Mekanisk hjärtassist
Transplantation är den bästa
behandlingen
vid svår terminal hjärtsvikt!
Ulf Kjellman
Thoraxkliniken
Akademiska Sjukhuset
REMATCH- studien
4500
4000
3500
3000
*
2500
2000
1500
1000
500
2000
2001*
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
0
1982
Number of Transplants
NUMBER OF HEART TRANSPLANTS
REPORTED BY YEAR
* Numbers may be low due to delayed report
Rose et. al., New England Journal of Medicine, 2001
REMATCH- studien
Rose et. al., New England Journal of Medicine, 2
1
CentriMagR Positioning
Problem med implantat i blodbanan:
Short-term
(e.g. CPB)
Bridge to decision
Long-term
(e.g. VAD)
- trombotrombo-embolism
- hemolys,
hemolys, kaskadaktivering
- infektion
Problem med mekanisk hjärtassist:
- stor kirurgi
- drivkabel, kontrollenhet o batterier
- pris
Cardiac Output = 4.3
Pulsativt flöde(deplacement) (HeartHeart-Mate®I,
Mate®I,
8,000
RPM
Novacor®,
Novacor®, Abiomed 5000®) - prepre-load beroende!
Pulse Pressure = 23
Mean BP = 68
Cardiac Output = 4.4
9,000
RPM
Pulse Pressure = 16
Mean BP = 70
Cardiac Output = 4.5
Nonimpella®, Centrimag®,
Centrimag®,
Non-pulsatilt flöde (impella®,
HeartHeart-Mate®II,
Mate®II, Micromed®)
Micromed®) - PrePre- och afterload
beroende!
10,000
RPM
11,000
RPM
12,000
RPM
Pulse Pressure = 12
Mean BP = 74
Cardiac Output = 4.9
Pulse Pressure = 9
Mean BP = 82
Cardiac Output = 5.1
Pulse Pressure = 6
Mean BP = 87
2
Current Ventricular Support Treatment Options
ingen skillnad mellan pulsativt och non pulsativt
flöde upp till 14 dagar post.op
post.op..
Deutsches Herzzentrum Berlin, Hetzer R
Degree of Invasiveness
Biochemiska markörer för hjärnskada (S100, NSE):
LVAD
Ventricular
Unloading
Catheters
IABP
Medical
Mgt
Degree of Hemodynamic Effectiveness
Korttidsasssiter (1(1-14 dagar)
Medellång assist (1 - 30 dagar)
BioMedicus®
BioMedicus®
impella®
impella®
Centrimag®
Centrimag®
Centrimag®
Centrimag®
Abiomed®5000
®)
Abiomed®5000 (Thoratec
(Thoratec®)
Abiomed®5000
Abiomed®5000
1 ”bridge to decision”
decision”
Långtidsassist (1 - 48 mån)
2 ”bridge to recovery”
recovery”
HeartHeart-Mate®I
Mate®I
MicroMed®
MicroMed®
HeartHeart-Mate®II
Mate®II
3 ”bridge to transplantation”
4 (”destination therapy”)
therapy”)
3
Systemet
Mobil konsol
Sprutpump
Impella® recover LV perifer
Cardiology - Recover® LP 2.5 / 5.0
Specifications - Recover® LP pumps
Recover®LP 5.0
Recover®LP 2.5
Catheter size
9F
9F
Cannula size
21F
12F
Flow
max. 5 l/min
max. 2.5 l/min
Insertion/
Placement
peripheral
(femoral artery)
percutaneous
(femoral artery)
Guide wire
Yes
Yes
Duration of use
7 days
5 days
Flow display
Yes
Yes
CE-certification
Yes
Yes
FDA
IDE Trial
IDE Trial
Cardiology - Recover® LP 2.5 / 5.0
Insertion - Recover ® LP 5.0
Inlet
Cat heter (with marking)
Outlet
Pigtail
Guide wire
Sensor
• guide wire is provided by Impella ( 0.025“)
Distal vess el loop
U-stiches
A. fem oralis
Pr oximal vess el loop
• insertion in the femoral artery via „cut down“ L ≈ 8 cm
4
Cardiology - Recover® LP 2.5 / 5.0
Pump position monitoring
Placement Monitoring:
• Correct or wrong pump position is displayed on the Mobile Console
5
Impella LP2.5 - Hemodynamic
Effect
Increased diastolic
and mean blood
pressure
Decreased systolic
LV workload
Cardiac Surgery- Recover® LD / RD
Implantation – Recover® RD
Securing eyelets
(pericardium)
Outlet area (above
the pulmonary valve)
Double purse
string suture
(centrolateral
to right atrium)
Felt ring
(seal)
Inlet area
(direction of
tricuspid valve)
Stitching plate and
felt ring (seal)
Double purse
string suture
2005-10-17
1
6
impella®
impella® implantationer (UAS)
behandlingstid:
LD
3 dagar
RD
1 - 8 dagar (mean
(mean 6)
LP
1 - 8 dagar (mean
(mean 4)
CentriMag
A magnetically levitated
Bloodpump for
Extracorporeal Use
CentriMag® ICU
Support
CentriMagR Bearingless Pump
pump housing
Inlet
impeller
outlet
rotor
winding
stator
Surgical Cannulation
Algoritm:
Kvinna 58 år, diabetes mellitus i.ö. frisk och fysiskt
aktiv. Dec.
Dec. 2005 14 dagars extrem trötthet och förförkylning. Akut infarkt, PCI mot LAD och 33-kärlssjuka.
kärlssjuka.
Svår vä.
vä. svikt, stort inotropt stöd.
”bridge to recovery”:
recovery”: impella®LP
impella®LP 5.0 inlagd, leverleverskada, laparatomi.
laparatomi.
Lågt flöde - HIT
7
impella®
impella® ut med recovery av kammaren och måttligt
inotropt stöd. 14h därefter cirkulationskollaps.
Till op.
op. och asystoli vid sternotomi.
sternotomi. Centrimag®
Centrimag® och
impella®RD
impella®RD ”bridge to decision”
decision”
Vä.
Vä. sidig hemipares och njurinsuff.
njurinsuff.
10 dagars support med regress av neurologi och
njurinsuff.
njurinsuff.
”bridge to transplantation”: HeartHeart-Mate®II
Mate®II
neurologisk helt återställd och normaliserad
njurfunktion.
8
Schematic of the DeBakey VAD®
FLOW STRAIGHTENER
DeBakey VAD® and DeBakey VAD® Child
INDUCER/IMPELLER
STATOR HOUSING
DIFFUSER
BLOOD
FLOW
FLOW TUBE
Size: 30 x 76 mm
Speed: 7500 - 12500 RPM
Flow rates: 10+ liters/minute
Titanium construction: 95 Grams
Technology licensed from NASA
MOTOR STATOR
T h
C ll
f EACTS 2002
9
”bridge to decision”
decision”
”bridge to recovery”
recovery”
10
driveline
impella®
driveline
Heart--Mate®
Heart
11
12
13
Tack för uppmärksamheten!
Ulf Kjellman
MD, PhD
Dept.. Cardio
Dept
Cardio--Thoracic Surgery
University Hospital, Uppsala
Sweden
14
