Left Ventricular Assistive Device as a Destination Therapy

Major Case Study:Heart Failure and Left Ventricular Assistive Device as a Destination TherapyJanuary 29th, 2013

By: Rachael Woods; dietetic intern

By: Rachael Woods: Dietetic Intern

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Purpose of the Study

Case was intriguing

Nutritional implications for left ventricular assistive devices (LVAD) are not well known among RDs

About A.S.

71 y/o retired Caucasian male

Catholic

113.90 kg (250.6 lb)

182.88 cm (72in)

BMI: 36.1

IBW: 80.9 kg

%IBW: 141%

Admitted with Heart Failure class III Stage IV (D) for LVAD placement

A.S.s Past Medical History

Congestive heart failure (heart failure) class III, stage IV (D)

Cardiomyopathy

Coronary artery disease

Chronic kidney disease

Throat and prostate cancer with radiation

Hypertension

CAD: narrowing of the small blood vessels that supply blood and oxygen to the heart

Cardiomyopathy: a weakening of the heart muscle or another problem with the heart muscle. It often occurs when the heart cannot pump as well as it should, or with other heart function problems. Most patients with cardiomyopathy have heart failure.

Heart Valve Disease: Heart valve disease occurs if one or more of your heart valves don't work well

Myocardial infarctions: are a secondary complication to heart valve disease.

lk

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PMH Continued

Gastritis

Atrial fibrillation

Right bundle branch block

Ischemic heart disease

History of myocardial infarction

Surgeries performed prior to admission: pacemaker placement and stented coronary artery

Heart Failure and its Causes

Occurs when the heart is unable to pump blood at the rate sufficient to meet the metabolic demands of the tissues or can only do so at an elevated filling pressure

3 leading causes causes: coronary artery disease, high blood pressure and diabetes

Other causes: cardiomyopathy, heart valve disease, arrhythmias and congenital defects

A.S.s was caused by a myocardial infarction in the 1990s

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Nutrition History

Limits sodium and fat intake at home; does not follow a particular diet

Wife does grocery shopping and prepares meals

Meals are eaten at a dining room table where a television set is visible

Eat out 1-2xs per week

Does not engage in physical activity regularly

Participated in Weight Watchers 1 year ago; lost 55 lbs

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Classes of Heart Failure

A.S. Class 3, Stage IV (D)

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Stages of Heart Failure

Normal Anatomy of the Heart

The heart is composed of four different chambers, the right atrium, the right ventricle, the left atrium, and the left ventricle. Deoxygenated blood (denoted blue) enters the heart through the right atrium via the superior vena cava and the inferior vena cava. The contraction of the right atrium allows the blood to move from the right atrium into the right ventricle, and the contraction of the right ventricle pumps blood through the pulmonary artery into the lung tissues allowing oxygenation of blood. Oxygenated blood (denoted red) is returned from the lungs to left atrium of the heart via the pulmonary vein. Similar to the right atrium, the contraction of the left atrium allows the movement of blood into the left ventricle. The contraction of the left ventricle pumps oxygenated blood into the aorta, which provides blood to the entire body. Cells comprising the bodys tissues and organs use oxygenated blood to provide the fuel for metabolism; deoxygenated blood is returned to the heart via the veins and the process continues.

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Biological Adaptations

Frank-Starling mechanism: increased filling volumes (of blood) enlarge the heart and increase cross bridge formation of muscle cells of the heart, which increases contractility

Hypertrophy: Heart muscle cells (sarcomeres) proliferate to increase muscle size and enhance force of contractility. Enlarged hearts secondary to hypertrophy require additional oxygen consumption to support the demands of additional muscle tissue; therefore hypertrophied hearts are more susceptible to deterioration

Neurohormonal Systems

Norepinephrine

Activation of renin-angiotensin-aldosterone system

Release of natriuretic peptide

Neurohormonal systems: 3 different mechanisms

1) Norepinephrine increases heart rate and allows for greater contractility and vascular resistance and thus increases blood pressure

2) Activation of the renin-angiotensin-aldosterone system, which allows for increase water retention and thus increases blood pressure

3) Release of natriuretic peptide: High ventricular filling pressures stimulate the release of ANP and BNP. Both peptides have diuretic, natriuretic, and antihypertensive effects, which they exert by inhibiting the renin-angiotensin-aldosterone system. They also have systemic and renal sympathetic activity. In addition, BNP may provide a protective effect against the detrimental fibrosis and remodeling that occurs in progressive heart failure.

