left ventricular assist device (lvad) complications and ... · cardiology for the non-cardiologist...

Cardiology for the Non-Cardiologist 2018

Left Ventricular Assist Device (LVAD)

Complications and Emergencies

Dr. Kristin J Lyons, MDCM, FRCPC

September 28, 2018


Faculty Presenter Disclosure

Cardiology for the Non-Cardiologist

Faculty: Kristin Lyons

Relationships with Financial Sponsors: None


Disclosure of Financial Support

Cardiology for the Non-Cardiologist has received financial support from the following Pharmaceutical companies; Bayer, Bristol-Meyers Squibb/Pfizer, Servier, Novartis, Amgen, AstraZeneca and Merck in the form of unrestricted educational grants.

Potential Conflicts of Interest: None


Mitigating Potential Bias

• While we have received unrestricted educational grants from several pharmaceutical companies, most presentations have no mention of specific products and are unrelated to the supporting companies or their products. No specific presentations will be supported or sponsored by a specific company.

• Information on specific products will be presented in the context of an unbiased overview of all products related to treating patients.

• All scientific research related to, reported or used in this CME activity in support or justification of patient care recommendations conforms to the generally accepted standards.

• Clinical medicine is based in evidence that is accepted within the profession.


What is an LVAD?

For the purposes of this discussion:

Durable, intracorporal left ventricular assist device

Short Term Devices

Paracorporal Berlin

Heart

Total Artifical

Heart

Abnousi et al, Curr Cardiol Reports, 2015

Hehir et al, World Journal for Pediatric and Congenital Heart Surgery, 2012

Cook et al, J Thorac Dis, 2015


LVADs

Peberdy et al, Circulation, 2017


The Pump



Why Are LVADs Needed?

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500

1000

1500

2000

2500

3000

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4500

5000

5500

Nu

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of

tra

ns

pla

nts

Other

North America

Europe

2017JHLT. 2017 Oct; 36(10): 1037-1079


How LVADs Are Used

• Bridge to transplant

• Bridge to decision or candidacy

• Destination therapy0

10

20

30

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50

60

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

% o

f P

ati

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ts

Year of Transplant

ECMOVAD+ECMOTAHLVAD+RVAD

2017JHLT. 2017 Oct; 36(10):

1037-1079


Indications for a LVAD

• NYHA Class IIIb or IV HF symptoms and:• LVEF < 25% and if measured, peak exercise oxygen

consumption < 14ml/kg/min

• Evidence of progressive end organ dysfunction related to reduced perfusion not due to inadequate ventricular filling pressures

• Recurrent HF hospitalizations (>3 in 1 year) not due to a clearly reversible cause

• Need to progressively reduce or eliminate evidence based HF therapies due to symptomatic hypotension or worsening HF

McKelvie et al, Can J Cardiol, 2011


Case #1

• 55 year old male, status post HVAD left ventricular assist device 3 months ago as bridge to transplant

• History of ischemic cardiomyopathy, hypertension and Type II diabetes

• Presents to the emergency room with bright red blood per rectum. No issues reported with pump


Physical Examination/Labs

• Looks slightly diaphoretic, GCS 15

• Blood pressure not obtainable

• Heart rate 100, respiratory rate 15, O2 saturation 99% room air

• Pulses not palpable but extremities warm to touch. No edema. Lungs clear

• JVP not well visualized. “VAD sounds” upon cardiac auscultation

• Minimal bright red blood on DRE, no frank active bleeding

• Electrolytes normal, creatine 55, urea 5, hemoglobin 70 (110 one week prior), normal platelets and WBC, INR 2.1


Question #1

• What is the best method to initially assess this patient’s blood pressure?

• A) Manual blood pressure cuff and auscultation

• B) Manual blood pressure cuff and Doppler vascular probe

• C) Automatic oscillometric cuff

• D) Radial arterial line


Blood Pressure Measurement in Continuous Flow LVAD Patients

• Palpate for a radial pulse-if a radial pulse is clearly present, measure blood pressure as per usual assessment

• If no pulse:• Apply a properly fitted cuff to upper arm and apply gel to

brachial artery

• Using Doppler vascular probe, find constant sound of blood flow

• Inflate the cuff until the sound disappears (and 10-20mmHg above where the sound disappears) and slowly deflate until you hear the constant sound of blood flow-this is your MAP (normal=60-80mmHg)


Emergency Department Patient Algorithm

VAD Patient Calls Transplant Physician/VAD

Coordinator:

Pt directed to ED

Patient ARRIVAL to ED

If unexpected arrival, ED to page:

-ON CALL Cardiac Transplant Service or

Advancved Heart Failure (ROCA)

Transplant Physician:

• Patient assessment by Cardiac

Transplant Physician or Delegate in ED

urgently (Goal:

within 60min)

Will consult with VAD Surgeon if required

• Expedites decision to admit patient if required.

