Advanced Heart Failure and LVADs - ACVP Online · 2018. 4. 14. · Cleveland Cardio Conference 2018...

Advanced Heart Failure and LVADs

Date: Saturday April 14, 2018

Author: Chad Gady

Title : Physician Assistant / Mechanical Circulatory Support

Advanced Heart Failure Definition

↓ pump (ejection)

↓

↓ perfusion to end organs

Kidney Liver Stomach Brain

Cleveland Cardio Conference 2018

Advanced Heart Failure Stages and Treatment

Clyde W. Yancy et al. Circulation. 2013;128:e240-e327 Copyright © American Heart Association, Inc. All rights reserved.


Advanced Heart Failure

Symptoms

www.southwestlondoncardiacnetwork.nhs.uk


Advanced Heart Failure Evidence

• NYHA III, IIIb, IV

• EF <30%

• Multiple readmissions

• Weight Loss

• Intolerance to ACEi/BB

• Hypotension

• PCWP > 16, RAP >12

• CXR congestion

• Decline in renal function

• Diuretic escalation

• Hyponatremia

• Frequent ICD shocks

• Elevated BNP

• 6 min walk < 300m

• PVO2 < 14 mL/kg/min

• Exam findings (JVP)



Advanced Heart Failure Therapeutic Options

Heart Transplant

Inotrope

LVAD

Hospice


Advanced Heart Failure Therapy

D

E

A

C

A

T

I

V

A

T

I

O

N

F

L

O

W

S

H

E

E

T

Participants

Surgeon

Cardiologist

Family

VAD coordinator

Nurse Coordinator

(CVICU)

Social Worker

Pal Med

+/- Ethicist

NP/Intensivist (CVICU)

Bedside RN

Spiritual Care (optional)

Meeting Goals

• Prognosis /expectations

• Advance directives/DNR Status

• DeactivationProcess

• Decide which family to be present during

deactivation

• Religious Rites

• Discontinuation of other life support modalities

(CRRT, Vent, Pressors)

• Comfort measures

• Life Banc

• Document in medical record outcome

• Request for Autopsy

Participants

VAD coordinator

Social Worker

Pal Med

Bedside RN

Clinical Nurse Liason /

Unit Manager

NP/Intensivist (CVICU)

Spiritual Care (optional)

Action

• Person in charge of deactivation identified and notified

• Person(s) in charge of deactivation of other life sustaining treatment modalities identified and notified

• Check list reviewed (see attached)

• DNR status updated

• Family members present as previously discussed

• Ensure patient comfort (pain, dyspnea, anxiety, secretions, N/V, etc)

• Religious rites / practices honored

• Spiritual care notified (if indicated by family)

• Social work, interpreter services, RN coordinators at bedside if indicated

• Code Calm initiated

• Nursing End of Life Protocol initiated

• Bedside monitor silenced / off

• LVAD Deactivated (see attached instructional sheets)

Meeting Goals

• Address patient comfort

• Review comfort care order set

• Ensure DNR status is DNR- Comfort Care

• Consult appropriate services for discontinuation

of other life support modalities

• EP: ICD

• Renal: Dialysis

• Pulmonology: Vent

• Plan date / time for deactivation of LVAD +/- other

life support modalities

• Steps / Sequence

• Review team members roles

• Decide who will deactivate LVAD

Deactivate

Clinical

Meeting

Family

Meeting

Discussion

Discussion



Advanced Heart Failure Therapy

• Fluid Restriction

• Inotrope Therapy

–Dobutamine

–Milrinone

Advanced Heart Failure Figure. Kaplan–Meier plots for patients with stage D heart failure receiving either dobutamine or milrinone.

Gorodeski E Z et al. Circ Heart Fail 2009;2:320-324

Copyright © American Heart Association

50% Alive at 6 months


Advanced Heart Failure Number of Heart Transplants by Year and Location

NOTE: This figure includes only the heart transplants that are

reported to the ISHLT Transplant Registry. As such, the

presented data may not mirror the changes in the number of

heart transplants performed worldwide.

