advanced heart failure and lvads - acvp online · 2018. 4. 14. · cleveland cardio conference 2018...
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Advanced Heart Failure and LVADs
Date: Saturday April 14, 2018
Author: Chad Gady
Title : Physician Assistant / Mechanical Circulatory Support
Advanced Heart Failure Definition
↓ pump (ejection)
↓
↓ perfusion to end organs
Kidney Liver Stomach Brain
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Advanced Heart Failure Stages and Treatment
Clyde W. Yancy et al. Circulation. 2013;128:e240-e327 Copyright © American Heart Association, Inc. All rights reserved.
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Advanced Heart Failure
Symptoms
www.southwestlondoncardiacnetwork.nhs.uk
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Advanced Heart Failure Evidence
• NYHA III, IIIb, IV
• EF <30%
• Multiple readmissions
• Weight Loss
• Intolerance to ACEi/BB
• Hypotension
• PCWP > 16, RAP >12
• CXR congestion
• Decline in renal function
• Diuretic escalation
• Hyponatremia
• Frequent ICD shocks
• Elevated BNP
• 6 min walk < 300m
• PVO2 < 14 mL/kg/min
• Exam findings (JVP)
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Advanced Heart Failure Therapeutic Options
Heart Transplant
Inotrope
LVAD
Hospice
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Advanced Heart Failure Therapy
D
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Participants
Surgeon
Cardiologist
Family
VAD coordinator
Nurse Coordinator
(CVICU)
Social Worker
Pal Med
+/- Ethicist
NP/Intensivist (CVICU)
Bedside RN
Spiritual Care (optional)
Meeting Goals
• Prognosis /expectations
• Advance directives/DNR Status
• DeactivationProcess
• Decide which family to be present during
deactivation
• Religious Rites
• Discontinuation of other life support modalities
(CRRT, Vent, Pressors)
• Comfort measures
• Life Banc
• Document in medical record outcome
• Request for Autopsy
Participants
VAD coordinator
Social Worker
Pal Med
Bedside RN
Clinical Nurse Liason /
Unit Manager
NP/Intensivist (CVICU)
Spiritual Care (optional)
Action
• Person in charge of deactivation identified and notified
• Person(s) in charge of deactivation of other life sustaining treatment modalities identified and notified
• Check list reviewed (see attached)
• DNR status updated
• Family members present as previously discussed
• Ensure patient comfort (pain, dyspnea, anxiety, secretions, N/V, etc)
• Religious rites / practices honored
• Spiritual care notified (if indicated by family)
• Social work, interpreter services, RN coordinators at bedside if indicated
• Code Calm initiated
• Nursing End of Life Protocol initiated
• Bedside monitor silenced / off
• LVAD Deactivated (see attached instructional sheets)
Meeting Goals
• Address patient comfort
• Review comfort care order set
• Ensure DNR status is DNR- Comfort Care
• Consult appropriate services for discontinuation
of other life support modalities
• EP: ICD
• Renal: Dialysis
• Pulmonology: Vent
• Plan date / time for deactivation of LVAD +/- other
life support modalities
• Steps / Sequence
• Review team members roles
• Decide who will deactivate LVAD
Deactivate
Clinical
Meeting
Family
Meeting
Discussion
Discussion
Advanced Heart Failure
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Advanced Heart Failure Therapy
• Fluid Restriction
• Inotrope Therapy
–Dobutamine
–Milrinone
Advanced Heart Failure Figure. Kaplan–Meier plots for patients with stage D heart failure receiving either dobutamine or milrinone.
Gorodeski E Z et al. Circ Heart Fail 2009;2:320-324
Copyright © American Heart Association
50% Alive at 6 months
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Advanced Heart Failure Number of Heart Transplants by Year and Location
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.