• Transplant Physician/VAD Coordinator Notifies ED of patient’s

imminent arrival CALL - Triage 403-944-2900

• ED to notify Transplant Physician once patient has arrived (ETA if

available), Transplant Physician can bring VAD equipment to the ED or

call the on call perfusionist (pgr #00999)

• Note: Transplant Cardiologist on call on ROCA

For EMERGENT device issues ONLY and patient at FMC:

CALL ON CALL PERFUSIONIST @ pager #00999

Call CVICU/PCU 94 @ 42494 - Speak to charge nurse: Request

a VAD certified nurse to come to ED urgently until Transplant

Physican and Perfusion arrive

On Call Perfusionist:

Calls ED Clinician (pgr#05077)

-to give ETA and check to see if there are

any immediate concerns


Back to the Case

• MAP assessed by vascular Doppler and is 60mmHg (patient states his normal is 70-80mmHg)

• Advanced heart failure cardiologist is called and is on route to assess the patient

• 3 units red blood cells are ordered and transfused

• No reversal agents given for INR of 2.1


Gastrointestinal Bleeding in VAD Patients

• Occurs in up to 60% of patients

• Major source of morbidity and hospital readmission

• Most commonly due to arteriovenous malformation in the upper GI tract and the small bowel

• Patients develop acquired von Willebrand deficiency

• Only 30% of patients with gastrointestinal bleed (GIB) will have an identified source on endoscopy

Kataria et al, Cardiol Rev, 2018

Axelrad et al, J Heart Lung Transplant, 2018


Case Conclusion

• Patient admitted to hospital and warfarin held. ASA continued

• Hemoglobin rose to 95 with 3 units of red blood cells with no further significant drops

• Gastroscopy and colonscopy performed with INR < 2 and no clear source of bleeding found

• Coumadin restarted with goal INR or 2-2.5 and patient discharged home


Question #2

• After the first 6 months post implant, what is the most common cause of death in LVAD patients?

• A) Stroke

• B) Bleeding

• C) Infection

• D) Device thrombosis and/or device failure


Case #2

• 42 year old male with ischemic cardiomyopathy status post HVAD ~1 year prior

• Presents to FMC emergency room with 1 hour history of left sided weakness consistent with a MCA territory stroke

• MAP 100mmHg. Other vital signs unremarkable. No signs of heart failure. INR 1.8.

• Device functioning normally as per patient and his wife


Imaging

• CT Angio Head and Neck

• No acute intracranial abnormality

• Remote right MCA territory infarct

• No hemodynamically significant stenosis visualized


Case Conclusion

• The left sided weakness improved within 1 hour

• The patient’s MAP was 90-100mmHg initially and was treated to a goal less than 80mmHg over the course of his hospital stay

• He was discharged home with close follow up and instructions to monitor MAP daily


The Morbidity of Stroke

Kirklin et al, Int J Heart Lung Transplant, 2018

Kirklin et al, Int J Heart Lung Transplant, 2017


Strokes in LVAD Patients

• Risk Factors• Hypertension, MAP > 90mmHg

• Infection, particularly bacteremia

• INR < 2 (ischemic) and INR > 3 (hemorrhagic)

• ASA dose (<81mg)

Frontera et al, Int J Heart Lung Transplant, 2017

Rogers et al, N Engl J Med, 2017


Case #3

• 60 year old male, history of non ischemic cardiomyopathy

• Post HVAD LVAD 1.5 months ago. Relatively uncomplicated post operative course and discharged 2 weeks ago.

• Presents to the emergency room complaining of shortness of breath and notes the “power” on his device has risen dramatically over the past 24 hours


LVAD Controller-HVAD

POWER

RPM (set)

FLOW

(calculated)

BATTERY

CONNECTION

DRIVE LINE

CONNECTION


Patient Data

• Vitals: HR 100bpm, MAP 80mmHg, sats 88% room air

• JVP elevated to the jaw, crackles to mid lung fields bilaterally, peripheral extremities cool

• ”Coarse” VAD sounds on auscultation

• Labs: Cr 118, Hb 108, WBC 12, LDH 689


Question #3

• What is the diagnosis?• A) Right heart failure

• B) Device failure

• C) Pump thrombosis

• D) Myocardial infarction


Points of Obstruction

• Pre and post pump obstruction lead to low flow

• Intra-pump thrombosis leads to high flow/power


Question #4

• What is the most appropriate therapy for the patient’s VAD thrombus?

• A) Intravenous thrombolytic

• B) Intra-ventricular thrombolytic

• C) LVAD exchange

• D) Urgent transplant listing


Pump Thrombosis

• Historically, affects 2-13% of patients• Not observed with new Heart Mate III Device

• Treatments• Altered anticoagulation-heparin, bivalirudin• Thrombolytic-Intravenous or intraventricular• Pump exchange

• Pump exchange recommended if heart failure is present Scandroglio et al, J Am Coll Cardiol, 2017

Dang et al, ASAIO Journal, 2016


Case Conclusion

• Pump exchange was performed but patient required a temporary RVAD due to RV failure

• Remained in CVICU and eventually listed Status 4 for transplantation

• Transplanted ~1.5 months post original LVAD explant

• Currently doing well


Other Common Complications

• Infection• Driveline• Device• Bacteremia

• Right heart failure

• Aortic regurgitation

• Arrhythmias

• Device malfunction


Questions


LVAD Patients Are Just Like Us

LVAD Dancing Daddy

https://www.youtube.com/watch?v=cHQGn

KgqUaA


AHA Recommendations


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