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Megan Shifrin, RN, MSN, ACNP-BC Vanderbilt University. Advanced Heart Failure and the Role of Mechanical Circulatory Support. Objectives. Review current recommendations for advanced heart failure management Identify the different types of VADs currently in use - PowerPoint PPT Presentation
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Advanced Heart Failure and the Role of Mechanical Circulatory Support
Megan Shifrin, RN, MSN, ACNP-BCVanderbilt University
Objectives• Review current recommendations for advanced heart
failure management• Identify the different types of VADs currently in use• Identify the indications and contraindications for
placement• Overview of immediate post-operative management
and potential complications
Why Should I Care About Heart Failure or LVADs?
• Prevalence – According to the American Heart Association, there are close to 6 million Americans living with heart failure. • Incidence – Almost 550,000 new cases are diagnosed
annually. • About 300,000 people die each year of heart-failure related causes.
• Heart failure is the single most common cause of hospitalization in the United States for people over the age of 65. • In 2012 alone, there were 2,066 permanent LVADs placed in
patients.• These patients live in your community.
The Cost of Heart Failure Management in the United States
10.5%
9.7%8.2%
6.4%
11.9%
53.3%
Hospitalization$20.9
Lost Productivity/Mortality*
$4.1Home Healthcare
$3.8Drugs/Other
Medical Durables$3.2
Physicians/Other Professionals
$2.5
Nursing Home$4.7
Total Cost
$39.2 billion
Heart Disease and Stroke Statistics—2010 Update: A Report From the AHA
Circulation, Feb 2010; 121: e46 - e215
Etiologies of Heart Failure• Non-ischemic cardiomyopathy• Valvular disease• Viral/bacterial cardiomyopathy• Peripartum cardiomyopathy• Idiopathic/familial cardiomyopathy• Myocarditis• Connective tissue disorders• Drugs/Toxins• Alcohol
• Ischemic cardiomyopathy• Hypertension• Coronary artery
disease • Myocardial infarction
Increasing Severity
Class I• Cardiac
disease• No symptoms• No limitation
in ordinary physical activity
Class II• Mild
symptoms (mild shortness of breath and/or angina)
• Slight limitation during ordinary activity
Class IIIa and IIIb• Marked
limitation in activity due to symptoms
• Comfortable only at rest
Class IV• Severe
limitations• Symptoms
even while at rest
• Mostly bedbound patients
New York Heart Association Functional Classification of Heart Failure
Goals of Heart Failure Management
1. Improving symptoms and quality of life
2. Slowing the progression or reversing cardiac and peripheral dysfunction
3. Reducing mortality
Addressing Heart Failure in 2013
Katz AM Heart Failure
Pharmacologic Optimization of the Heart Failure Patient with LVEF <40%
(Strength of Evidence = A)• ACE inhibitors
• ARBs• To be utilized when intolerant to
ACE inhibitors due to angioedema or cough
• Patients intolerant to ACE-I due to renal insufficiency or hyperkalemia are likely to experience the same effects with ARBs
• Warfarin• In patients with atrial fibrillation,
pulmonary embolism, or TIA
• Beta Blockers
• Aldosterone Antagonists
• Hydralazine and Isosorbide Dinitrate• In African American population
with stage III and IV heart failure, strength of evidence = A
• Loop Diuretics Lindenfeld, J, et al.J Card Failure2010; 6, 486-491
Pharmacologic Optimization of the Heart Failure Patient with LVEF <40%
Strength of Evidence = B• Antiplatelet agents (Aspirin)
• Ischemic etiology of HF• Digoxin
• In stage II and III HF• Thiazide diuretics• Warfarin
• MI patients with LV thrombus
Strength of Evidence = C• Digoxin• In stage IV HF
• Metalazone
Lindenfeld, J, et al.J Card Failure2010; 6, 486-491
Pharmacologic Optimization of the Heart Failure Patient with LVEF <40%
Inotropes• Commonly used on an outpatient basis for stage IIIb – IV
heart failure• Milrinone and Dobutamine are the only FDA approved
drugs for outpatient use• Not recommended for acute heart failure exacerbations in
ischemic patients• Probable benefit in non-ischemic exacerbations
• OPTIME-CHF JAMA 2002; 287:1541-7
Non-pharmacologic Optimization of the Heart Failure Patient with Low LVEF
Cardiac Resynchronization Therapy (CRT)• LVEF <35%• NYHA class III – IV• QRS > 120 ms• Optimal medical therapy
Non-pharmacologic Optimization of the Heart Failure Patient with Low LVEF
Implantable Cardiac Defibrillators• Ischemic Etiology • (Strength of Evidence = A)
• Non-ischemic Etiology • (Strength of Evidence = B)
• Primary prevention of ventricular arrhythmias• LVEF <35% Lindenfeld, J, et al.
J Card Failure2010; 6, 486-491
Evidence of Progressing Heart Failure
Decreased end organ perfusion• Renal function• Liver function• Pulmonary function
We need more support!
