Z A K C E R M I N A R A P H A R M DU W M E D I C I N E R E S I D E N T

S E P T E M B E R 4 , 2 0 1 4

LVADS IN THE EMERGENCY DEPARTMENT

CONTENT

• Background• Pharmacotherapy• Infections• GI Bleeds• Arrhythmias/Codes• Miscellaneous

PATIENT PRESENTATION

• MJM 64 y/o male• ICM s/p LVAD 6/2014• Hx of 2 recent admits for GI bleeds• Presented to the ED on 8/21 with solid, black

stools since 1200 that day with mild fatigue

PMH

• Coronary artery disease• Hx of complete heart block• HeartMate II LVAD in place• Chronic anticoagulation• Hx of acute renal failure• Acute blood loss anemia• Protein calorie malnutrition• Situational depression• Insomnia

HISTORIES

• Allergies:• NKDA

• Family History:• Father: CVA• Brothers: DM

• Social History:• EtOH: Occasional• Tobacco: Smoked for 40-45y, quit• IVDU: Denies

HOME MEDICATION LIST

Indication Medication

Heart History ASA 81 mg PO Daily

Metoprolol Succinate 25 mg PO BID

Pravastatin 20 mg PO daily

Warfarin 1.5 mg PO QmondayWarfarin 2 mg PO QTuWThFSaSu

GERD/GI Bleed Hx Pantoprazole 40 mg PO daily

Pain APAP 650 mg PO Q6H PRN

Oxycodone 5 mg PO Q6H PRN

Constipation Docusate 200 mg PO daily PRN

Supplements Multivitamin PO daily

Vitamin D 1000 IU PO daily

Magnesium Oxide 400 mg PO BID

VITALS

• Admission to ED• Weight: 86.5 kg• Height: 6’ 1”• BMI: 25.2• BP=MAP: 61• Temp: 36.7• RR: 20

LABS: CBC

WBC RBC Hgb Hct MCV Plt

8/21 5.82 2.39 7.2 22 94 279

Na K Cl CO2 Anion Gap

SCr BUN Ca Corrected Ca

8/21 140

4.2 111

24 5 1.12 24 8.2 9.32

LABS: BMP

LABS: LFTS

PT INR aPTT

8/21 27.4 2.6 37

AST ALT Alk Phos

Bili Albumin

8/21 25 25 56 0.7 2.6

LABS: COAGULATION

BACKGROUND

• Heart failure (HF) is increasing in prevalence• 5.7 million currently have diagnosis• 670,000 are newly diagnosed yearly• 1 year mortality rate is 20%• Less than 15% survive 8-12 years• Pharmacotherapy can be used to manage HF in

the earlier stages• Transplant is the preferred therapy for end-stage

HF• Left ventricular assist devices (LVADs) have

become increasingly more popular

Circulation. 2012 Jan 3;125(1):e2-e220.

BACKGROUND CONT.

• LVADs decrease symptoms by decreasing the work of the heart• LVADs:• Reverse HF• Bridge to transplant• Destination therapy

Circulation. 2012 Jan 3;125(1):e2-e220. Int J Cardiol. 2013 Oct 15;168(6):5143-8.

PHARMACOTHERAPY

• Angiotensin-converting enzyme inhibitors (ACEIs)• Angiotensin II receptor blockers (ARBs)• Aldosterone Antagonists• Digoxin• Beta blockers• Diuretics• Hydralazine (+/- nitrates)• Warfarin

Int J Cardiol. 2013 Oct 15;168(6):5143-8.

INFECTIONS

INFECTIONS

• Infection rates have been shown to be 25-80%• VAD-related infections should be treated

aggressively• Common VAD-related infections• Driveline• Pocket• Mediastinitis• Pump endocarditis

Int J Cardiol. 2013 Oct 15;168(6):5143-8.

J Heart Lung Transplant. 2011 Apr;30(4):375-84.

INFECTIONS CONT.

• Goal of therapy is to keep infection confined to prevent progression• Device related infections do not prevent

transplant• Non-VAD related infections require aggressive

treatment

Int J Cardiol. 2013 Oct 15;168(6):5143-8.

INFECTIONS CONT.

Int J Cardiol. 2013 Oct 15;168(6):5143-8.

• Retrospective study by Nienaber et al. • They identified 101 episodes of LVAD infections in 78

of 247 patients (32%)• Most common infection: Drive line infections (47%)• Followed by VAD and non-VAD related BSIs (24% and

22%)• Pathogens:• Gram-positive cocci, staphylococci (45%) • Gram-negative bacilli, nosocomial (27%)

• Chronic suppressive antimicrobial therapy: 42% • Intraoperative debridement: 14%• VAD removal: 3 patients

BLEEDING

BLEEDING

• Bleeding is the most common adverse event associated with VAD therapy• Common bleeding issues:• Epistaxis• Gastrointestinal bleeding• Vaginal bleeding• Cuts or other trauma• Complications after outpatient procedures

• Bleeding may be related to:• Systemic anticoagulation• Operation• Acquired von Willebrand disease

Int J Cardiol. 2013 Oct 15;168(6):5143-8.

