2022esc心室辅助装置治

TheBestChoiceofLVADsTreatingHerartFailure--2010ESCguide-lineWhenit’slate,butnot“toolate”inheartfailure:VentricularAssistDevices.VADsVADsStep1:Evaluatingthepatientandthefullextentoftheheartfailuresyndrome.

Step2:ThechoiceofVADs(therightpumpfortherightpatient)ThegoodnewsLotsofpumpstochoosefromThebadnewsLimitedavailabilityatmosthospitalComparativetrailsinfrequentPhysicianpreferencecloudsalotofthediscussion.Temporarysupport:BackgroundCardiogenicshock-Compromiseofcardiacoutputleadingtoend-organhypo-perfusion.-Complexcascadeofend-organdysfunctioncombinedwithactivationofinflammatorypathways.-Complicatesabout7%ofSTsegmentelevationMIand2.5%ofnon-STsegmentelevationMI.Whowouldbenefitfromtemporarysupport?Acutecardiogenicshock-Acutemyocardialinfarction-Acutemyocarditis-ComplicationspostMI:PapillarymuscleruptureandventricularseptaldefectPostcardiotomyfailureAcuteonchronic(end-stage)heartfailureElectrical“storm”orpost-VTablationDrugoverdosewithmyocardialdepressionHypothermiaThepumpchoicesfortheacutelyillpatientIntra-aorticballoonpumpExtracorporealmembraneoxygenation(peripheralcardio-pulmonarybypass)TndemHeartImpellasurgicalTraditionalventricularassistdevicesTotalartificialheartpercutaneousAdvantagesofPercutaneousDevice

PlacedquicklyAvoidneedfor“opensurgery”PlacedatmanycenterseventhosewithoutVADortransplantprogramMoreeasilyremovedinsettingofrecoveryPlacedbyinterventionalcardiologistsandsurgeonsAllowforrecoveryortransporttoanothercenterDisadvantagesofpercutaneousDevicesBleedingLimitedtoleftventricularsupport(exceptECMO)

NotforbiventricularsupportNotforRVsupportVentriculararrhythmiasIschemiclimbUnabletomobilizeorrehabSepsisECMOECMO-AdvantagesCardio-pulmonarybypassCanbeplacedperipherally(withoutthoracotomy)TheonlypercutaneousoptionforbiventricularsupportTheonlyoptioninthesettingoflunginjuryECMO-DisadvantagesRequirestrainedteamandequipmentavailabilityon-siteandearlyinresuscitationHigherriskofinfection,bleeding,andvascularinjuryTheData-ECMOSeveralcentershavereportedtheirexperiencewithECMOinthesettingofCPR/Cardiogenicshock-Survivalratesof31to63%Intra-aorticBalloonPumpIABP-AdvantagesEasilyplacedinthecatheterizationlaboratoryoroperatingroomImprovescoronaryperfusionDecreaseafterloadDecreasemyocardialoxygendemandCantransportpatienttoanothercenterEstablishedtechnologythatiswidelyavailableIABP-DisadvantagesDoesnotdirectlysupportcardiacoutputLimitedsupportinthesettingoftachycardiaandarrhythmiaMaybelesseffectiveinolderpatientswithsignificantatherosclerosisinaortaImpellaImpellaAdvantagesSmallrotarypumpCanbeplacedpercutaneousfromfemoralarteryacrossaorticvalvewithoutneedoftrans-septalpunctureorvenousaccessCanbeeasilyremovedImpellaDisadvantagesHemolysis–althoughnotfelttobeclinicallyrelevantProvidespartialcardiacoutputsupport-upto2.5liters/minuteinpercutaneousmodelDifficulttoplaceinsettingofsevereperipheralvasculardiseaseTandemHeartTandemHeartAdvantagesCanbeplacedeasilyinthecatheterizationlaboratoryCansupplyupto5l/minflowCanbeeasilyremovedTandemHeartDisadvantagesRequirestrans-septalplacementDifficulttoplaceinsettingofsevereperipheralvasculardiseaseTandemHeartDataComparedtoIABPinacuteMIwithshock(n=41)(singlecenter)-Improvedcardiacpowerindex,decreasedlactate,improvedrenalfunctionascomparedtoIABP.-Nodifferencein30dayssurvivalandmorecomplicationsinTandemHeartgroup.TandemHeartDataMulti-centertrailcomparingTandemHeartandIABPinacuteMIwithshock(n=42)-TandemHeartimprovedcardiacoutput.DecreasedPCWPandincreasedmeanarterialpressureascomparedtoIABP.-Nodifferencein30dayssurvival-Similarcomplicationrates.30-daymortalityLimitationsStudiesdonetodatehavebeensmallandatalimitednumberofcenters.Inclusionandexclusioncriteriaarechallenginginthesettingofsuddenshock.Populationsstudiedhavebeensomewhatheterogeneousincludingacutelyandchronicallyillpatients.Thedatafor“prophylacticuse”tosupportproceduresisveryencouraging.Conclusions:PercutaneousdevicesCirculatorysupportinthesettingofcardiogenicshockimprovesoutcomesMostcentersdonothaveaccesstosurgicalventricularassistdevices.Percutaneousassistdevicesplayanimportantroleinprovidingrapidsupportincardiogenicshockandsupportforriskproceduresandcanbeusedatmanycenters.Additionalstudiesareneededtodefinetheroleoftheseimportanttools.BloodPumpTechnologyBloodpumpIssuesintheimplantationofdurableVADsProperselectionofpatients-Recognizingthepatientwhois“toosick”,withend-organdamage.-Recognizingthepatientwhoistoodebilitatedormalnourished-Recognizingthepatientwhoneedsbi-ventricularsupportTimingofsurgery

-Especiallyimportantintheelderly“destination”patient.HFA/ESC:AdvancedheartfailureHFA/ESC:AdvancedheartfailureClinicalPatientProfilesProfilingthepatientwithsevereheartfailureTheprofiledeterminestheprognosisINTERMACS:SurvivalafterLVADImplantINTERM