PowerPoint Presentation (PDF) - Perfusion.com

Moving Forward in Perfusion:
What’s Hot and What’s Evolving
Alfred Stammers
Cody Trowbridge
Nicholas Brindisi
James Pezzuto
Myra Klayman
Kyla Jubach
Joseph Petzold
Sean Fleming
Department of Perfusion Services
Division of Cardiothoracic Surgery
Geisinger Health Systems
Danville, PA, USA

Disclosure
No financial relationship with any
company or entity discussed here within.
No product will be used in an off-label
manner.

What’s Hot
What’s Not
Evidence – ICEBP
‣ Registries
Educational decline
‣ Program
Blood Management
‣ IBBM
Fragmentation
‣ Societal migration
‣ STS Guidelines
Strategic Focus
Quality and Safety
‣ PEMR
‣ No consensus
‣ Eroding caseload

Characteristics for Inclusion
Provocative
Proof of Concept
Recent
Four Letter Maximum
VADS
TAVI
NIRS

United States Heart Failure Statistics
AHA Heart Disease and Stroke Statistics 2010
‣ 5.8 Million Patients with heart failure
‣ 550,000 patients diagnosed each year
‣ 15 million office visits 6.5 million hospital days
‣ Annual # of hospitalizations
> 1 million as 1 o diagnosis > 3 million 1 o or 1 o
‣ Rehospitalization rates
> 25% within 1 month > 50% within 6 months
‣ Total US costs for heart failure 2010 – 39.2 billion

Ventricular Assist Devices

HeartMate II Destination Therapy Trial
HeartMate XVE vs. HeartMate II
• Prospective, randomized, multicenter study
Inclusion Criteria
• LVEF < 25%
• Peak VO2 < 14 mL/kg/min (or 50% age and sex predicted)
and either
• NYHA class IIIb-IV symptoms for at least 45 of the prior 60
days on maximally tolerated oral heart failure medications, or
• Dependence on IV inotropes for at least 14 days, or
• Dependence on an IABP for at least 7 days
• Not a candidate for transplantation
Exclusion Criteria
• Irreversible renal, pulmonary, hepatic dysfunction
• Active Infection

Duration of Support (yrs) Median Longest
CF LVAD 1.7 3.7
PF LVAD 0.6 2.1

FDA Approval of CF DT
1. Increase in number
of centers providing
care to patients in
end-stage heart
failure.
1. Expansion in
utilization of VADs
at non-transplant
centers.

Trans Aortic Valve Implantation (TAVI)
1. 50,000 AVR in US per year
2. AVR increase life expectancy over 4-fold
3. AVR complications: 4-18% risk of mortality
4. Increasing population will increase AVR
Edwards Sapien THV
Medtronic CoreValve

Transcatheter Valve Implantation (TAVI)
Risk Benefit Analysis Assumptions
Transcatheter valves will be more effective, but have
more risks, than medical therapy
Transcatheter valves might be less effective, but less
risky, than surgery
?????
Transcatheter valves will be more effective than
medical therapy and less risky than surgery
Julie Swain, MD
Division of Cardiovascular Devices, FDA
STS Transcatheter Valve Symposium

TAVI
Access
Transfemoral
Transapical
Trans-Subclavian or Trans-Carotid
Intervention Location
Off-site – catheterization laboratory
Hybrid OR – endovascular room

TAVI
Complications
Valvuloplasty
Valve Implantation
Aortic instrumentation
1. Ascending aorta dissection
2. Embolic debris liberation
3. Valve embolization
4. Coronary artery obstruction
5. Mitral valve interference
6. LV rupture or hemorrhage
7. Vascular access injury
8. Post-implant instability
9. Distal/Proximal dislocation
of prosthesis

TAVI
Patient Management
Anesthesia
General anesthesia with ET intubation
Heparinization with ACTs > 250 s
Clopidogrel 300 mg
Rapid ventricular pacing
Vasopressors to maintain MAP

TAVI
Patient Management
Perfusion
Emergent CPB Plan (planning and drills)
Pump in-room with dedicated perfusionist
Intraoperative Autotransfusion (cell salvage)
Rapid deployment precautions
Considerations
Hybrid room (C-arm and table movement)
Extra-personnel – non-cardiac surgical team??
NIRS monitoring

TAVI
Perfusion
Conventional Perfusion CPB
1. Ascending 1. CPS aorta vs. Conventional dissection CPS-MMLSS-MECC
CPB
2. LV rupture central or hemorrhage vs. percutaneous 1. Post-implant cannulation instability
3. Coronary 2. Carotid artery or obstruction Subclavian 2. Valve – bifurcated embolization graft
4. Mitral 3. Mini-ECMO
valve interference
4. TandemHeart

CPS-MMLSP-MECC
Benefits
1. Portability and thumbprint
2. Rapid deployment
3. Self-contained - ECMO
Detriments
1. Flexibility - cardioplegia
2. Limited aspiration
3. Absent PEMR interface

Conventional CPB
Benefits
1. Familiarity - complete
2. Intact safety systems
3. Cardioplegia
Detriments
1. Limited flexibility
2. Incapable of ECMO
3. Location of procedure

Intraoperative Neuromonitoring
NIRS
Non-invasive technique used to monitor regional
oxygenation in cerebral or somatic tissue, measuring
oxygen saturation of hemoglobin in venous capillaries.
Utility
Although assessment is at specific site, variation in
saturation has been shown to act as surrogate marker to
end-organ, or global, perfusion.

CasMed ® Fore-Sight ®
Covidien INVOS

NIRS
Intervention Guidelines
1. Head positioning for cannula placement and/or
decreasing CVP during CPB
2. Depth of anesthesia (CMRO 2 , SMRO 2 )
3. Increase PaO 2 through FiO 2
4. Increase perfusion pressure (CPB MAP)
5. Increased perfusion (CO or Q b Pump)
6. Acid-Base manipulation (hypercarbia)
7. Increased red blood cell volume
hemoconcentration vs. transfusion

NIRS
Critical Values or Threshold
IFU: Greater than 20% from resting baseline or
nadir of 40%
Casati:
Murkin:
Maintain ScTO 2 greater than 75% of resting
baseline
Maintain rSO 2 greater than 75% of resting
baseline.
Derived parameters:

Cerebral
Hepatic
Renal
Muscular

Summary Opportunities for Perfusionists
The efficacy of continuous flow VADs for
destination therapy will expand the role of
perfusionists.
Transcatheter valve implantation techniques
will present perfusionists with new challenges
and opportunities.
Neuromonitoring with NIRS will provide
perfusionists with a modality for measurement
and statistical analysis to improve outcomes.