echo OK pump off BP stable
pump off
N approach 2
Y
Y
Y
N
Pump off Exercise CVP gt6 or ?gt3 PCWP gt10 or
?gt5 SBP lt90 Symptoms Supine bike lt50W ltVO2 10
In clinic repeat 3 times Full heparin to 6000
rpm Echo pump off OK
Y
N
Y
N
No recovery
Explant
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Case 1 37 year-old African-American woman Gives
birth sep 2007 10 days later pulmonary edema,
cardiogenic shock, EF 5-10, LVEDD 51 ECMO, fails
weaning HM II 6 months later NYHA I BP 80 EF
70, LVEDD 37 mm NT-proBNP 100 ng/L furosemide
20 x1 metoprolol 50 x1 ramipril 5
x2 spironolakton 25 x1 itch from
candesartan physical therapy Candidate for
weaning and explant? Yes !
Case 2 47 year-old man Active hepatitis C 2
weeks fever, weakness, fatigue EF 10-15, LVEDD
58 On dobutamine and levosimendan BP 85/60, PCW
17, CI 1.8 Impella 5.0 L, fails weaning HM II 4
months later NYHA I BP 100 EF 35, LVEDD 41
mm NT-proBNP 850 ng/L No furosemide carvedilol
50 x2 enalapril 20 x2 spironolactone 25 x1 ARB to
be added physical therapy Candidate for weaning
and explant? Yes / No ?
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Centrum för mekanisk assisterad cirkulation och
Hjärttransplantation i Mälardalen LVAD
sub-group
Perfusion Physical Therapy Nursing Linnea
Tiren Kerstin Karlsson Ann Hallberg Maria
Halseth Irene Lindell Emma Isaksson
Surgery Anaesthesiology
Cardiology Physiology Social Work Gunilla
Nilsson
- Maria Eriksson data - Conny Rundby what we
did Drs Khagani, Buckberg, Anyanwu and
Weitkemper - Optimal care during LVAD support
exercise? - Incomplete recovery enough? - HARPS
criteria enough?