Ventricular Assist Device (VAD)
Long-Term LVADImplanted surgically with
the intention of support for months to years
Short-Term LVADUtilized for urgent/
emergent support over the course of days to weeks
A mechanical circulatory device used to partially or completely replace the function of either the left
ventricle (LVAD); the right ventricle (RVAD); or both ventricles (BiVAD)
Things to Consider Before Placing ANY type of VAD Support
• Are there any contraindications to VAD support?• End-stage lung, liver, or renal disease• Metastatic disease • Medical non-adherence or active drug addiction• Active infectious disease• Inability to tolerate systemic anticoagulation (recent CVA, GI
bleed, etc.,)• Moderate to severe RV dysfunction for some LVADs
• What are our other issues in this particular patient?• What are the patient’s goals? What are our goals? • What happens if we don’t meet our goals?
Lietz and Miller Curr Opin Cardiol 2009, 24:246–251
INTERMACS SCOREInteragency Registry for Mechanically Assisted Circulatory
Support Long-Term LVAD
Ideal candidates are INTERMACS classes 3-4Short-Term LVAD
Candidates are INTERMACS
classes 1-2Not a LVAD Candidate
INTERMACS 1 or those with multisystem organ failure
Destination Therapy vs. Bridge to TransplantationLong-term placement
Destination Therapy (DT)• Not a heart transplant
candidate• NYHA IV• LVEF <25%• Maximized medical
therapy >45 of 60 days; IABP for 7 days; OR 14 days
• Functional limitation with a peak oxygen consumption of less than or equal to 14 ml/kg/min
• Life expectancy < 2 years
Bridge to Transplantation (BTT)
• Patient is approved and currently listed for transplant
• NYHA IV• Failed maximized medical
therapy
http://www.cms.gov/medicare-coverage-database
Adult FDA Approved LVADsBridge to Transplantation
(BTT)HeartMate II (Thoratec)HeartWare (HeartWare)
PVAD (Thoratec)IVAD (Thoratec)
Destination Therapy (DT)HeartMate II (Thoratec)
HeartMate II (Thoratec)
Basics of HM IIPump Speed (RPM) – How quickly the pump rotates
Pump Power (Watts) – Measure of motor voltage and current
Pump Flow (L/min) - Estimated value of the volume running through the pump
Pulsitility Index – The measure of the left ventricular pressure during systole
Immediate Post-op Management
VS
Management Considerations• Typically pulseless • Use a doppler or arterial line for BP assessment (Target MAP 60-80)
• Afterload sensitive • An increase against pump propulsion is reflected in decreased
pump flow• Preload sensitive• Anticoagulation status• Correction of coagulopathy immediately post-operatively• At 24-48 hours, Warfarin with goal INR 2-3 +/- Aspirin, Dipiridamole,
Clopidogrel
• Should not receive chest compressions during an arrest• Patients still have heart failure
Potential Device Complications
Inflow cannula (poor position, obstruction)
Pump/rotor dysfunction (thrombus)
Battery dysfunction
Outflow graft (kink, leak)
Drive line infection / fracture
Controller malfunction
Hematologic Long-Term Complications
•GI bleed • 13-40% of LVAD patients• Constitute 9.8% of LVAD readmissions
• CVA (embolic and hemorrhagic) • 17% of patients who survived 24 months post-
implant•Hemolysis • Increases rate of mortality by 25% over six months
“However beautiful the strategy, you should occasionally look at the results.”
Winston Churchill
Medical Management vs. LVAD
Rose, EA; et alNEJM 2001; 345:1435-1443
Survival Rates
Kirkland, JK, et. alJHLT 2013; 32:141-156
ADLs of DT Patients
Kirkland, JK, et. alJHLT 2013; 32:141-156
What Happens to These Patients?
• Shock Team Evaluation for mechanical circulatory support (MCS)
• Try to avoid the bridge to decision or the bridge to nowhere
Variations of Short-Term VADs• Impella 2.5 and 5.0•Tandem Heart•CentriMag•ECMO (V-A)
Impella 2.5 and 5.0• Utilized for LV support only; not
appropriate to use with RV failure• Impella 2.5 can be inserted through
the femoral artery during a standard catheterization procedure; provides up to 2.5 L of flow
• Impella 5.0 inserted via femoral or axillary artery cut down; provides up to 5L of flow
• The catheter is advanced through the ascending aorta into the left ventricle
• Pulls blood from an inlet near the tip of the catheter and expels blood into the ascending aorta
• FDA approved for support of up to 6 hours
TandemHeart pVAD• Used for LV support; not
appropriate in RV failure• Cannulas are inserted
percutaneously through the femoral vein and advanced across the intraatrial septum into the left atrium
• The pump withdraws oxygenated blood from the left atrium and returns it to the femoral arteries via arterial cannulas
• Provides up to 5L/min of flow
• Can be used for up to 14 days
CentriMag• Can be used for LV
and/or RV support• Cannula are typically
inserted via a midline sternotomy
• Capable of delivering flows up to 9.9 L/min
• Can be used for up to 30 days
ECMO (VA)• Used for patients with a
combination of acute cardiac and respiratory failure
• A cannula takes deoxygenated blood from a central vein or the right atrium, pumps it past the oxygenator, and then returns the oxygenated blood, under pressure, to the arterial side of the circulation
• Can be used for days to weeks
Summary• The management of advanced heart failure is a
dynamic process that requires frequent re-evaluation
• Timing of LVAD placement is critical
• LVADs for DT have been shown to improve mortality rates and quality of life
• There are short-term VAD options available for emergent situations
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