POSTOPERATIVE BLEEDING

• Immediate postoperative bleeding may be related to:• Adhesions• Cannulation sites• Coagulopathy

• In many causes can be controlled using:• Blood products• Hemostatic agents (aminocaproic acid) • Desmopressin acetate• Protamine sulfate

Int J Cardiol. 2013 Oct 15;168(6):5143-8.

VON WILLEBRAND SYNDROME

• In a study of 26 patients with LVADs• All subjects developed von Willebrand syndrome • It was reversible on explant

• A different prospective study examined the characteristics of von Willebrand syndrome related to LVADs• All patients developed von Willebrand syndrome

• The cause is unknown• It may be due to the stress of the continuous flow VAD

leading to proteolysis of the multimers

Int J Cardiol. 2013 Oct 15;168(6):5143-8.

HEMOLYTIC ANEMIA

• Hemolysis occurs when RBCs lyse as they pass through the VAD • Related to platelet activation

• Patients may develop symptoms:• Fatigue• Dark tea-colored urine• Icterus

• Management includes:• Close monitoring • Possible addition of dipyridamole

• May occur at a rate of 1.2% to 3%

Int J Cardiol. 2013 Oct 15;168(6):5143-8.

ARRHYTHMIAS/CODING

ARRHYTHMIAS

• Arrhythmias occur in approximately 27% to 38% of VAD patients• Treatment options include: • Fluid boluses• Antiarrhythmic agents (amiodarone, beta-blockers +/-

mexilitene)• Normalization of serum electrolyte• Weaning pressors• Direct current cardioversion/Defibrillation

• Always continue preoperative antiarrhythmics after LVAD implantation

Int J Cardiol. 2013 Oct 15;168(6):5143-8.Crit Care Med. 2014 Jan;42(1):158-68.

CODING

• When terminal rhythms occur with power outputs indicating flow through the device use only:• Electrical cardioversion/defibrillation• Epinephrine• Atropine

• When power output is low, compressions may be necessary

• The major risk with chest compressions is dislodgement of:• The device • The outflow cannula

• This is mainly of concern with the larger devices• Alternative is abdominal compressions, given 1–2 inches

left of midline

Int J Cardiol. 2013 Oct 15;168(6):5143-8.Resuscitation. 2014;85(5):702-4. doi: 10.1016.

ABDOMINAL COMPRESSIONS

• One case study of performed abdominal resuscitation in an LVAD patient successfully• Abdominal compressions can maintain a coronary

perfusion pressure of 15 mm Hg• At ROSC, care should be taken to support the

ischemic RV

J Cardiothorac Surg 2011; 6:91.

MISCELLANEOUS

MISCELLANEOUS

• Neurologic• Turbulent flow leads to thrombus formation and stroke• Newer pumps decrease this risk

• RV Failure• An imbalance can develop between the ventricles• Incidence ranges from 11.8% to 14.8%• Can lead to pulmonary hypertension

• Multiple Organ Failure• Device Malfunction

Int J Cardiol. 2013 Oct 15;168(6):5143-8.

BACK TO MJM

• Medications given in the ED:• Pantoprazole 80 mg bolus• Pantoprazole 8 mg/hr drip

• Medications in the ICU:• Pantoprazole 8 mg/hr drip for total 24 hrs• Pantoprazole 40 mg PO BID through 8/27• All home medications• Warfarin was held

REFERENCES

1. Roger VL, Go AS, Lloyd-Jones DM et al. Heart disease and stroke statistics 2012 update: a report from the American Heart Association. Circulation. 2012 Jan 3;125(1):e2-e220.

2. Pistono M, Corrà U, Gnemmi M et al. How to face emergencies in heart failure patients with ventricular assist device. Int J Cardiol. 2013 Oct 15;168(6):5143-8.

3. Nienaber JJ, Kusne S, Riaz T et al. Clinical manifestations and management of left ventricular assist device-associated infections. Mayo Cardiovascular Infections Study Group. Clin Infect Dis. 2013;57(10):1438-48. Hannan MM, Husain S, Mattner F et al. Working formulation for the standardization of definitions of infections in patients using ventricular assist devices. International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2011;30(4):375-84.

4. Pratt AK, Shah NS, and Boyce SW. Left Ventricular Assist Device Management in the ICU. Crit Care Med. 2014 Jan;42(1):158-68.

5. Rottenberg EM, Heard J, Hamlin R et al. Abdominal only CPR during cardiac arrest for a patient with an LVAD during resternotomy: A case report. J Cardiothorac Surg 2011; 6:91.

6. Shinara Z, Bellezzoa J, Stahovich M et al. Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs). Resuscitation. 2014;85(5):702-4. doi: 10.1016.