JHLT. 2013 Oct; 32(10): 951-964

2013 Cleveland Cardio Conference 2018

Advanced Heart Failure Xenotransplantation


Advanced Heart Failure Adult and Pediatric Heart Transplants Survival (January 1982 – June 2012)

N = 108,343

N at risk at 27 years = 108

2014 JHLT. 2014 Oct; 33(10): 996-1008


~240 Million Population ≥

age 20 years old

HF=2.6 % Population* or

6.24 Million Total ~50 % Preserved Systolic

Function 3.12 M

~50 % Systolic HF

3.12 Million

Advanced Stage C and Stage D ≥ age 20 years old

109,200 – 280,800

Advanced Stage C / NYHA class IIIB

93,600-124,800

80-85% Stage A-B

0.5-5 % Stage D

Advanced Heart Failure Theoretical adult candidates for Mechanical Circulatory Support in

United States

Stage D / NYHA functional class IV

15,600-156,000

15-20% Stage C (3-4% advanced Stage

C)

Gorodeski, Starling


Advanced Heart Failure CMS DT and BTT Criteria

DT LVAD specific criteria

• New York Heart Association Class IV end stage left ventricular

failure.

• Have failed to respond to optimal medical management (including

beta-blockers and ACE inhibitors if tolerated) for at least 45 of the

last 60 days, or have been balloon pump dependent for 7 days, or IV

inotrope-dependent for 14 days

• Have a left ventricular ejection fraction (LVEF) < 25%

• Have demonstrated functional limitation with a peak oxygen

consumption of < 14 ml/kg/min unless balloon pump or inotrope-

dependent or physically unable to perform the test.

BTT LVAD specific criteria

• All BTT patients MUST be actively listed with UNOS prior to VAD

implant


Advanced Heart Failure Implants per year

• This is where main copy goes


Advanced Heart Failure Survival

• This is where main copy goes

Yr 1: Estep et al. J Am Coll Cardiol 2015;66:1747-61

LVAD BetterOMM Better

0.1 0.3 0.5 1.0 2.0 5.0 10.0

Event-Free Survival

Intent-to-Treat Survival

Primary End PointAlive at timepoint with

6MWD > 75m

Adverse Events

As treated on original therapy

Composite rate for yr

R.R

H.R

O.R

Ratio (95% CI) p-value

1.7 (1.1-2.7) p=0.024

4.1 (1.9-8.9) p<0.001

2.4 (1.2-4.8) p=0.012

1.0 (0.6-1.8) p=0.931

2.3 (1.5-3.7) p<0.001

5.7 (2.1-14.9) p<0.001

3.2 (1.3-7.7) p=0.012

1.3 (0.8-2.1) p=0.307

0.79 (0.46-1.36) p=0.492

0.46 (0.31-0.68) p<0.001

Yr 1

Yr 2

NYHA Class, HRQoL, and DepressionAlive at timepoint with

NYHA improvement > 1 class

O.R

8.9 (4.5-17.8) p<0.001

5.9 (2.8-12.6) p<0.001

VAS improvement > 20 pts

PHQ-9 improvement > 5 pts4.2 (1.7-10.2) p<0.001

4.1 (1.5-10.8) p=0.004


Advanced Heart Failure Risk-Benefit Analysis


Advanced Heart Failure Primary Indication for VAD Support

In general, the inability to adequately oxygenate thereby maintaining

normal end-organ function despite maximal medical therapy

-Postcardiotomy shock

-Acute Myocardial Infarction

-Chronic Heart Failure

-Myocarditis

-Ventricular Arrhythmia


Advanced Heart Failure Secondary Indications for VAD Support

1. Bridge To Recovery (BTR)

- Temporary devices (IABP, ECMO, etc.)

2. Bridge To Transplantation (BTT)

3. Destination Therapy (DT): Option for Patients Who May Not Qualify for Cardiac

Transplantation

General Specific Relative

Any condition limiting a

successful transplant outcome

Elevated pulmonary vascular

resistance

Active infection

Renal or pulmonary disease

Diabetes with end-organ

damage

Cross-match incompatibility

Active psychiatric disease

Substance abuse

Smoking

Age

Peripheral vascular

disease

Malignancy

Size/Obesity


Advanced Heart Failure Short Term MCS

• Percutaneous

• Bridge to recovery, transplant, or more durable device

• Counterpulsation

– IABP

• Non - Pulsatile

–Axial (e.g. Impella)

–Centrifugal (e.g. ECMO, Tandem Heart)


Advanced Heart Failure Examples

• Pulsatile

- Total Artificial Heart (TAH)

