6/22/2013. Mechanical Support of the Right Ventricle in Children with Pulmonary Hypertensive Vascular Disease. No conflicts to disclose

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1 Mechanical Support of the Right Ventricle in Children with Pulmonary Hypertensive Vascular Disease 6 th International Conference Neonatal & Childhood Pulmonary Vascular Disease San Francisco, California June 21-22, 2013 Ivan M. Rebeyka, M.D. University of Alberta & Stollery Childrens Hospitals Edmonton, Alberta, Canada Disclosures No conflicts to disclose 1

2 LVAD Support as a Bridge to Transplant in Patients with Heart Failure Complicated by Pulmonary Hypertension Heart transplant listing criteria Mortality vs Pulmonary Vascular Resistance LVAD Support as a Bridge to Transplant in Patients with Heart Failure Complicated by Pulmonary Hypertension Transplant Mortality PVR (WU.M 2 ) Transpulmonary Gradient (TPG) Basic Premise Low risk < 5% < 4 < 10 Medium Risk 10% High risk 20% > 6 > 15 Unloading of the LV via LVAD support can improve pulmonary hemodynamics and improve candidacy for transplantation 2

3 LVAD support in patients with end-stage heart failure and pulmonary hypertension - Improves pulmonary hemodynamics - Improvement in PVR/TPG usually occurs early and is sustained - Is associated with acceptable risk - Independent of device type -?? Should be considered in all cardiac transplant candidates previously considered to have irreversible pulmonary hypertension 3

4 Pediatric Mechanical Circulatory Support Short-term VAD vs ImplantableVAD Emergency support Short-term support ( Bridge to Decision device ) Long-term support (Implantable VAD) CentriMag $5, HeartWare $100, Extra Corporeal Membrane Oxygenation 4

5 ECMO Complications Bleeding, Bleeding, Bleeding Neurological injury Lung / liver / renal dysfunction LV not decompressed RVAD Inflow - RA Outflow - PA RVAD / LVAD Support LVAD Inflow - LA Outflow - Aorta 5

6 PA - LA Novalung Assist Novalung vs Quadrox Novalung Polymethylpentine (PMP) Low resistance No pump needed Good CO2 clearance Poor oxygen transfer Quadrox Polymethylpentine (PMP) High resistance Pump required Good CO2 clearance Good oxygen transfer 6

7 RVAD / LVAD Support PA LA cannulation RVAD Inflow - RA Outflow - PA LVAD Inflow - LA Outflow - Aorta Pros - better RV unloading - simpler circuit (no pump) Cons - thromboembolism risk (especially in children) - requires good RV / LV function - flow not adjustable 7

8 RA Aortic cannulation Pros - not dependent on RV / LV function - flow adjustable (CentriMag) - better oxygenation (Quadrox) - stable cannulae for patient mobilization Cons - less RV unloading Salvage Cardiectomy Salvage Cardiectomy Goretex graft to aorta Gelweave graft to left atrial cuff Aortic cannula Atrial cannula Berlin Heart cannulae 8

9 Salvage Cardiectomy CentriMag support following total excision of heart Atrial cannula Aortic cannula Saline bag filler Thank you for your attention 9