Preoperative screening for LVAD an TAH implantation P

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Preoperative screening for LVAD an TAH implantation P. Leprince Institut de cardiologie Chirurgie Cardiovasculaire

Preoperative screening for LVAD an TAH implantation P. Leprince Institut de cardiologie Chirurgie Cardiovasculaire Groupe Hospitalier Pitié-Salpétrière Paris, France Pascal. [email protected] fr

Disclosure • • St Jude (Abott): Heartmate II Medtronic: HVAD, ECMO Jarvik 2000 Syncardia

Disclosure • • St Jude (Abott): Heartmate II Medtronic: HVAD, ECMO Jarvik 2000 Syncardia

Pre operative assessment Ø Assess Illness severity ØPatient selection ØOptimize the sickest patients Ø

Pre operative assessment Ø Assess Illness severity ØPatient selection ØOptimize the sickest patients Ø Define risk factor for surgery Ø Right ventricle assessment Ø Other organic and functional considerations Ø Select appropriate device

Illness assessment for operative risk

Illness assessment for operative risk

Low: < 1. 58 Mid: 1. 58 -2, 58 High: > 1. 58

Low: < 1. 58 Mid: 1. 58 -2, 58 High: > 1. 58

3 centers 101 patients Intermacs 1 (28) Intermacs 2 -3 (49) Intermacs 4 -7

3 centers 101 patients Intermacs 1 (28) Intermacs 2 -3 (49) Intermacs 4 -7 (24) AJ Boyle et al. JHLT 2011, 30: 402

Intermacs 2016 report Chart Title 45% 40% 35% 30% 25% 20% 15% 10% 5%

Intermacs 2016 report Chart Title 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% <2010 -2011 I 2012 -2016 II IV V VI VII

BTB: HVAD 2012 -2014 La Pitié 38 patients, 33 males 51± 12. 5 y

BTB: HVAD 2012 -2014 La Pitié 38 patients, 33 males 51± 12. 5 y Ø 12(31%) bridge to LVAD with peripheral ECMO Ø 29 (76%) implanted on ECMO (vs CPB +valvular surgery) Ø 7 (18%) peripheral ECMO + HVAD Ø 17 (45%) percutaneous ECMO RVAD + HVAD 63 % RVAD support Ø 71% hospital discharge

 No ECMO N=26 No support N=8 31% 87% ECMO pre N=12 ECMO Pc

No ECMO N=26 No support N=8 31% 87% ECMO pre N=12 ECMO Pc RVAD N=5 19% N=13 50% N=6 50% N=2 16% N=4 33% 54% 83% 100% 75% 60% No support ECMO Pc RVAD

Infection screening and control

Infection screening and control

Right ventricular function Echocardiography TAPSE S wave Strain Septal function LV/RV ratio

Right ventricular function Echocardiography TAPSE S wave Strain Septal function LV/RV ratio

In case of RV dysfunction • Patient optimisation: inotropes, diuresis, CVVHD • Biventricular or

In case of RV dysfunction • Patient optimisation: inotropes, diuresis, CVVHD • Biventricular or TAH support • LVAD with temporary RVAD

Percutaneous temporary RVAD

Percutaneous temporary RVAD

Temporary percutaneous ECMO RVAD

Temporary percutaneous ECMO RVAD

Percutaneous temporary ECMO RVAD N = 27 John Bad-O Dang n=12 n=45 n=14 RVAD

Percutaneous temporary ECMO RVAD N = 27 John Bad-O Dang n=12 n=45 n=14 RVAD Timing (j) Duration (j) 2, 1 ± 5, 4 12, 9 ± 7, 6 14 d 21 j 13 d Devenir Death under RVAD Weaning from RVAD Transplantation 6 months death 10 (37, 0%) 17 (63, 0%) 50% 21% 3 (11, 1%) 14 (51, 8%) 67% 53% 64%

Other considerations • • • Pulmonary function Neurologic function +++Carotide art. assessment Valvular disease

Other considerations • • • Pulmonary function Neurologic function +++Carotide art. assessment Valvular disease +++ aortic valve Arrhytmias Psychologic and psychiatric conditions Social conditions

Which device for which patient? Ø Center experience with multiple devices Ø RV Function?

Which device for which patient? Ø Center experience with multiple devices Ø RV Function? Heart transplant candidate or DT patient? Body size: output vs space Surgical technic: sternotomy vs thoracotomy redo patient CPB vs ECMO vs off pump? Hemorrhagic risk

Requirement for biventricular support Syncardia Carmat Double LVAD TAH with Bi. HVAD La Pitié

Requirement for biventricular support Syncardia Carmat Double LVAD TAH with Bi. HVAD La Pitié LVAD + temporary RVAD

Which device for which patient? Center experience with multiple devices RV Function? Ø Heart

Which device for which patient? Center experience with multiple devices RV Function? Ø Heart transplant candidate or DT patient? Body size: output vs space Surgical technic: sternotomy vs thoracotomy redo patient CPB vs ECMO vs off pump? Hemorrhagic risk

Which device for which patient? Center experience with multiple devices RV Function? Heart transplant

Which device for which patient? Center experience with multiple devices RV Function? Heart transplant candidate or DT patient? Ø Body size: output vs space Ø Surgical technic: sternotomy vs thoracotomy redo patient CPB vs ECMO vs off pump? Ø Hemorrhagic risk

Biventricular Destination BTT HMIII LVAD

Biventricular Destination BTT HMIII LVAD