JHLT. 2013 Oct; 32(10): 951-964
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Advanced Heart Failure Xenotransplantation
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Advanced Heart Failure Adult and Pediatric Heart Transplants Survival (January 1982 – June 2012)
N = 108,343
N at risk at 27 years = 108
2014 JHLT. 2014 Oct; 33(10): 996-1008
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~240 Million Population ≥
age 20 years old
HF=2.6 % Population* or
6.24 Million Total ~50 % Preserved Systolic
Function 3.12 M
~50 % Systolic HF
3.12 Million
Advanced Stage C and Stage D ≥ age 20 years old
109,200 – 280,800
Advanced Stage C / NYHA class IIIB
93,600-124,800
80-85% Stage A-B
0.5-5 % Stage D
Advanced Heart Failure Theoretical adult candidates for Mechanical Circulatory Support in
United States
Stage D / NYHA functional class IV
15,600-156,000
15-20% Stage C (3-4% advanced Stage
C)
Gorodeski, Starling
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Advanced Heart Failure CMS DT and BTT Criteria
DT LVAD specific criteria
• New York Heart Association Class IV end stage left ventricular
failure.
• Have failed to respond to optimal medical management (including
beta-blockers and ACE inhibitors if tolerated) for at least 45 of the
last 60 days, or have been balloon pump dependent for 7 days, or IV
inotrope-dependent for 14 days
• Have a left ventricular ejection fraction (LVEF) < 25%
• Have demonstrated functional limitation with a peak oxygen
consumption of < 14 ml/kg/min unless balloon pump or inotrope-
dependent or physically unable to perform the test.
BTT LVAD specific criteria
• All BTT patients MUST be actively listed with UNOS prior to VAD
implant
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Advanced Heart Failure Implants per year
• This is where main copy goes
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Advanced Heart Failure Survival
• This is where main copy goes
Yr 1: Estep et al. J Am Coll Cardiol 2015;66:1747-61
LVAD BetterOMM Better
0.1 0.3 0.5 1.0 2.0 5.0 10.0
Event-Free Survival
Intent-to-Treat Survival
Primary End PointAlive at timepoint with
6MWD > 75m
Adverse Events
As treated on original therapy
Composite rate for yr
R.R
H.R
O.R
Ratio (95% CI) p-value
1.7 (1.1-2.7) p=0.024
4.1 (1.9-8.9) p<0.001
2.4 (1.2-4.8) p=0.012
1.0 (0.6-1.8) p=0.931
2.3 (1.5-3.7) p<0.001
5.7 (2.1-14.9) p<0.001
3.2 (1.3-7.7) p=0.012
1.3 (0.8-2.1) p=0.307
0.79 (0.46-1.36) p=0.492
0.46 (0.31-0.68) p<0.001
Yr 1
Yr 2
NYHA Class, HRQoL, and DepressionAlive at timepoint with
NYHA improvement > 1 class
O.R
8.9 (4.5-17.8) p<0.001
5.9 (2.8-12.6) p<0.001
VAS improvement > 20 pts
PHQ-9 improvement > 5 pts4.2 (1.7-10.2) p<0.001
4.1 (1.5-10.8) p=0.004
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Advanced Heart Failure Risk-Benefit Analysis
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Advanced Heart Failure Primary Indication for VAD Support
In general, the inability to adequately oxygenate thereby maintaining
normal end-organ function despite maximal medical therapy
-Postcardiotomy shock
-Acute Myocardial Infarction
-Chronic Heart Failure
-Myocarditis
-Ventricular Arrhythmia
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Advanced Heart Failure Secondary Indications for VAD Support
1. Bridge To Recovery (BTR)
- Temporary devices (IABP, ECMO, etc.)
