rise of the machines- vads presentation august 2011
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Rise of the Machines: Mechanical Circulatory Support
Stephanie A. M. Olcese, MS, ACNP
Objectives• What are VADs?• Who benefits?• Physiological principles • Devices• Indications • Management • Complications
VADs• Ventricular assist devices• Circulatory support
Image from: www.transmedic-ind.com
Who Benefits?• Post-cardiotomy ventricular
dysfunction refractory to medical therapy & IABP
• Acute MI with cardiogenic shock • High-risk cath lab procedures• Resuscitation from cardiac arrest• Stage D Heart Failure
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.
Who Benefits?• Stage D Heart Failure
•Bridge-to-transplantation •Destination Therapy
Park SJ., et al. Left ventricular assist devices as destination therapy: a new look at survival. J Thorac Cardiovasc Surg. 2005;129:9-17.
Copyright ©2005 American Heart Association
Hunt, S. A. et al. Circulation 2005;112:1825-1852
Hunt, S. A. et al. Circulation 2005;112:1825-1852
Copyright ©2007 American Heart Association
Lietz, K. et al. Circulation 2007;116:497-505
Survival after LVAD implantation as DT in the post-REMATCH era
Physiological Principles• Reduction in CO & DaO2
• Vasoconstriction & SVR• Compromised cardiac contractility • Low EF• Hypotension
Morton et al. Critical Care Nursing: A Holistic Approach. 8th ed. Lippincott Williams & Wilkins, 2005.
Clinical Picture • Despite medical therapies & IABP
• CI < 2.0 L/min/m2
• PAWP > 20 mm Hg• SBP < 80 mm Hg
Morton et al. Critical Care Nursing: A Holistic Approach. 8th ed. Lippincott Williams & Wilkins, 2005.
Goals• Restoration of adequate blood flow• Preservation of end-organ function
Morton et al. Critical Care Nursing: A Holistic Approach. 8th ed. Lippincott Williams & Wilkins, 2005. Images from: www.morphonix.com & www.aurorahealthcare.org
Ventricular Assist Devices • Short term vs. long term• Univentricular vs. biventricular• Internal vs. external • Pulsatile vs. non-pulsatile
Morton et al. Critical Care Nursing: A Holistic Approach. 8th ed. Lippincott Williams & Wilkins, 2005.
Pulsatile Pumps• Short-term
• Abiomed BVS 5000**• Long-term
• Abiomed AB5000• Thoratec VAD• Thoratec HeartMate VE
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.
Non-Pulsatile Pumps• Long-term
• Thoratec Heartmate II **• Javrik 2000• Micromed Heart Assist 5
(DeBakey)
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.
Cannulation
• Left ventricle • Ascending aortaOUTFLOW
CONDUIT• LV or LAINFLOW CONDUIT
• Right ventricle• RAINFLOW CONDUIT• PAOUTFLOW CONDUIT
Morton et al. Critical Care Nursing: A Holistic Approach. 8th ed. Lippincott Williams & Wilkins, 2005.
Components of the Continuous-Flow Left Ventricular Assist Device (LVAD).
Miller LW et al. N Engl J Med 2007;357:885-896.
Pulsatile-Flow (Panel A) and Continuous-Flow (Panel B) Left Ventricular Assist Devices (LVADs).
Slaughter MS et al. N Engl J Med 2009;361:2241-2251.
Kaplan–Meier Estimates of Survival from the As-Treated Analysis, According to Treatment Group.
Slaughter MS et al. N Engl J Med 2009;361:2241-2251.
Adverse Events and Associated Relative Risks from the As-Treated Analysis, According to Treatment Group.
Slaughter MS et al. N Engl J Med 2009;361:2241-2251.
Device Operation• Pulsatile Pumps
• EKG blood ejects with QRS • Dynamic modeΔ HR
• Nonpulsatile Pumps• Independent of HR• Flat A-lineDoppler mean BP
Morton et al. Critical Care Nursing: A Holistic Approach. 8th ed. Lippincott Williams & Wilkins, 2005.
Indications: LVAD• Despite medical therapies & IABP
• CI < 1.8 L/min/m2
• SBP < 90 mm Hg• LAP > 20 mm Hg• SVR > 2100 dyne-s/cm5
• UO < 20 mL/h
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.
Indications: RVAD• Despite medical therapies & IABP
• Mean RAP > 20 mm Hg• LAP < 15 mm Hg• No tricuspid regurgitation
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.
Indications: BiVAD• Despite medical therapies & IABP
• LAP > 20 mm Hg• RAP > 20-25 mm Hg• No tricuspid regurgitation• Inability to maintain LVAD flow >
2.0L/min/m2 with RAP > 20mm Hg
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.
Things to Consider
• Reasonable chance of recovery • Transplant vs. destination therapy
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.Image from: www.my2ndheartbeat.wordpress.com
Management: LVAD• Systemic flow of 2.2 L/min/m2
• LAP 10-15 mm Hg• MAP > 75 mm Hg• Anticoagulation • Tissue perfusion • Pulmonary vasodilators**• TEE
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.
