CARDIAC SURGERY - heart transplantation - mechanical circulatory support Petr Fila [USEMAP] Dear students, welcome to third part of commented presentation from cardiac surgery. In this part I will talk about HTx a MCS Heart transplantation - Indications terminal heart failure (coronary artery disease, valve disease, cardiomyopathy) Contraindications fixed pulmonary hypertension neoplasms active alcohol or drug abuse age over 65 years (individual assessment), Potential relative contraindications active infection, pulmonary embolism, active peptic ulcer disease liver, kidney failure – 2 or 3 organs transplantation [USEMAP] We start wit talk about heart transplantation. Indication for HTx is terminal heart failure causes by CAD, valve diseases, CMP Contraindications are… In case of liver or kidney failure two or three organ transplantation cań be performed Heart failure - etiology - [USEMAP] The main etiology of heart failure are CAD and CMP. Both around 45%. The others are valve disease, congenital heart disease, reHx Heart transplantation - surgical technique - image biatrial (Lower-Shumway) image bicaval [USEMAP] Shumway and Lower at Stanford University introduced surgical technique, called biatrial techniqu. In this technique the anterior part of donor’s left and right atria was anastomosed to the posterior wall of the recipient’s atria. This became the standard heart transplant surgical technique until the 1990s. Actually mainly bicaval technique is used which was introduced into clinical practice 30 years ago (early 90‘s). Bicaval technique is characterized by two arterial, one left atrial, and two caval anastomoses, leaving the right atrium intact and leaving only a small posterior part of recipient’s left atrial tissue between the pulmonary veins. Heart transplantation - video OTS-new-EN.mp4 [USEMAP] Now I will show you video from heart tranplantation. You see donor surgery. Donor after brain death diagnosis. Usually it is multiorgan donor surgery – for heart, lungd, liver, kidney, or pancreas - [USEMAP] Patient´s heart with heart failure before transplantation – big heart, poor contractility - D:\USB_backup_021011\Kardio\Medici\Foto medici\OTS2.JPG [USEMAP] C-P bypass starts. Patient is on extracorporal circulation. - D:\USB_backup_021011\Kardio\Medici\Foto medici\OTS3.JPG [USEMAP] Empty pericardial cavity after heart excision - D:\USB_backup_021011\Kardio\Medici\Foto medici\OTS4.JPG [USEMAP] Donor´s heart in ice before implantation. - D:\USB_backup_021011\Kardio\Medici\Foto medici\OTS7.JPG [USEMAP] Implantation - D:\USB_backup_021011\Kardio\Medici\Foto medici\OTS9.JPG [USEMAP] „new“ heart is working. You see difference in diameter before and after HTx - D:\USB_backup_021011\Kardio\Medici\Foto medici\OTS1.JPG [USEMAP] Before… Mechanical circulatory support - § short-term reversible damage § § long-term „brigde-to-transplantation“ § § permanent contraindications for heart transplantation § left-side § § right-side § § biventricular § Pulsatile • pneumatic • electromechanic § Non-pulsatile • axial • centrifugal Duration of support Type of support needed Flow Localization § paracorporeal § § implantable [USEMAP] Modern and quickly developing part of cardiac surgery is MCS. In case of heart failure heart function is supported and replaced by any type of mechanical pump. Acording duration of support we distinguish.. Some patients need left-, right or biventricular support. Short term pumps are usually extracorporeal and long term are usually implantable. Acording to flow we distinguish pulsatile or non-pulsatile flow (patient has no pulse)!!! Mechanical circulatory support - indication - Postcardiotomy cardiogenic shock unsuccessful weaning from extracorporeal circulation malignant ventricular arrythmias low cardiac output syndrom Other etiology of cardiogenic shock after acute myocardial infarction, after PCI, myocarditis… Chronic heart failure pts on waiting list for heart transplantation Acute rejection after HTx Heart failure (primary graft non-function) after HTx Patients with contraindications for heart transplantation [USEMAP] Indications for MCS are... Rarely primary graft non-function after Htx Pts with contraindications for Htx are indicated for long term MCS Intraaortic baloon counterpulsation - http://t0.gstatic.com/images?q=tbn:ANd9GcSxvxTtVeLwM2HzmFqOKDdSfuvLB8aFo7s6esxw6SXWLhX3HwNw http://lifeinthefastlane.com/wp-content/uploads/2010/03/IABP_cardiac-cycle.jpg http://www.wikiskripta.eu/images/thumb/9/96/IABP.png/350px-IABP.png http://www.dijamed.rs/images/maquet-pump-en.jpg [USEMAP] The intra-aortic balloon conterpulsation (IABP) isn‘t really pump but mechanical device that increases myocardial oxygen perfusion and indirectly increases cardiac output due to afterload reduction. Balloon in descendiang aorta approximately 2 centimeters distally from the left subclavian artery inflates and deflates, actively deflates in systole and inflates in diastole. Systolic deflation decreases afterload and indirectly increases forward flow from the heart. Diastolic inflation increases blood flow to the coronary arteries by retrograde flow. Inflation and deflation is usully synchronic to electrovardiogram. Short-term MCS - Centrimag - [USEMAP] For short term mechanical circulatory support we use extrecorporeal (nonimplantable) pump called Centrimag. Blood from LA-outside