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.