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Healthy vs. Diseased

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Nutrition/Medical Interventions

Heart healthy diet (such as the TLC diet)*

Physical activity

Medications (5 classes)*

ACE inhibitors & Angiotension

receptor blockers

Beta-Blockers*

Diuretics*

Aldosterone receptor antagonists*

Nitrates

* Indicate those interventions A.S. has undergone

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Surgical Interventions

Pacemaker Implantations*

Implantable Cardioverter Defibrillators

Coronary Artery Bypass Grafts

LVAD implantation*

Heart Transplant

Individuals with heart failure can receive a heart transplant if they are a candidate for such. Some receive LVADs while they are waiting for a heart transplant if they are a candidate for a heart transplant so that they can continue daily activities of living while they wait. Others who are not candidates for heart transplants receive LVADs as a destination therapy.

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What is an LVAD?

Like the heart, the LVAD is a pump. One end hooks up to the left ventricle -- that's the chamber of the heart that pumps blood out of the lungs and into the body. The other end hooks up to the aorta, the body's main artery. A tube passes from the device through the skin. The outside of the tube is covered with a special material to aid in healing and allow the skin to regrow.

The pump and its connections are implanted during open-heart surgery. A computer controller, a power pack, and a reserve power pack remain outside the body. Some models let a person wear these external units on a belt or harness outside.

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LVAD: Heart Mate II

LVAD Video

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Laboratory Values 12/5

Potassium: Decreased levels could be caused by loop diuretic, even though potassium sparing diuretic was also being used. However, based on the amount of information, it is not possible to conclude the exact cause of low potassium at this time Glucose can be elevated during times of stress and while taking certain medications (such as steroids) and Carvedilol. Stress or Carvedilol or both are most likely the cause for elevated blood glucose in A.S., as he does not have a history of diabetes and was not receiving steroids during the time that the above labs were drawn.

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Laboratory Values 12/16

Chloride can be low for many different reasons including heart failure. Chloride being decreased secondary to heart failure is most likely the case for A.S. as his primary reason for admission to the hospital was for treatment of heart failure via LVAD therapy.

BUN and Creatinine can be elevated secondary to Renal Disease

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Medications

Albuterol

Amiodarone

Bumetanide

Carvedilol

Docusate-Senna

Humulin

Humalog

Lactobacillus Acidophillus

Pantoprazole

Ranolazine

Spironolactone

Coumadin

Albuterol: Bronchodilator/vasodilator; N/V/D/C, GERD, LOW POTASSIUM

Amiodarone: Antiarrhytmatic; N/V, ANOREXIA, XEROSTOMIA, LOSS OF APPETITE, CANNOT DRINK GRAPEFRUIT JUICE

Bumetanide: loop diuretic; N/V/C, THIRST, DECREASED POTASSIUM

Carvedilol: vasodilator/reduces vascular resistance; N/V/D, HYPERGLYCEMIA, MELENA, EXTREME HUNGER/THIRST

Docusate-Senna: Stool softner; N, CRAMPING

Humulin: Decreases blood glucose; HYPOGLYCEMIA, WT GAIN, CONSTIPATION

Humalog: Decreases blood glucose; HYPOGLYCEMIA, WT GAIN, CONSTIPATION

Lactobacillus Acidophillus: treats/prevents diarrhea, especailly for those taking antibiotics; NO KNOWN NUTRITIONAL IMPLICATIONS

Pantoprazole: treats GERD; B12 DEFICIENCY, N, GAS, WEAKENED STOMACH LINING

Ranolazine: Anti-angina; THIAMINE DEFICIENCY, FOLATE DEFICIENCY, N/C, MUST AVOID GRAPEFRUIT JUICE

Spironolactone: Diuretic (potassium sparing); MONITOR POTASSIUM INTAKE, V/D/N, LOSS OF APPETITE

Coumadin: blood thinner; MONITOR VITAMIN K

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Typical Intake for A.S.