• Non – Pulsatile or Continuous Flow

- Heart Mate II & III

- Heart Ware

Advanced Heart Failure Long Term MCS


Advanced Heart Failure TAH Device Components

• Mechanical Valves

• Large

• Least resistance to flow

• Two ventricles

• 70 ml stroke volume

• LVAD (left atrial cuff to aorta)

• RVAD (right atrial cuff to pulmonary artery)

• Pneumatically driven

• Pulsatile flow (9.5 L/min max flow)



Advanced Heart Failure Total Artificial Heart


Advanced Heart Failure Total Artificial Heart: The Past


Advanced Heart Failure Total Artificial Heart: The Present

Advanced Heart Failure Continuous Flow Devices

• Non – Pulsatile

• Follow native pulse

• Pump output varies over cardiac cycle

• Centrifugal, Axial, Radial flow pumps

• Generate blood flow via rotational momentum

• Spinning of concentric cones or impellers Revolutions

per minute (RPMs)



• Advantages

- Quiet

- Less Power than pulsatile

- Durable (single moving part, no

valves, nominal friction)

- Size

- Continuous unloading of LV

• Disadvantages

- No hand pump

- Hemolysis

- Negative Intraventricular Pressure

( thrombosis, arrhythmia potential)

- Proper Cannula Placement

- Preload dependent & Afterload

sensitive

- Effect on Microcirculation

- LVAD only


Heartmate II

Heartmate III



Advanced Heart Failure HeartMate II LVAD


Advanced Heart Failure HeartMate III LVAD


Advanced Heart Failure HeartWare LVAD

33 Cleveland Cardio Conference 2018

• Doppler BP vs. Automatic Cuff

- Try both methods

• Target range

- MAP [(2 x diastolic)+systolic] / 3

or Doppled Pressure 70-90 mmHg

- Record BP as systolic/diastolic if present

- If obtain doppler pressure, write 80/0.

• Why do we care?

- Autocuff 100/70 (80) vs Doppled Pressure 100

VS


Advanced Heart Failure Management: Blood Pressure

• Assess patient

• Assess device. Assess alarms

Start at driveline, check connection into controller, check power sources, change power sources.

• If changing power sources does not start the pump, change the controller

• If pump still does not start, assess the patient, treat medically (ie. ACLS, Inotropes, heparin, possible return to the OR)

• If necessary, Chest Compressions are OK.

Advanced Heart Failure Management: Emergency Management



Advanced Heart Failure Management: Emergency Management

Circulation. 2017;135:e1115-e1134.


Advanced Heart Failure Common Complications

Advanced Heart Failure Infection

Cause

– Driveline Infection (most common)

– Other portal of entry

Effect

– Fever

– Chills

– Drainage

– Bacteremia / Sepsis

– Septic Emboli

Evaluation / Treatment

– Blood cultures

– Driveline culture

– Antibiotics

– Consult ID

– I&D

Good Driveline

Bad Driveline


Advanced Heart Failure Pump Thrombosis

Cause

– Ingestion of tissue or emboli

– Growth or deposition in pump

– Inadequate anticoagulation / platelet inhibition

Effect

– Obstruction of flow

– Increased drag on rotor

– Inability to unload the LV

– Hemolysis

– Hematuria

– Heart Failure


– CT scan

– ECHO

– Device parameters

– Ramp study

– Lytic therapy

– Anticoagulation

– Device exchange / Transplant

– Palliative care



Outflow Graft Thrombus Overgrowth of Myocardium



Advanced Heart Failure CVA

Cause

- Hemorrhagic

- Embolic

Effect

- Change in neurologic status


- CT scan

- Neurology consult

- Anticoagulation, Lytic therapy

(depending on etiology)

- Palliative care

Left frontotemporal subdural and left parietal occipital cerebral

acute hematoma with mass-effect and midline shift.

Advanced Heart Failure GI Bleeding

Cause

– Anticoagulation

– Intestinal Ischemia

– vWF deformation

– AVM’s

Effect

– Weak, Lightheaded, Pre-syncope

– Flow / PI changes

– Hypotensive

– Melena

– Hematochezia


– Eliminate anticoagulation

– Transfuse

– Consult GI (Endoscopic evaluation)

– ? Decrease pump speed

– ? Octreotide

– ? Estrogen Therapy

– Transplantation


Advanced Heart Failure The End


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Advanced Heart Failure and LVADs - ACVP Online · 2018. 4. 14. · Cleveland Cardio Conference 2018...

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