![Page 1: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/1.jpg)
Rise of the Machines: Mechanical Circulatory Support
Stephanie A. M. Olcese, MS, ACNP
![Page 2: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/2.jpg)
Objectives• What are VADs?• Who benefits?• Physiological principles • Devices• Indications • Management • Complications
![Page 3: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/3.jpg)
VADs• Ventricular assist devices• Circulatory support
Image from: www.transmedic-ind.com
![Page 4: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/4.jpg)
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.
![Page 5: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/5.jpg)
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.
![Page 6: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/6.jpg)
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
![Page 7: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/7.jpg)
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
![Page 8: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/8.jpg)
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.
![Page 9: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/9.jpg)
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.
![Page 10: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/10.jpg)
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
![Page 11: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/11.jpg)
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.
![Page 12: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/12.jpg)
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.
![Page 13: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/13.jpg)
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.
![Page 14: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/14.jpg)
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.
![Page 15: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/15.jpg)
Components of the Continuous-Flow Left Ventricular Assist Device (LVAD).
Miller LW et al. N Engl J Med 2007;357:885-896.
![Page 16: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/16.jpg)
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.
![Page 17: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/17.jpg)
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.
![Page 18: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/18.jpg)
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.
![Page 19: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/19.jpg)
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.
![Page 20: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/20.jpg)
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.
![Page 21: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/21.jpg)
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.
![Page 22: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/22.jpg)
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.
![Page 23: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/23.jpg)
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
![Page 24: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/24.jpg)
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.
![Page 25: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/25.jpg)
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.
![Page 26: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/26.jpg)
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.
![Page 27: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/27.jpg)
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.
![Page 28: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/28.jpg)
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.
![Page 29: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/29.jpg)
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
![Page 30: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/30.jpg)
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
![Page 31: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/31.jpg)
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.
![Page 32: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/32.jpg)
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.
![Page 33: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/33.jpg)
RVF Explanation • #2
• preload of RH• Unmasks pre-existing RV
impairment
Kormos, RL., et al. J Thorac Cardiovasc Surg. 2010; 139:1316-24.
![Page 34: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/34.jpg)
Practical Hurdles • Bleeding
• Multiple transfusions• Difficult to HLA match
• Infection• Weakened immune system• Preclude transplantation
![Page 35: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/35.jpg)
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
![Page 36: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/36.jpg)
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.
![Page 37: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/37.jpg)
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.
![Page 38: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/38.jpg)
Summary• Supports systemic &/or pulmonary
circulation while resting heart• Bridge to transplant vs. destination
therapy • Device & patient selection • Bedside management • Complications (RVF, Bleeding, Infx)**
![Page 39: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/39.jpg)
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.
![Page 40: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/40.jpg)
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.
![Page 41: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/41.jpg)
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.
![Page 42: Rise of the Machines- VADs Presentation August 2011](https://reader034.vdocuments.net/reader034/viewer/2022052606/58ee311b1a28ab51458b4631/html5/thumbnails/42.jpg)
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.