Cereal for breakfast at around 9:00 am

A typical lunch for A.S. is an unspecified sandwich, hot dog, or peanut butter and jelly sandwich at around 1:30 pm

A typical dinner for A.S. consists of turkey breast, meatloaf, chicken, hamburgers, or pizza if he and his wife go out to dinner

In retrospect, I realized that I did not talk about and emphasize the importance of fruits and vegetables and did not probe any deeper to see if he was in fact consuming them. I was more focused on obtaining a 24 hour recall while he was here.

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Hospital 24-Hour Recall

Table 1.6 24-hour recallFood ProductKcalsCarbohydrateProteinFatEnsure Plus350 kcals15g13g11gPudding140 kcals24g4g4gJello64 kcals16g1g0gEnsure Plus350 kcals13g51g11gDiet Tea0 kcals0g0g0gTotal904 kcals68g69g26g

Only eating 25% of actual try (not including Ensure). Before Ensure only consuming about 200 calories and 5g of protein

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Nutrition Care Process: Assessment

At the time of A.S.s first visit, he was on a full liquid diet and was eating roughly 25% of his meals due to his lack of interest in the foods being served

ACCORDING TO KRAUSE: The diet was prescribed because A.S. was intubated four days prior and was receiving enteral nutrition during his intubation. The general protocol for diet advancement post enteral nutrition is to progress from clear liquid to full liquid to solid foods. Although many practitioners use the progression from clear liquids to full liquids to solid foods, there is currently not any scientific literature stating that solid foods cannot be initiated as soon as the gut is functioning and tolerating some liquids

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Nutrition Care Process: Diagnosis

At the time of A.S.s first visit, his diagnosis was:

Inadequate protein energy intake related to decreased ability to consume sufficient protein and energy as evidenced by intake less than recommended needs

This diagnosis was formulated on the premises of the full liquid diet that was only fractionally consumed

Calculations for Estimated Needs (ASPEN)

Basal energy expenditure calculated using the Harris-Benedict Equation

Add to basal value an additional 15%-25% for minimal physical activity

Add another 10%-20% for hypermetabolism of severe heart failure

Determine carbohydrate (40%-60%), protein (10%-15%), and fat (30%-40%) adjust based on concurrent conditions

Major surgery or sepsis increases energy requirements by 20%-50%

Based on the above criteria A.S.s estimated energy needs during the visit on December 5th were 3,200 kcals: (BEE =2050kcals + 20% for minimal activity = 2500 + 10% for hypermetabolism = 2700 + 20% for surgery= ~ 3200 kcals/day and 80-120g protein/day

Also important to note that other equations can be used such as Mifflin St. Jeor, especially because pt was over wt. But for the purpose of this study, I used Harris Benedict.

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Nutrition Care Process: Intervention

The importance of adequate calories and protein consumption for wound healing was discussed since he was only consuming ~25% of each meal

The topic of fat, sodium, and fluid restriction were not discussed at the time because A.S. was on a full liquid diet

Nutrition Care Process: Monitoring/Evaulation

Follow up visit was scheduled

Nutrition Care Process: Assessment

At the time of A.S.s second visit, A.S.s diet was advanced to a Solid Regular Coumadin/Warfarin Cardiac diet with Wolk Shake TID

A.S. was much more receptive to this diet than the previously prescribed diet consuming 100%

The purpose of this diet was to limit the amount of fat, sodium, and vitamin K A.S. was receiving. The cardiac diet is used in the clinical setting to manage symptoms of hypertension and fluid retention secondary to diseases associated with the heart. A.S. was also on a vitamin K monitored diet because he was receiving Coumadin. Vitamin K assists in blood coagulation and so the dosage of Coumadin and vitamin K consumption must be closely monitored to ensure that there is a balance between the two. Having a balance prevents blood clotting (too much vitamin K and not enough Coumadin) and extreme thinness of blood (not enough vitamin K and too much Coumadin). Wolk Shakes are produced onsite by the hospital. The purpose of this supplement is to increase calories and protein consumption in those patients who would benefit from additional calories and protein if the diet alone is not providing an adequate amount for weight gain and wound healing.