pump- aorta – LVAD RA—outside pump- pulmonary artery - RVAD BiVAD Short-term MCS - Centrimag - Výřez obrazovky Výřez obrazovky Výřez obrazovky [USEMAP] Centrimag´s parts – drive console, motor and magnetic levitating pump. Short-term MCS - Centrimag - \\192.168.249.7\Zalohy CKTCH\DrHorváth\Horvath_Levitronix_Obr2.JPG [USEMAP] Patient on ICU with Centrimag. Four lines, two pumps, one for left heart, second for right heart. Short-term MCS - ECMO - HLS System Pulmonary Support - Veno-venous Cannulation Cardiopulmonary Support - Veno-arterial Cannulation extracorporeal membrane oxygenation [USEMAP] Most uses short term MCS is ECMO. pumps blood, oxagenation. There are VV configuration in respiratory failure. We will talk abou VA configuration – as circulatory an also respiratory support. Usually from groin – inflow cannula through the femoral vein to RA, outflow to femoral artery (subclavian artery, aorta...). main adventages are:Transportable device, quick setup which allow quick circulation restoration. Long-term MCS – Heartmate II - [USEMAP] More than 10 years ago for long term support we started with implantable pump with nonpulsatile axial flow. Heart mate II. Only one driveline goes throw skin out of human body. Driveline is connected to controller and two bateries. MCS – HeartWare HVAD - [USEMAP] Next LVAD generation is HeartWare HVAD. Centrifungal pump with inflow part, which insert into the LV cavitu throug the LV apex. Outlow part with prosthesis usually is usually anastomosed on ascending aorta. - [USEMAP] - [USEMAP] - [USEMAP] - [USEMAP] - [USEMAP] - [USEMAP] - [USEMAP] - [USEMAP] - [USEMAP] We prefere using two small incision for implantation. Minithoracotomy for pump implantation. Outflow graft is is placed into the pericardial cavity and is anastomosed to ascending aorta. Implantation is on C-P bypass, on beating heart. - L:\Kardio\Foto\RTG plic-Heartware-Bartusek.jpg [USEMAP] Chest X-ray MCS – 2x LVAD as BiVAD - Výřez obrazovky [USEMAP] Two Heartware HVAD as Bivad. Xray from Berlin. HVAD is not constructed primarly as RVAD MCS – HEARTMATE 3 - [USEMAP] Now we use the newest type of LVAD- Heartmate 3. Costruction is similar to Heartware HVAD Total artificial heart - Syncardia - Výsledek obrázku pro syncardia Výsledek obrázku pro syncardia -pneumatic pump – pulsatile flow -bridge-to-transplant -noise [USEMAP] The SynCardia total artificial heart (TAH) currently provides option for patients with biventricular failure who are not candidates for isolated left ventricular (LV) assist device placement. It is pneumatic pump. You can see noise from pneumatic pump. 24hour/7 days. During implantation left and right ventricles are removed ant the TAH is conected with inflow part to right and left atrium a with outflow graft to pulmonary artery and ascending aorta. TAH is asserted as BTT for pts on wainting list for Htx. Total artificial heart - Carmat - https://www.carmatsa.com/carmat-content/uploads/2017/10/coeur.png -electrohydraulic pump, biological valves, membranes - bovine pericardium -pulsatile flow, autoregulation Související obrázek [USEMAP] New type of TAH is Carmat. It is electrohydraulic pump (without any noise) with biological valve and membrane from bovine pericardium inside. Carmat is the first auto-regulating artificial heart able to mimic the natural physiology of the human heart. MCS - future - - miniaturization??? – external components - wireless - telemonitoring - no anticoagulation [USEMAP] When we talk about MCS. The future can be in miniaturization – mainly external components, win wireless technology – without driveline. In telemonitoring. All pts with MCS need AKT. There is the question if the MCS future wil be w/o anticoagulation. MCS – future - miniaturization - Obsah obrázku budova, bílá Popis byl vytvořen automaticky Obsah obrázku zeď, interiér Popis byl vytvořen automaticky Výsledek obrázku pro syncardia external Výsledek obrázku pro heartware external Související obrázek [USEMAP] Future in miniaturization is not only in own pumps module but especially in external parts. You see external pump component several years ago and now. External pump console is easy transportable. MCS – future - wireless - [USEMAP] Future is also in wireless. Because driveline through the skin is main problem with driveline infections. So the future is in implantable bateries and charging across the skin surface . MCS – future - telemonitoring - Výsledek obrázku pro lvad telemonitoring [USEMAP] The other part of future is in telemonitoring due tu special applications, which allows connection between the patient a physician for better follow up and better care about pts with MCS. MCS – future – no anticoagulation - Netuka, I, et al. JHLT, 2018, 37.5: 579-586 Netuka I., et al. JHLT, 2019, 38.4: S113 Obsah obrázku snímek obrazovky Popis byl vytvořen automaticky Obsah obrázku snímek obrazovky Popis byl vytvořen automaticky from MAGENTUM 1 study – n = 5 MAGENTUM 2 – after 6 months – complete withdrawal anticoagulation therapy Výřez obrazovky after 6 weeks - ↓ INR 1,5-1,9 n = 15 after 6 months - no stroke, no pump thrombosis - 1x GI bleeding [USEMAP] There are first data about reduction of ACT in pts with MCS (INR reduction to 1.5-1.9). This results are optimistics so there are severel selected pts with MCS with complete withdrawal ACT Petr Fila petr.fila@cktch.cz [USEMAP]