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ALL THE BELLS AND WHISTLES OF TROUBLING SHOOTING A
VAD!PATRICK C. CULLINAN, DO, FCCM, FACOEP, FACOI
Associate Clinical Professor, UIWSOM
Adjunct Assistant Professor, University of Texas Health Science Center,
Department of Emergency Medicine
San Antonio, Texas Methodist, Santa Rosa and Baptist Health Systems
NO DISCLOSURES!
OBJECTIVES:
•Review Types of Ventricular Assist Devices
•Discuss the physiology of VADs
•Review a systematic approach to evaluating a sick ED
patient with a VAD
FACTS AND NOTHING BUT THE FACTS
•5.7 million people treated for heart failure
•50% with the diagnosis of CHF will die in the next 5 years
•> 30 Billion/year to treat heart failure
VADS
•1st implanted left ventricular assist device was … 1966
•1st long term implant was … 1988
•1st FDA approval came in … 1994
VADS
•Bridge to transplantation
•Bridge to decision
•Bridge to recovery
•Destination therapy
VADS•Pulsatile
•HeartMate I
•Continuous
•HeartMate II
•Jarvik 2000
•HeartWare
•HeartMate III
HEARTMATE I
HEARTMATE II
JARVIK 2000
HEARTWARE
VADS
•Axial
•Centrifugal
AXIAL
CENTRIFUGAL
PRE-ARRIVAL
•Type of device
•Implantation hospital/VAD coordinator
•DNR status
PHONE A FRIEND
INITIAL ASSESSMENT•C, A, Bs …circulation/connections
•Mental status
•EKG
•US, Doppler … BP assessment
•Skin, capillary refill, signs of sepsis
•Caution with pulse ox
THINK LIKE ATLS
SECONDARY ASSESSMENT•DEVICE
•Power
•Auscultate LUQ of abdomen – “HUM”
•Connections – Just like a ventilator
•Adjusting settings?
VAD PARAMETERS•RPMs – Set
•Power – measured
•Directly proportional to flow across the pump
• Low – Low flow, high systemic BP
•High – High flow, pump thrombosis
•Flow – calculated, surrogate for cardiac output
•Pulse Index – reflects variation in ventricular
pressure
• Indirectly reflects LV contractility
COMPLICATIONS•Cardiac arrest – CPR?
•AMS
•CVA
•Hemorrhage
•Sepsis
•Dysrhythmias
COMPLICATIONS
•Cardiac arrest – CPR?
•Drugs - yes
•Compressions – maybe
AMS
•Etiology
•Standard evaluation
•Treat the underlying problem
CVA
•Ischemic
•Carotids
•Pump thrombus
•Hemorrhagic
HEMORRHAGE
•Antiplatelet drugs
•Anticoagulants - Coumadin
•AVMs with GI bleeding (20-40%)
•Acquired Von Willebrand deficiency
•FFP
•Cryoprecipitate
•DDAVP and/or vasopressin
SEPSIS
•Typical sites
•Drive line infection
•Early antibiotics
•Cover MDR and MRSA
DYSRHYTHMIA
•Stable – medication
•Unstable - cardioversion
COMPLICATIONS
•Hypovolemia…vasodilated, sepsis, diarrhea
•Bleeding…GI, trauma
•Hemolysis…Dark urine, jaundice
•Preload issue
•Clinical status, Power
PRELOAD•Right heart failure
•Pulmonary hypertension
•Arrhythmia…afib, SVT, Vtach, Vfib
•Cardiac tamponade
•Thromboembolism…PE, pump clot
- PUMP POWER?
AFTERLOAD
•Malignant hypertension
•Goal MAP 60-80
RIGHT VENTRICULAR FAILURE•Increased pulmonary resistance
•Hypoxia, hypercarbia, acidosis
•Increased CVP
•Arrhythmia – afib, vfib, vtach
•LV pump malposition – suction events
RIGHT VENTRICULAR FAILURE
•Management ?
•Cardioversion
•Inotropes
•Vasopressors
•Slowing RPMs
SUMMARY•Phone a friend – VAD coordinator
•Rapid assessment of A, B, C, Device
• EKG, ECHO, US/Doppler BP
•Trouble shoot Device
•Ancillary tests
SUMMARY•Treatment
• Cardioversion?
• Airway/Breathing
• Volume vs no volume
• Pressors vs inotropes vs antihypertensives
• RV and MAP
• Blood products?
• Antibiotics