Advanced Heart Failure and the Role of Mechanical Circulatory Support

Megan Shifrin, RN, MSN, ACNP-BCVanderbilt University

Objectives• Review current recommendations for advanced heart failure

management• Identify the different types of VADs currently in use• Identify the indications and contraindications for placement• Overview of immediate post-operative management and potential

complications

Why Should I Care About Heart Failure or LVADs?

• Prevalence – According to the American Heart Association, there are close to 6 million Americans living with heart failure. • Incidence – Almost 550,000 new cases are diagnosed annually. • About 300,000 people die each year of heart-failure related causes.

• Heart failure is the single most common cause of hospitalization in the United States for people over the age of 65. • In 2012 alone, there were 2,066 permanent LVADs placed in

patients.• These patients live in your community.

The Cost of Heart Failure Management in the United States

10.5%

9.7%8.2%

6.4%

11.9%

53.3%

Hospitalization$20.9

Lost Productivity/Mortality*

$4.1Home Healthcare

$3.8

Drugs/Other Medical Durables

$3.2

Physicians/Other Professionals

$2.5

Nursing Home$4.7

Total Cost

$39.2 billion

Heart Disease and Stroke Statistics—2010 Update: A Report From the AHA

Circulation, Feb 2010; 121: e46 - e215

Etiologies of Heart Failure• Non-ischemic cardiomyopathy• Valvular disease• Viral/bacterial cardiomyopathy• Peripartum cardiomyopathy• Idiopathic/familial cardiomyopathy• Myocarditis• Connective tissue disorders• Drugs/Toxins• Alcohol

• Ischemic cardiomyopathy• Hypertension• Coronary artery disease • Myocardial infarction

Increasing Severity

Class I

• Cardiac disease• No symptoms• No limitation in

ordinary physical activity

Class II• Mild symptoms

(mild shortness of breath and/or angina)

• Slight limitation during ordinary activity

Class IIIa and IIIb• Marked limitation

in activity due to symptoms

• Comfortable only at rest

Class IV• Severe limitations• Symptoms even

while at rest• Mostly bedbound

patients

New York Heart Association Functional Classification of Heart Failure

Goals of Heart Failure Management1. Improving symptoms and quality of life

2. Slowing the progression or reversing cardiac and peripheral dysfunction

3. Reducing mortality

Addressing Heart Failure in 2013

Katz AM

Heart Failure

Evidence of Progressing Heart Failure

Decreased end organ perfusion• Renal function• Liver function• Pulmonary function

We need more support!

Ventricular Assist Device (VAD)

Long-Term LVADImplanted surgically with the

intention of support for months to years

Short-Term LVADUtilized for urgent/ emergent

support over the course of days to weeks

A mechanical circulatory device used to partially or completely replace the function of either the left ventricle (LVAD); the right

ventricle (RVAD); or both ventricles (BiVAD)

Things to Consider Before Placing ANY type of VAD Support

• Are there any contraindications to VAD support?• End-stage lung, liver, or renal disease• Metastatic disease • Medical non-adherence or active drug addiction• Active infectious disease• Inability to tolerate systemic anticoagulation (recent CVA, GI bleed, etc.,)• Moderate to severe RV dysfunction for some LVADs

• What are our other issues in this particular patient?• What are the patient’s goals? What are our goals? • What happens if we don’t meet our goals?

Lietz and Miller Curr Opin Cardiol 2009, 24:246–251

INTERMACS SCOREInteragency Registry for Mechanically Assisted Circulatory Support

Long-Term LVADIdeal candidates are INTERMACS classes 3-

4Short-Term LVADCandidates are INTERMACS classes 1-

2Not a LVAD CandidateINTERMACS 1 or those

with multisystem organ failure

Destination Therapy vs. Bridge to TransplantationLong-term placement

Destination Therapy (DT)• Not a heart transplant candidate• NYHA IV• LVEF <25%• Maximized medical therapy >45

of 60 days; IABP for 7 days• Functional limitation with a peak

oxygen consumption of less than or equal to 14 ml/kg/min

• Life expectancy < 2 years

Bridge to Transplantation (BTT)• Patient is approved and currently

listed for transplant• NYHA IV• Failed maximized medical therapy

http://www.cms.gov/medicare-coverage-database

Adult FDA Approved LVADs

Bridge to Transplantation (BTT)HeartMate II (Thoratec)HeartWare (HeartWare)

PVAD (Thoratec)IVAD (Thoratec)

Destination Therapy (DT)HeartMate II (Thoratec)

HeartMate II (Thoratec)