2. Bridge To Transplantation (BTT)
3. Destination Therapy (DT): Option for Patients Who May Not Qualify for Cardiac
Transplantation
General Specific Relative
Any condition limiting a
successful transplant outcome
Elevated pulmonary vascular
resistance
Active infection
Renal or pulmonary disease
Diabetes with end-organ
damage
Cross-match incompatibility
Active psychiatric disease
Substance abuse
Smoking
Age
Peripheral vascular
disease
Malignancy
Size/Obesity
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Advanced Heart Failure Short Term MCS
• Percutaneous
• Bridge to recovery, transplant, or more durable device
• Counterpulsation
– IABP
• Non - Pulsatile
–Axial (e.g. Impella)
–Centrifugal (e.g. ECMO, Tandem Heart)
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Advanced Heart Failure Examples
• Pulsatile
- Total Artificial Heart (TAH)
• Non – Pulsatile or Continuous Flow
- Heart Mate II & III
- Heart Ware
Advanced Heart Failure Long Term MCS
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Advanced Heart Failure TAH Device Components
• Mechanical Valves
• Large
• Least resistance to flow
• Two ventricles
• 70 ml stroke volume
• LVAD (left atrial cuff to aorta)
• RVAD (right atrial cuff to pulmonary artery)
• Pneumatically driven
• Pulsatile flow (9.5 L/min max flow)
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Advanced Heart Failure Total Artificial Heart
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Advanced Heart Failure Total Artificial Heart: The Past
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Advanced Heart Failure Total Artificial Heart: The Present
Advanced Heart Failure Continuous Flow Devices
• Non – Pulsatile
• Follow native pulse
• Pump output varies over cardiac cycle
• Centrifugal, Axial, Radial flow pumps
• Generate blood flow via rotational momentum
• Spinning of concentric cones or impellers Revolutions
per minute (RPMs)
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Advanced Heart Failure Continuous Flow Devices
• Advantages
- Quiet
- Less Power than pulsatile
- Durable (single moving part, no
valves, nominal friction)
- Size
- Continuous unloading of LV
• Disadvantages
- No hand pump
- Hemolysis
- Negative Intraventricular Pressure
( thrombosis, arrhythmia potential)
- Proper Cannula Placement
- Preload dependent & Afterload
sensitive
- Effect on Microcirculation
- LVAD only
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Heartmate II
Heartmate III
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Advanced Heart Failure Continuous Flow Devices
Advanced Heart Failure HeartMate II LVAD
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Advanced Heart Failure HeartMate III LVAD
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Advanced Heart Failure HeartWare LVAD
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• Doppler BP vs. Automatic Cuff
- Try both methods
• Target range
- MAP [(2 x diastolic)+systolic] / 3
or Doppled Pressure 70-90 mmHg
- Record BP as systolic/diastolic if present
- If obtain doppler pressure, write 80/0.
• Why do we care?
- Autocuff 100/70 (80) vs Doppled Pressure 100
VS
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Advanced Heart Failure Management: Blood Pressure
• Assess patient
• Assess device. Assess alarms
Start at driveline, check connection into controller, check power sources, change power sources.
• If changing power sources does not start the pump, change the controller
• If pump still does not start, assess the patient, treat medically (ie. ACLS, Inotropes, heparin, possible return to the OR)
• If necessary, Chest Compressions are OK.
Advanced Heart Failure Management: Emergency Management
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Advanced Heart Failure Management: Emergency Management
Circulation. 2017;135:e1115-e1134.
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Advanced Heart Failure Common Complications
Advanced Heart Failure Infection
Cause
– Driveline Infection (most common)
– Other portal of entry
Effect
– Fever
– Chills
– Drainage
– Bacteremia / Sepsis
– Septic Emboli
Evaluation / Treatment
– Blood cultures
– Driveline culture
– Antibiotics
– Consult ID
– I&D
Good Driveline
Bad Driveline
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Advanced Heart Failure Pump Thrombosis
Cause
– Ingestion of tissue or emboli
– Growth or deposition in pump
– Inadequate anticoagulation / platelet inhibition
Effect
– Obstruction of flow
– Increased drag on rotor
– Inability to unload the LV
– Hemolysis
– Hematuria
– Heart Failure
Evaluation / Treatment
– CT scan
– ECHO
– Device parameters
– Ramp study
– Lytic therapy
– Anticoagulation
– Device exchange / Transplant
– Palliative care
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Advanced Heart Failure
Outflow Graft Thrombus Overgrowth of Myocardium
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Advanced Heart Failure CVA
Cause
- Hemorrhagic
- Embolic
Effect
- Change in neurologic status
Evaluation / Treatment
- CT scan
- Neurology consult
- Anticoagulation, Lytic therapy
(depending on etiology)
- Palliative care
Left frontotemporal subdural and left parietal occipital cerebral
acute hematoma with mass-effect and midline shift.
Advanced Heart Failure GI Bleeding
Cause
– Anticoagulation
– Intestinal Ischemia
– vWF deformation
– AVM’s
Effect
– Weak, Lightheaded, Pre-syncope
– Flow / PI changes
– Hypotensive
– Melena
– Hematochezia
Evaluation / Treatment
– Eliminate anticoagulation
– Transfuse
– Consult GI (Endoscopic evaluation)
– ? Decrease pump speed
– ? Octreotide
– ? Estrogen Therapy
– Transplantation
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Advanced Heart Failure The End
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