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Nutrition Care Process: Diagnosis

During the second visit of the study A.S. did not have any acute nutrition related problems and so a formal nutrition diagnosis was not made secondary to 100% food/beverage intake and 100% Wolk Shake intake TID

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Nutrition Care Process: Intervention/Monitoring/Evaluation

No intervention, monitoring criteria, or evaluation was formulated as a formal diagnosis was not made

Observable Physiological and Psychological advancements

A.S. was feeling lethargic, experiencing shortness of breath and was not able to carry on the daily activities of life prior to surgery

A few days post surgery A.S. was not ambulating and appeared to be very tired and frail. His wife was present in the room and was able to assist with the interview process. Throughout A.S.s stay at the hospital, his physical and psychological changes were evident; with each visit, his physical and mental status greatly improved.

The second time A.S. was seen, he was able to answer all of his questions himself, and was ambulating. As the visits continued, A.S. became more talkative and began telling more personal stories about his life; such as the hardships he faced struggling with heart failure until he had the LVAD placement, rather than just talking about his eating patterns.

The cause for A.S.s lethargy was his hearts inability to pump blood effectively throughout his body. When the heart is unable to pump blood through the body effectively, oxygen and essential nutrients cannot be delivered to the organs, tissues, and cells of the body. When the cells comprising tissues and organs are not able to get the oxygen and nutrients they need from the blood, they are not able to carry out their normal functions and so they become compromised, leaving the affected individual feeling ill and tired. Shortness of breath and fatigue can also be caused by fluid retention around the heart and the lungs. When blood becomes congested in the heart it results in systemic venous pressure that can lead to widespread edema; excessive fluid retention can cause pulmonary edema, which makes it difficult for those affected by the disease to breathe

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Medical Prognosis

Based on A.S.s length of stay at the hospital and the physiological and psychological advancements that were observed, it appears that the prognosis for A.S. is quite good

The most common complications post LVAD implantations are infection and sepsis (18%-59% of recipients)

Stroke is another common risk factor associated with LVAD therapy; the risk increases as long as the device remains in the patients body

Nutritional Prognosis

With increasing BMI, the risk for mortality decreases (good for A.S. as his BMI was 36.1) post LVAD implantation

Metabolites such as glucose and lactate will restore to normal levels post LVAD implantation

Changes in myocardial metabolism occur in heart failure, resulting in decreased amino acid levels in cardiac tissues; LVAD therapy does not allow for the recovery of these amino acid stores

References

WebMD. Heart Failure Health Center. Available at: http://www.webmd.com/heart-disease/heart-failure/left-ventricular-assist-device. Accessed January 2nd, 2014.

Fregmen BF, Frucht SS. Medical Terminology: A Living Language. 4th ed. Upper Saddle River, NJ: Pearson; 2009:132-137.

Tool Loop. Veins in the Cardiovascular System. Available at: http://www.tooloop.com/veins-in-the-cardiovascular-system/. Accessed January 9th, 2014.

Kumar V, Abbas AK, Fausto N, Aster JC. Pathologic Basis of Disease. 8th ed. Philadelphia, PA: Sunders Elsevier; 2010:533-537.

National Heart, Lung, and Blood Institute. What is Heart Failure? Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/hf/. Updated January 9th 2012. Accessed January 9th, 2014.

References continued

Emory Healthcare. Heart Failure Stages & Functional Classifications. Available at: http://www.emoryhealthcare.org/heart-failure/learn-about-heart-failure/stages-classification.html. Accessed January 11th 2014.

Heart Failure Society of America. Questions About HF. Available at: http://www.abouthf.org/questions_stages.htm. Accessed January 11th, 2014.

Schwartz DB, DiMaria, RA. The A.S.P.E.N. Nutrition Support Core Curriculum a Case-Based Approach-The Adult Patient. 1st ed. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2007:495-501.

Mahan KL, Escott-Stump S, Raymond, JL. Krauses Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier Saunders; 2012:194;897.

