Pulseless pumps &

artificial hearts
Mehmet Oz MD
Irving Assistant Professor of Surgery
Columbia University
New York, NY
Patrick McCarthy MD
Surgical Director, Kaufman Center for Heart Failure
Cleveland, OH
Program Director, Heart Transplantation
Cleveland Clinic Foundation
Cleveland, OH
 LVADs
Left ventricular assist devices

Portable battery-powered devices that allow

hospital discharge are currently being used in
virtually all patients.

Implanting these devices has become routine;

from 1 per month in the early 1990s to 1 per
week currently.

New implantable LVADs are being developed

that are much smaller, continuous flow pumps.
 Jarvik 2000

The Jarvik 2000 was implanted at the Texas

Heart Institute in April 2000.
It is a valveless, electrically powered,
miniature axial flow pump about the size of a
"C" battery.
It fits directly into the left ventricle and pushes
oxygenated blood throughout the body
 DeBakey VAD

The DeBakey heart has recently been approved

for use in the US by the FDA.

It is a miniaturized axial flow device that pumps

blood from the left ventricle through a titanium
inflow cannula inserted into the heart's apex.

It increases blood flow up to 10 L/min in

patients suffering from congestive heart failure.

The only moving part is the inducer-impeller;

magnets in its blades cause it to spin between
7 500 to 12 500 rpm.
 Clinical trials
DeBakey VAD

Clinical trials began in Europe in November

1998.

As of June 8, 2000, 32 patients had received a

DeBakey implant.

The US has recently received FDA approval to

begin clinical trials.
 Centrifugal LVADs

Rotary centrifugal LVADs have 2 sealed chambers

 a pump chamber that moves the blood

 a motor chamber which contains the

mechanism that drives the pump

Power is transmitted between the chambers by

magnetism.

Two tubes leaving the pump chamber carry the

blood between the LVAD and the heart.

The third tube to the motor chamber contains the

wires to power the unit.
 HeartSaver VAD

The HeartSaver, weighing about 500 grams, is a

fully implantable device for long-term use that can
be remotely powered, monitored and controlled
using TET and biotelemetry technologies.
Its shape follows the contour of the chest wall and
connects via short conduits to the apex of the left
ventricle of the natural heart and to the ascending
aorta.
It is intended for long-term circulatory support and
recipients are expected to leave the hospital and
resume near normal day-to-day activities.
 TET coils
Power supply

The TET (transcutaneous energy transmission)

system transfers electrical energy through the
user's intact skin and tissue to directly power
the implanted VAD and the implanted, internal
back-up battery.
 Permanent LVADs
Advantages

 better quality of life

 eliminates the need to take
immunosuppressive medications
The transition to more permanent LVADs
will be gradual.
 LVADs

The durability and engineering of the pumps is much

better than it was.
Our understanding of heart failure management has
advanced, with innovative new drugs and surgical
reparative approaches.
To tailor our therapies, we need to better understand
the impact that immunology has and the way
patients with artificial devices respond to foreign
bodies.
The most commonly used pump today owes its
success in part to the fact that it prevents
anticoagulation.
 Design challenge
Pulsitile flow

It was first thought that the lack of pulsitility with

axial flow pumps would have some impact to the
body.

However, the first cases from Europe using the

Debakey pump have shown that this isn’t the case.

In a few isolated instances pulsitile flow may be

important (e.g., in the case of a traumatic insult to
an organ for which optimal conditions are required for
full recovery).

However, for the average daily existence, it is

probably not necessary.
 The heart
Not just a pump

This very complicated field is still in the

earliest phase.
The heart is not just a pump, it is also a
neuroendocrine organ.
There are signs that the heart recovers,
which opens the possibilities for adjunctive
therapies to LVADs like angiogenesis
factors, myoblasts and growth hormone.
 Selecting patients
Bridge to recovery

The inability to predict who will have a sustainable

recovery has led to the practice of leaving pumps
in.

The biochemistry of the heart may help us

understand why an individual cell of the heart
stops carrying its workload, why it doesn't process
fatty acids, or why it doesn’t take up calcium the
way it once did.

Dealing with these underlying metabolic problems

may help us make these recoveries sustainable

Once response to treatment can be predicted,

heart devices can be used as a bridge to recovery
instead of a bridge to transplant.
 Abiomed
Total artificial heart
The Abiomed total artificial heart is a
biventricular assist device implanted inside the
chest to replace the heart.

Whereas the LVAD is only for the left side, the

artificial heart is for both sides.

The Abiomed total artificial heart uses a

centrifugal pump to move silicone hydraulic
fluid, which drives the device.

A sleeved, rotating valve shuttles the fluid

between the left and right blood pumps.
 Biventricular support
Candidates

 patients who are plagued with continuing

moderate rate heart failure on the LVAD
 patients with ventricular arrhythmias that
may inhibit their recovery while on an LVAD
alone
 patients who have very severe right heart
failure
 patients who have ventricular arrhythmias
 patients with acute MI complicated by such
things as a ventricular septal defect
 Stroke prophylaxis

It is very difficult to predict from animals

what the stroke rate is going to be in
humans.

Caution and some anticoagulation will

probably be the recommended course of
action to begin with.
 HeartMate device

An electrically powered device, which, unlike

the LVAD, does not need a vent to the
outside.
The current LVADs have a vent that allows
the air to go back and forth as a pusher
plate moves inside the device.
Risk of stroke with the HeartMate device is
extremely low.
 Progress report

With the Jarvik-7, it was hardly worth living

because quality of life was so low.

LVADs
Today's LVADs are portable and patients are
discharged from hospital.

Total artificial heart

Patients will be discharged with battery
powered devices that have a low risk of
mechanical failure.

It is expected that risk of stroke will also be

low.
 Ideal candidates
Total artificial heart
Patients who have end-stage heart disease; a
patient population similar to the heart
transplantation group.

People who have a very limited quality of life

and length of life because of their heart
disease but who do not have other major
organ limitations.

Not patients who are in their 80s, who have

end-stage diabetes and numerous other
organs with complications.
 LVAD as a bridge
Candidates

 patients with ventricular arrhythmias on LVAD

support
 patients for whom LVAD isn't adequate
 patients who have had failed heart
transplants, whether there is transplant
coronary disease or some type of refractory
rejection
 patients who have lymphomas related to the
immunosuppression
 New developments

In various stages of development

 8 axial flow pumps
 2 artificial hearts
 Media attention

The idea of using devices for supporting the

heart is becoming more accepted.
Economic issues will probably be the most
controversial topic.
Leading role for investigators
Emphasize the importance of basing
conclusions on the first 100 patients, not on
the first patient.
 The next step
Cardiac support
The next step in cardiac support will never
be heart transplantation.

Heart transplantation can only supply 2200

hearts per year.

Mechanical devices are things that will have

epidemiologically significant impact on
cardiac support