Basics of HM IIPump Speed (RPM) – How quickly the pump rotates

Pump Power (Watts) – Measure of motor voltage and current

Pump Flow (L/min) - Estimated value of the volume running through the pump

Pulsitility Index – The measure of the left ventricular pressure during systole

Immediate Post-op Management

VS

Management Considerations• Typically pulseless • Afterload sensitive • Preload sensitive• Anticoagulation• Should not receive chest compressions during an arrest• Patients still have heart failure

Potential Device Complications

Inflow cannula (poor position, obstruction)

Pump/rotor dysfunction (thrombus)

Battery dysfunction

Outflow graft (kink , leak)

Drive line infection / fracture

Controller malfunction

Hematologic Long-Term Complications

• GI bleed • 13-40% of LVAD patients• Constitute 9.8% of LVAD readmissions

• CVA (embolic and hemorrhagic) • 17% of patients who survived 24 months post-implant

• Hemolysis • Increases rate of mortality by 25% over six months

“However beautiful the strategy, you should occasionally look at the results.”

Winston Churchill

Medical Management vs. LVAD

Rose, EA; et alNEJM 2001; 345:1435-1443

Survival Rates

Kirkland, JK, et. alJHLT 2013; 32:141-156

ADLs of DT Patients

Kirkland, JK, et. alJHLT 2013; 32:141-156

What Happens to These Patients?• Shock Team Evaluation for

mechanical circulatory support (MCS)

• Try to avoid the bridge to decision or the bridge to nowhere

Variations of Short-Term VADs• Impella 5.0• Tandem Heart•CentriMag• ECMO (V-A)

Impella 5.0• Utilized for LV support only; not appropriate to

use with RV failure• Impella 5.0 inserted via femoral or axillary

artery cut down; provides up to 5L of flow• The catheter is advanced through the ascending

aorta into the left ventricle• Pulls blood from an inlet near the tip of the

catheter and expels blood into the ascending aorta

• FDA approved for support of up to 6 hours

TandemHeart pVAD• Used for LV support; not

appropriate in RV failure• Cannulas are inserted

percutaneously through the femoral vein and advanced across the intraatrial septum into the left atrium

• The pump withdraws oxygenated blood from the left atrium and returns it to the femoral arteries via arterial cannulas

• Provides up to 5L/min of flow• Can be used for up to 14 days

CentriMag

• Can be used for LV and/or RV support

• Cannula are typically inserted via a midline sternotomy

• Capable of delivering flows up to 9.9 L/min

• Can be used for up to 30 days

ECMO (V-A)• Used for patients with a

combination of acute cardiac and respiratory failure

• A cannula takes deoxygenated blood from a central vein or the right atrium, pumps it past the oxygenator, and then returns the oxygenated blood, under pressure, to the arterial side of the circulation

• Can be used for days to weeks

Summary• The management of advanced heart failure is a dynamic process

that requires frequent re-evaluation

• Timing of LVAD placement is critical

• LVADs for DT have been shown to improve mortality rates and quality of life

• There are short-term VAD options available for emergent situations

Case StudyLN is a 34 year old female with a past medical history of peripartum cardiomyopathy following the vaginal delivery of her first child nine months ago. Her LVEF is 20%, and she has NYHA class IV symptoms. She has been on optimal medical therapy including carvedilol, captopril, aldactone, and lasix. In addition, she was started on an outpatient milrinone infusion at 0.25 mcg/kg/min one month ago. She has been listed for heart transplantation, but due to her blood type of A- and her body habitus, it is unlikely that a donor heart will be found quickly.

Case StudyBased on the cast study presented, LN’s peripartum cardiomyopathy would fall into which of the following categories:A) Ischemic cardiomyopathyB) Non-ischemic cardiomyopathy

Case StudyLN is undergoing evaluation for LVAD placement. Based on the case study, LN would fall into which LVAD category?A) Destination therapyB) Bridge to transplantationC) Bridge to nowhereD) Bridge to decision

Case StudyLN asks about the benefits of having an LVAD placed. Which of the following statements is TRUE regarding LVAD placement as a bridge to transplantation?A) Patients are guaranteed a transplant if they get a LVADB) Most LVAD patients see an improvement in their ability to carry out their usual activities of daily livingC) A LVAD will make her heart failure resolveD) She will be able to stop all of her heart failure medication shortly after LVAD placement

Case StudySome of the long-term risks associated with LVAD placement include which of the following:A) Infection B) GI bleedC) CVAD) All of the above

Case Study As the ACNP preparing to care for LN in the immediate post-operative period, you recognize that the following issues will likely be present:A) LN may be afterload sensitiveB) LN may be preload sensitiveC) LN will likely be pulseless due to her continuous flow LVADD) All of the above

Case StudyTrue/False: If LN’s heart failure continues to advance, you know that it’s an easy decision to throw her on a short-term VAD such as a TandemHeart or CentriMag. A) TrueB) False