Designed to dramatically improve survival and quality of life for a broad range of patients with End Stage Heart Failure
What is Heart Failure?
Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. In some cases, the heart can't fill with enough blood. In other cases, the heart can't pump blood to the rest of the body with enough force. Some people have both problems.The term "heart failure" doesn't mean that your heart has stopped or is about to stop working. However, heart failure is a serious condition that requires medical care. Heart failure develops over time as the heart's pumping action grows weaker. The condition can affect the right side of the heart only, or it can affect both sides of the heart. Most cases involve both sides of the heart.
Symptoms of Heart Failure?
The most common signs and symptoms of heart failure are:
- Shortness of breath or trouble breathing
- Fatigue (tiredness)
- Swelling in the ankles, feet, legs, abdomen, and veins in the neck All of these symptoms are the result of fluid buildup in your body. When symptoms start, you may feel tired and short of breath after routine physical effort, like climbing stairs. Fluid buildup from heart failure also causes weight gain, frequent urination, and cough that's worse at night and when you're lying down. This cough may be a sign of acute pulmonary edema. This is a condition in which too much fluid builds up in your lungs. Despite widespread use of evidence-based therapies the morbidity and mortality of heart failure are still high.
Risk Factors of Heart Failure
Conditions that damage or overwork the heart muscle can cause heart failure. Over time, the heart weakens. It isn’t able to fill with and/or pump blood as well as it should. As the heart weakens, certain proteins and substances might be released into the blood. These substances have a toxic effect on the heart and blood flow, and they worsen heart failure.
Causes of heart failure include:
- Coronary heart disease
- High blood pressure
Other heart conditions or diseases like Heart valve disease
- Arrhythmia. Happens when a problem occurs with the rate or rhythm of the heartbeat.
- Cardiomyopathy. Happens when the heart muscle becomes enlarged, thick, or rigid.
- Congenital heart defects. Problems with the heart’s structure are present at birth.
- Alcohol abuse or cocaine and other illegal drug use
- Thyroid disorders like thyrotoxicosis
What is LVAD?
LVAD is a surgically implanted mechanical pump that is attached to the heart. An LVAD is different from an artificial heart. An artificial heart replaces the failing heart completely whereas an LVAD works with the heart to help it pump more blood with less work. It does this by continuously taking blood from the left ventricle and moving it to the aorta, which then delivers oxygen-rich blood throughout the body.
The LVAD has both internal and external components. The actual pump sits on or next to your heart’s left ventricle with a tube attached that routes the blood to your aorta. A cable called driveline extends from the pump, out through the skin, and connects the pump to a controller and power sources worn outside the body.
The driveline must be connected to the controller, and the controller must be connected to power at all times to keep the pump working properly. The pump is powered by batteries or electricity. Each device has specific carrying cases to allow you to move about freely.
Life After LVAD
Once your LVAD is implanted, you’ll be connected to the LVAD external controller and power source at all times. Your device will be on battery power whenever you’re active and connected to electrical power when you are sleeping. You will also need to have an extra controller and fully charged batteries (and power cables if applicable) available at all times as an emergency backup. You’ll need to be sure to take this backup equipment with you whenever you leave home.
Today’s LVADs are lightweight and smaller than earlier models, so you’ll most likely be able to move around fairly easily, get certain kinds of moderate exercise and enjoy intimacy with your spouse or partner. Depending on your medical team’s advice and policies, you may also be able to drive. Children and pets will need to be careful around the equipment so they don't damage it or pull the driveline .
LVADs Till date
More than 28000 LVADs have been implanted globally and 10000 patients are on device at present. Out of these, more than 500 patients are on this device for more than 10 years.
Team That Cares
Our comprehensive heart failure services include medical therapy, LVAD, ECMO,Ambulatory Balloon pumps and heart transplantation. Our specialized team would use innovative technology and therapies to treat patients with heart failure.
We have introduced Advanced Heart Failure Clinic Introducing Heart Failure Clinic with the aim to identify potential candidates for heart transplant and ventricular assist device.
The aim of heart failure clinic is an organized effort by heart failure experts to provide quality care for patients suffering from acute and chronic heart failure.
Contact for any query: Heart Failure Coordinator:- 9540-500-800 (helpline)
Post cardiotomy failure
Acute myocardial infarctionwhohave undergone such significant myocardial damage that recoveryis unlikely.