RVAD Management • Systemic flow of 2.2 L/min/m2
• LAP 15 mm Hg• RAP 5-10 mm Hg• LV function• Pulmonary vasodilators • Anticoagulation • TEE
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.
BiVAD Management • Sequential manipulation of
RVAD & LVAD• Systemic flow 2.2 L/min/m2
• RAP 15-20 mm Hg• LAP 5-10 mm Hg• Anticoagulation
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5th ed. Wiley-Blackwell, 2011.
Complications• Technical failure• Aortic Regurgitation • Thrombosis• Bleeding• HIT II• Cerebrovascular ischemia/infarction
Potapov, EV., et al. Managing long-term complications of left ventricular assist device therapy. Current Opinion in Cardiology. 2011; 26:237-244.
Complications• Hemolysis • Malposition of inflow cannula• Infection**• Cable damage• Rhythm disturbances• RV Dysfunction**• HTN (arterial & pulmonary)
Potapov, EV., et al. Managing long-term complications of left ventricular assist device therapy. Current Opinion in Cardiology. 2011; 26:237-244.
Complications• General surgical procedures• Psychosocial • Human errors
Potapov, EV., et al. Managing long-term complications of left ventricular assist device therapy. Current Opinion in Cardiology. 2011; 26:237-244.Images from: www.whatsupgold.com
Right Ventricular Failure• Significant problem with LVADs• Develops in 13% of recipients
Kormos, RL., et al. J Thorac Cardiovasc Surg. 2010; 139:1316-24.Image from: www.trialx.com
Kaplan-Meier Survival for Patients With & Without Early RVF Receiving the HeartMate II LVAD
Kormos, RL., et al. J Thorac Cardiovasc Surg. 2010; 139:1316-24.
RVF Explanation • #1
• Unloading of LV• Septal shift• Alters RV shape & size• Contractility affected
Kormos, RL., et al. J Thorac Cardiovasc Surg. 2010; 139:1316-24.
RVF Explanation • #2
• preload of RH• Unmasks pre-existing RV
impairment
Kormos, RL., et al. J Thorac Cardiovasc Surg. 2010; 139:1316-24.
Practical Hurdles • Bleeding
• Multiple transfusions• Difficult to HLA match
• Infection• Weakened immune system• Preclude transplantation
Psychosocial Depression
• At risk for suicide• Psychologist• Psychiatrist• Strong Support System
Potapov, EV., et al. Managing long-term complications of left ventricular assist device therapy. Current Opinion in Cardiology. 2011; 26:237-244.Image from: www.agingresearch.buffalo.edu
Psychosocial• VAD training • Home support 24 hours
Potapov, EV., et al. Managing long-term complications of left ventricular assist device therapy. Current Opinion in Cardiology. 2011; 26:237-244.
Quality of Life With EQ-5D Improved by 3 Months During LVAD Support and Sustained Through 12 Months
Starling RC., et al. J Am Coll Cardiol 2011; 57:1890-8.
Summary• Supports systemic &/or pulmonary
circulation while resting heart• Bridge to transplant vs. destination
therapy • Device & patient selection • Bedside management • Complications (RVF, Bleeding, Infx)**
References 1. Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery. 5 th ed.
Wiley-Blackwell, 2011.
2. Fang JC. Rise of the machines—left ventricular assist devices as permanent therapy for advanced heart failure. N Engl J Med. 2009. DOI: 10.1056/NEJMe0910394.
3. Hunt SA, Abraham ST, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure- summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to update the 2001 guidelines for the evaluation and management of heart failure): developed in collaboration with the American College of Physicians and the International Society for Heart and Lung Transplant: endorsed by the Heart Rhythm Society. Circulation. 2005;112:1825-1852.
References4. Kormos RL, Teuteberg JJ, Pagani FD, et al. Right ventricular
failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg. 2010;139:1316-24.
5. Lietz K, Long JW, Kfoury AG, et al. Outcomes on left ventricular assist device implantation as destination therapy in the post-REMATCH era: implications for patient selection. Circulation. 2007;116;497-505.
6. Miller LW, Pagani FD, Russell SD, et al. Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med. 2007;357:885-96.
References7. Morton PG, Fontaine DK, Hudak CM, Gallo BM. Critical Care
Nursing: A Holistic Approach. 8th ed. Lippincott Williams & Wilkins, 2005.
8. Park SJ, Tector A, Piccioni W, Raines E, Gelijns A, et al. Left ventricular assist devices as destination therapy: a new look at survival. J Thorac Cardiovasc Surg. 2005;129:9-17.
9. Potapov EV, Stepanenko A, Krabatsch T, Hetzer R. Managing long-term complications of left ventricular assist device therapy. Curr Opin Cardiol. 2011;26:237-244.
References 10.Slaughter MS, Rogers JG, Milano CA, et al.
Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009;361. DOI:10.1056/NEJMoa0909938.
11. Starling RC, Naka Y, Boyle AJ, et al. Results of the Post-U.S. and Drug Administration-approval study with a continuous flow left ventricular assist device as a bridge to heart transplantation. J Am Coll Cardiol. 2011;57:1890-8.
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