Mayo Clinic. Diseases and Conditions. Available at: http://www.mayoclinic.org/diseases-conditions/diabetes/expert-blog/diabetes-blog/BGP-20056560. Accessed January 11th, 2014

References continued

Mayo Clinic: Mayo Medical Laboratories. Test ID: Cl. Available at: http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/8460. Accessed January 11th, 2014.

Rizzieri, A., Verheijde, J., Rady, M., & McGregor, J. (2008). Ethical challenges with the left ventricular assist device as a destination therapy. Available at http://www.ncbi.nih.gov/pmc/articles/PMC2527574/. Accessed December 17th, 2013.

American Dietetic Association. Nutrition Care Manual. Heart Failure: Nutrition Prescription. http://nutritioncaremanual.org/topic. Accessed December 17th, 2013.

Medline Plus Trusted Health Information for You. Drugs, Supplements, and Herbal Information. Available at: http://www.nlm.nih.gov/medlineplus/druginformation.html. Accessed January 9th, 2014.

Florida Hospital. Enteral Nutrition Formulary. 2013

Weitzel LB, Ambardekar AV, Brieke A, Cleveland JC, Serkova NJ, Wischmeyer PE, Lowes BD. Left Ventricular Assist Device Effects on Metabolic Substrates in the Failing Heart. April 2013; 8(4):1-6

Classes of Heart Disease according to the New York Heart Disease Association

Class I

Mild

No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath)

Class II

Mild

Slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in fatigue, palpitation, or dyspnea

Class III

Moderate

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea

Class IV

Severe

Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertake, discomfort is increased

ClassesofHeartDiseaseaccordingtotheNewYorkHeartDiseaseAssociation

ClassI

Mild

Nolimitationofphysical

activity.Ordinaryphysical

activitydoesnotcauseundue

fatigue,palpitation,ordyspnea

(shortnessofbreath)

ClassII

Mild

Slightlimitationofphysical

activity.Comfortableatrestbut

ordinaryphysicalactivity

resultsinfatigue,palpitation,or

dyspnea

ClassIII

Moderate

Markedlimitationofphysical

activity.Comfortableatrest,

butlessthanordinaryactivity

causesfatigue,palpitation,or

dyspnea

ClassIV

Severe

Unabletocarryoutany

physicalactivitywithout

discomfort.Symptomsof

cardiacinsufficiencyatrest.If

anyphysicalactivityis

undertake,discomfortis

increased

American Heart Association Stages of Heart Failure

Stage A

High Risk Presence of heart failure risk factors but no heart disease and no symptoms

Stage B

Asymptomatic

Heart disease is present but there are no symptoms (structural changes in heart before symptoms occur)

Stage C

Symptomatic

Structural heart disease is present and symptoms have occurred

Stage D

Advanced Disease

Presence of advanced heart disease with continued heart failure symptoms requiring aggressive medical therapy

AmericanHeartAssociationStagesofHeartFailure

StageA

HighRisk

Presenceofheartfailurerisk

factorsbutnoheartdiseaseand

nosymptoms

StageB

Asymptomatic

Heartdiseaseispresentbut

therearenosymptoms

(structuralchangesinheart

beforesymptomsoccur)

StageC

Symptomatic

Structuralheartdiseaseis

presentandsymptomshave

occurred

StageD

AdvancedDisease

Presenceofadvancedheart

diseasewithcontinuedheart

failuresymptomsrequiring

aggressivemedicaltherapy

Laboratory findings (12/5)

Electrolytes K: 3.3 (3.6-5 mEq/L)

Glucose 124 (70-99 mg/dL)

BUN, Creatinine WNL

Laboratoryfindings(12/5)

Electrolytes K:3.3(3.6-5mEq/L)

Glucose 124(70-99mg/dL)

BUN,Creatinine WNL

Laboratory findings (12/16)

Electrolytes Cl: 94 (101-111 mEq/L)

Glucose 94 (70-99 mg/dL)

BUN, Creatinine 32(5-20 mg/dL); 1.48(0.6-1.2 mg/dL)

Laboratoryfindings(12/16)

Electrolytes Cl:94(101-111mEq/L)

Glucose 94(70-99mg/dL)

BUN,Creatinine 32(5-20mg/dL);1.48(0.6-1.2mg/dL)