state of the art: updates in vads and transplant for ... · current management of advanced stage...
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State of the Art: Updates in VADs and Transplant for Advanced Heart Failure
Jonathan D. Rich, MD
Medical Director, MCS Program
Northwestern University
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Disclosures
• Medtronic, Abbott: Consultant
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Heart Failure: Scope of the Problem• US prevalence*: 5.8 million
• US annual incidence: 670,000
• Annual mortality: 282,754
• 5-10% depending on severity
• Cost: $39.2 billion
• 53% of cost due to hospitalization
1991 2001 2037
3.54.8
10.0
0
2
4
6
8
10Pa
tien
ts in
US
(mill
ion
s)
0
15
%
50’s 60’s 70’s >80
HF increases with age
AHA Statistical Update. Circulation. 2010;121:e46-e215.Croft JB et al. J Am Geriatr Soc. 1997;45:270–275. Rich M. J Am Geriatric Soc. 1997;45:968–974.
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The Clinical Course of Heart Failure
Allen L A et al. Circulation. 2012;125:1928-1952
Cost of final 2 yrs of life:
$156K
75% for hospitalizations
during last 6 months
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Current Estimates of Advanced HF Pts
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0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Su
rviv
al
(%)
Years
2016JHLT. 2016 Oct; 35(10): 1149-1205
Adult and Pediatric Heart Transplants
Kaplan-Meier Survival
Median survival = 10.7 years;
Median survival conditional on surviving 1 year = 13.3 years
N = 118,788
(Transplants: January 1982 – June 2015)
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Adult and Pediatric Heart TransplantsNumber of Transplants by Year and Location
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Nu
mb
er o
f tr
an
spla
nts
Other
North America
Europe
NOTE: This figure includes only the heart transplants that
are reported to the ISHLT Transplant Registry. As such, the
presented data may not mirror the changes in the number of
heart transplants performed worldwide.
2016JHLT. 2016 Oct; 35(10): 1149-1205
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CRT-D in NYHA IV
Lindenfeld et al. Circulation 2007;115:204-212.
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How about Continuous Inotropes?
36 Class D patients55 ± 10 years
Median survival = 3.4 months
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Mechanical Circulatory Support(REMATCH) Trial
Rose, EA et al. NEJM, 2001.
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HeartMate II vs. HeartMate XVE LVAD
Pulsatile-flow VAD
(XVE)
Large size
Noisy
Large
percutaneous
lead
Limited
durability
Continuous-flow
VAD (HM II)
1/7 size; 1/4
weight
Quiet
40% smaller
perc lead
One moving
part
Long term
durability
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HeartMate II Trial
Slaughter M et al. NEJM 2009;361:2241-51
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The Rise of the Machines
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The Rise of the Machines
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Current Management of Advanced Stage HF
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The Right Time for LVAD or Transplant: The “Perfect Window”
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DT REMATCH (PAST DT EXPERIENCE*)
1.0
0.8
0.6
0.4
0.2
0.0
0 6 12 18 24 30 36
Pr
[ali
ve]
Time (months)
OMM (n=61)
+
++ +
LVAD (n=68)
+
+++ +++
++
+++
+++
* Rose et al, Long-term mechanical left ventricular assist
for end-stage heart failure. N Eng J Med.,2001;345:1435-1443
Transplantation
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RECENT DT HM II EXPERIENCE
1.0
0.8
0.6
0.4
0.2
0.0
0 6 12 18 24 30 36
Pr
[ali
ve]
Time (months)
OMM (n=61)
+
++ +
+
+++ +++
++
+++
+++
Slaughter,et al NEJM 2009
Transplantation
HM II DT
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PRESENT BTT and DT HMII EXPERIENCE
1.0
0.8
0.6
0.4
0.2
0.0
0 6 12 18 24 30 36
Pr
[ali
ve]
Time (months)
OMM (n=61)
+
++ +
+
+++ +++
++
+++
+++
Transplantation
Heartware
Select centers reported 2012
DT HM II LVAD
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The Major Challenge Facing LVADs in 2017 is not Survival: It is Complications
Kirklin JHLT 2013
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J Am Coll Cardiol 2010; 55: 1826-34
6 Minute Walk Distance
NYHA Functional Class
I
II
II
I
IV
I I I I I
IIII II II II
IIIIII III III III
III
IV
Minnesota Living with Heart Failure
Kansas City Cardiomyopathy Score
* p<0.05 vs. baseline
Quality of Life in LVADs
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The Heartmate II LVAD
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The Heartmate II LVAD
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The Heartware HVAD
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The Heartmate 3 LVAD
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Heartware HVAD Implant
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Patient with HVAD BIVADs
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Mechanical Circulatory Support
1940 1960 1980 20202000
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The Future (is here!)Heartmate III™ MVAD™
Circulite™
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Advanced Heart Failure: Therapeutic Options
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“And in the end, it’s not the
years in your life that counts, it’s
the life in your years.”
Abraham Lincoln
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THANK YOU!