Acute decompensation of chronic failure
Chronic heart failure in transplantation candidates
Intractable ventricular arrhythmias not responding to cardiac defibrillators and aggressive pharmacologicregimens
High-risk reparative cardiac operation
Terminology and Classification of MCS Devices
- Ventricle Supported
- Left ventricular assist device
- Right ventricular assist device
- Biventricular assist device
- Total artificial heart
- Intended Use
- Duration of support
- Short-term MCS
- Patient remains within hospital eg. Intraaortic balloon pump, Tandem heart, Centrimag, Impella ,Abiomed BVS 5000
- Long-term, “Durable” MCS
- Patient discharged to home – “hands free” untethered mobility eg.ThoratecHeartMate I1 MicroMedDeBakeyHeartAssist 5Jarvik 2000Berlin HeartIncor, HeartWareHVAD,DuraHeart
- Bridge to recovery
- Bridge to transplant
- Destination therapy
Intraoartic balloon pump,TandemHeartpVAD, AbiomedImpella 2.5 LP provide partial circulatory support (15-30%). Other short and long term devices provide full circulatory support.
TandemHeartpVAD (Percutaneous left atrial-to-femoral-arterial VAD)
Figure 3. Tandem Heart pVAD
It is Continuous-flow centrifugal pump which provides partial sup
port, average flow is usually 3.5 to 4.0 L/min at 7500 RPM. The cannulae are placed percutaneously under fluoroscopy. The 21 french (F) left atrial drainage cannula through transeptal approach and 15 to 17 F femoral artery cannula are used. The role of this device for short-term stabilization as bridge to recovery or as a bridge to definite surgical treatment
Figure 4. Surgical placement of Impella device.
Figure 5.Percutaneous placement of Impella device.
Impellamicroaxial flow device, which is a miniature impeller pump located within a catheter. Impella was designed for either surgical placement via a graft in the ascending aorta (5.0 LD) or for percutaneous placement (2.5 L )via the femoral artery (13,14).It provides partial to full support.(Figure 4 & 5)
CENTRIFUGAL PUMPS :
Figure 8.The Thoratec ventricular assist
system in the biventricular support
Figure 9. LevitronixCentrimag®
Centrifugal pumps are an extension of cardiopulmonary bypass. They use rotating cones or impellers to generate energy that is recovered in the form of pressure flow work. There are presently three centrifugal pumps available, the Bio- Medicus (Bio-MedicusInc, Minneapolis, MN), the Sarns (Sarns/3M Ann Arbor, MI) and the LevitronixCentrimag® (Levitronix LLC, Waltham, MA) (Figure 5). All of them have the capability of supporting patients who cannot be weaned from cardiopulmonary bypass or who are waiting cardiac transplantation. The pumps are versatile and can be used as a right ventricular assist device (RVAD), left ventricular assist device (LVAD) or biventricular (BiVAD) support.
CentriMag or other short term devices are frequently used mainly for the following reasons.
- Left ventricular failure post cardiotomy or transplant graft failure
- Right ventricular failure post cardiotomy
- Right ventricular failure post LVAD insertion
- Post infarction shock
- As ECMO support
- Bridge to a decision, whether it be to attempt recovery, long-term LVAD, or transplant
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) :
This is mainly used when pulmonary support is required with or without systemic support. It removes carbon dioxide from and adds oxygen to venous blood via an artificial membrane lung. The pulmonary circulation is bypassed, and oxygenated blood returns to the patient via an arterial or venous route. With veno-venous bypass, ECMO is effective primarily as a therapeutic option for patients with severe respiratory failure. With veno-arterial bypass, an extracorporeal pump is employed to support systemic perfusion, thus providing a hemodynamic support option in patients with cardiac failure. ECMO is a temporary life support for patients with potentially reversible severe acute respiratory failure or cardiac failure (15).
1. Pulsatile Volume Displacement pump (First Generation Pumps) :
Figure 11.Heart Mate XVE
Out of first generation pumps Heart Mate XVE is the most commonly used device.It was the first device used for REMATCH trial which showed benefit of device placement over medical therapy.This device is also approved by FDA for the destination therapy.Now a days this is being used less frequently because of cumbersome size, limited durability and availability of smaller and more durable pumps.
