Case StudiesAdvanced Heart Failure and the Role of

Mechanical Circulatory Support

Megan Shifrin, RN, MSN, ACNP-BCVanderbilt University

Case Study #1JK is a 58 year old male with a PMH of HTN, HLD, DM II (A1c 7.4), asthma, and myocardial infarction in 2009. At the time of his MI, he was found to have multi-vessel coronary artery disease and underwent a CABGx4 (2009). Over the past four years, his LVEF has decreased from 45% to 25%, and he currently has NYHA class IV symptoms.

He presents to you today in clinic for his regularly scheduled follow-up appointment. He reports being mostly home-bound with the exception of going to his son’s high school football games on Friday nights. He describes having dypnea and diaphoresis when carrying out ADLs such as bathing and dressing. He is able to ambulate approximately 20 feet at a time. His physical exam is notable for 2+ lower and upper extremity edema; S3 on auscultation to his heart sounds, and crackles in his bilateral lung fields.

Based on the cast study presented, JK’s heart failure would fall into which of the following categories:

A. Ischemic cardiomyopathy

B. Non-ischemic cardiomyopathy

Based on JK’s past medical history, which of the following is likely NOT to be contributory to his ischemic cardiomyopathy?

A. DiabetesB. HypertensionC. AsthmaD. Hyperlipidemia

Based on JK’s past medical history and LVEF of 25%, which of the following classes of medications are NOT supported by the literature (Strength of evidence = A)?

A. Beta BlockersB. ACE InhibitorsC. Calcium Channel BlockersD. Loop diuretics

You, in conjunction with the collaborative heart failure team, believe that it is time to start outpatient inotropic support. Which TWO of the following medications are FDA approved for outpatient use in heart failure?

A. EpinephrineB. DopamineC. DobutamineD. Milrinone

The heart failure team is considering ICD placement in JK. You know that an ICD is warranted in JK due to all of the following reasons EXCEPT:

A) His past medical history of DM II

B) His LVEF < 35%C) For primary

prevention of arrhythmias

D) His history of heart failure (ischemic etiology)

Case Study #2

LN is a 34 year old female with a past medical history of peripartum cardiomyopathy following the vaginal delivery of her first child nine months ago. Her LVEF is 20%, and she has NYHA class IV symptoms. She has been on optimal medical therapy including carvedilol, captopril, aldactone, and lasix. In addition, she was started on an outpatient milrinone infusion at 0.25 mcg/kg/min one month ago. She has been listed for heart transplantation, but due to her blood type of A- and her body habitus, it is unlikely that a donor heart will be found quickly.

Based on the cast study presented, LN’s peripartum cardiomyopathy would fall into which of the following categories:

A. Ischemic cardiomyopathyB. Non-ischemic cardiomyopathy

LN is undergoing evaluation for LVAD placement. Based on the case study, LN would fall into which LVAD category?

A) Destination therapyB) Bridge to transplantationC) Bridge to nowhereD) Bridge to decision

LN asks about the benefits of having an LVAD placed. Which of the following statements is TRUE regarding LVAD placement as a bridge to transplantation?

A) Patients are guaranteed a transplant if they get a LVADB) Most LVAD patients see an improvement in their ability to carry out their usual activities of daily livingC) A LVAD will make her heart failure resolveD) She will be able to stop all of her heart failure medication shortly after LVAD placement

Some of the long-term risks associated with LVAD placement include which of the following:

A) Infection B) GI bleedC) CVAD) All of the above

As the ACNP preparing to care for LN in the immediate post-operative period, you recognize that the following issues will likely be present:

A) LN may be afterload sensitiveB) LN may be preload sensitiveC) LN will likely be pulseless due to her continuous flow LVADD) All of the above

If LN’s heart failure continues to advance, you know that it’s an easy decision to throw her on a short-term VAD such as a TandemHeart or CentriMag.

A. TrueB. False