Mechanics of Percutaneous Circulatory Support.ppt

fdwqef sdfafwvdfa sdc

1. Mechanics of Percutaneous Circulatory
Support
IssamD. Moussa, MD
Professor of Medicine
Mayo Clinic College of Medicine
Chair, Division of Cardiovascular Medicine
Mayo Clinic
Jacksonville, Florida

2. Conflict of Interest
•Baxter Research Grant
•Medtronic Research Grant
•Terumo Research Grant

3. Percutaneous Circulatory Support
•Which patients
•Goals of circulatory support
•What devices
•Mechanics of circulatory support

4. Percutaneous Circulatory Support
Which Patients?
•Patientsundergoing high-risk PCI (Elective)
•Patients with acute myocardial infarction with or without
cardiogenic shock, to reduce infarct size and support end-
organ perfusion (Emergent)
•Patients with acute decompensated heart failure, due to
acute coronary syndrome, myocarditis or exacerbation of a
chronic heart failure state(Urgent)

5. Percutaneous Circulatory Support
Goals –Elective Setting
•Allow the cardiovascular system to withstand
transient insults during PCI and resume normal
function post procedure.
•Increase myocardial ischemic threshold to allow
time for procedural complications to resolve.

6. Percutaneous Circulatory Support
Goals –Urgent and Emergent Settings
•Unload the heart, take over the work –partially or
totally –to minimize ischemic damage
•Maintain a stable hemodynamic state of systemic
pressure and perfusion without the need for
vasopressors and inotropes.

7. Percutaneous Circulatory Support
Ideal Hemodynamic Impact
•Hemodynamic support
–Maintain blood pressure
–Maintain cardiac output
–Maintain pulmonary venous pressure
•Myocardial protection
–Increase oxygen supply (coronary blood flow)
–Reduce oxygen demand (HR & PVA)
Cardiac Power Output (Watts)
CPO= (MAP x CO) / 451
Maintain End-Organ
Perfusion

8. Percutaneous Circulatory Support
Mechanics of Circulatory Support
Basics of Cardiac Work Load

9. Mechanics of Circulatory Support
Pressure-Volume Area = Cardiac Work Load

10. Mechanics of Circulatory Support
Oxygen Demand and PVA

11. Mechanics of Circulatory Support
Cardiac Contractility and Oxygen Demand

12. Percutaneous Circulatory Support
What Devices?
•Intra aortic balloon pump (IABP)
•Left atrial-to-arterial pumping (e.g., TandemHeart,
Cardiac Assist)
•Intracorporeal transvalvular ventricular-to-aortic
pumping (e.g., Impella, Abiomed).

13. IABP
Inflation
Diastole
•Augmentation of
diastolic pressure
•Increase coronary
perfusion
•Increase myocardial
oxygen supply
•Decrease cardiac
work
•Decrease afterload
•Increase cardiac
output
Deflation
Systole

14. Impella
Infusion Pump
Impella Console
Power Supply

15. IMPELLA 2.5 System

16. IMPELLA 2.5 SysteIMPELLA 2.5 System

17. IMPELLA 2.5 System
Braun Vista Purge System

18. TandemHeart
Left

19. The Tandem Heart

20. The TandemHeart
The pump
•Low prime volume (10cc) centrifugal pump driven by a
three phase, brushless, DC servomotor
•Delivers flows up to:
–5.0 liters per minute with percutaneous cannulation
–8.0 liters per minute with surgical cannulation
•Pulls oxygenated blood from the left atrium and returns it
to the systemic arterial circulation
•Integrated pump & motor is fully sterilized and small in
size, enabling placement close to the patient in the sterile
field

21. DeviceMechanism HemodynamicImpact
IABP Pressure
Augmentation
Increased diastolic, decreased
systolic aortic pressure,
decreased PCWP, no active flow
Tandem
Heart
LA --------AortaIndirectly unloads LV by
decompressing LA, Up to 4 L/Min
flow (retrograde)
ImpellaLV----------AortaDirectly unloads LV, up to 2.5
L/Min flow (antegrade)
Percutaneous Circulatory Support
Devices
Burkoff D et al. CCI 80:816-829 (2012)

22. Device Comparison Using Circulatory
Simulation
Burkoff D et al. CCI 80:816-829 (2012)

23. Percutaneous Circulatory Support
Devices
Systemic
Support
(CPO)
Myocardial
Protection
(Increase O2
Supply)
Myocardial
Protection
(ReduceO2
Demand)
Inotropes ++ 0 ---
IABP + ++ +
Tandem Heart +++ ++ -/ +
Impella2.5 ++ ++ ++
Impella5.0 +++ +++ +++
Burkoff D et al. CCI 80:816-829 (2012)