2. Continuous-flow Rotary Pumps (2nd and 3rd Generation pumps):
Figure 12 .HeartMate II
The second generation pump most commonly used is Heart Mate II axial flow pump.The third generation pumps are magnetically levitated centrifugal blood flow pumps with no contact bearing design.
Continuous-flow Rotary Pumps
- No heart Valves
- No flexible diaphragm
- No large housing to accommodate pump "stroke volume"
- Fewer moving parts
- Potential for biventricular application
- Minimal pulse
- Significant occurs
- Operated in fixed mode speed may limit cardiac output
- After load dependent
Heart Mate II : is a 2nd generation axial flow pump Most commonly implanted device.Its durability, reliability and promising results opened the avenue for mechanical support. Its potential for small size, low noise, and absence of a compliance chamber, have been developed for clinical use. It provides continuous rather than pulsatile flow and are totally implantable.
Magnetically levitated centrifugal pumps : These are currently undergoing clinical trials for the treatment of heart failure. They have several advantages over the axial flow pumps: 1) they are energetically more efficient 2) they have lower tolerances so manufacturing is easier and they are less prone to thrombosis 3) they are potential very durable (>10 year life-span). The three main devices in this category are the VentracorVentrAssist LVAD, the Heartware LVAD and RVAD and the Terumo Duraheart.
Figure 13 HeartWare
This is a third generation centrifugal pump.
It weighs 145 grams and pumps 4 to 5 liters of blood per minute.This does not requires pocket formation unlike other devices
Figue 14 Circilite device and its placement.
CircuLite’s circulatory support systems are designed with unique attributes, which include:
World's smallest implantable blood pump (the size of a AA battery and weighing 25g) First superficially implanted micro-pump, designed to be placed without cardiopulmonary bypass or sternotomy Small percutaneous lead Designed to supplement native cardiac output Designed for long-term support Magnetically and hydrodynamically stabilized rotor designLightweight, rechargeable dual battery pack system (average power 6-8 hours)
With the immutable limitation in the supply of suitable donor hearts a lot of patients with heart failure could not be offered the possibility of long survival and in the last 10- 15 years were developed a second and third generation of pumps. Those patients who do not qualify for transplantation long term devices are used for them as a destination therapy. In addition, destination recipients can undergo heart transplantation after their relative contraindications improves on mechanical support. The vast majority of deaths occur within the first 3 months after LVAD surgery. Sepsis, right heart failure and multi organ failure are the main causes of postoperative death and are the main contributors to the relatively high in-hospital mortality after device implantation.
TOTAL ARTIFICIAL HEART
Figure 15. Total artificial heart
SynCardia total artificial heart
The SynCardia total artificial heart (TAH) is a pulsatile, biventricular, pneumatically driven, orthotopic TAH that replaces some of the recipient atrial tissue, all 4 cardiac valves, both ventricles, and the proximal portions of the aorta and pulmonary arteries (16).
Each ventricle has a polyurethane diaphragm that separates blood from air. Medtronic-Hall mechanical valves in the atrioventricular and the semilunar positions (27 mm inflow and 25 mm outflow) provide unidirectional blood flow. Maximum stroke volume is 70 mL, and maximum cardiac output is 9.5 L/min. Total weight is 160 g with a volume displacement of 400 mL. A pneumatic driveline is connected to each ventricle, which is tunneled through the chest wall and connected to an external console.
AbioCor total artificial heart
The AbioCor TAH is a fully implantable, biventricular, orthotopic, pulsatile electrohydraulic TAH that is driven by a battery-powered motor. The motor powers an internal centrifugal pump, which hydraulically moves a membrane sac responsible for the pumping action.TheAbioCor TAH replaces recipient atrial tissue, all 4 cardiac valves, both ventricles, and the proximal portions of the aorta and artery. The pump and valves are made from titanium and proprietary polyurethane. A miniaturized internal electronics package monitors the pumping speed (17).
An internally implantable battery is continuously recharged from an external power source by a process called transcutaneous energy transmission (TET), which obviates the need for percutaneous power or pneumatic drive lines. An external battery pack with a TET coil provides 2-4 hours of use, while the internal battery allows 30 minutes of tether-free operation.TheAbioCor TAH weighs 1090 g and has a volume displacement of 800 mL, making it significantly larger and heavier than the SynCardia TAH.
Now a days TAH is being used more frequently and patients can be sent home with portable driver.The main advantage of TAH is it provides biventricular support in orthotopic position.