Mechanical Circulatory Support for Advanced Heart Failure Speakers: Lynne A Benish, ACNP-BC...
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Transcript of Mechanical Circulatory Support for Advanced Heart Failure Speakers: Lynne A Benish, ACNP-BC...
Mechanical Circulatory Support for
Advanced Heart Failure
Speakers:
Lynne A Benish, ACNP-BC
Mechanical Assist Device Nurse Practitioner, Cardiac Surgery
Yesabel Bustos, RN, CCRN
VAD Coordinator
Objectives
Overview of End-Stage Heart Failure
Treatments for End Stage Heart Failure Heart Transplantation Mechanical Circulatory Support
What is Heart Failure?
Physiologic state in which cardiac output is insufficient in meeting the needs of the body
• Can involve the left side, right side or both sides• Typically, begins in left side since left ventricle is the main pumping
chamber Chronic, progressive disease.
Not curable, but treatable.
Broadly defined as a clinical syndrome characterized by dyspnea and fatigue, at rest or with exertion, diminished quality of life, and shortened life expectancy.
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Heart Failure Prevalence and Incidence
Incidence in the U.S.5.7 million
More than 280,000 patients die of heart failure in the US each year2nd highest mortality at one year with optimal medical management
More than 600,000 new cases are diagnosed each year in the United States.
Patients that have advanced end-stage heart failure are characterized by:- frequent hospitalizations- reduced quality of life- a complex therapeutic regimen, and a high mortality rate
Heart failure costs the nation an estimated $32 billion each year. This total includes the cost of health care services, medications to treat heart failure, and missed days of work.
Causes of Heart Failure Most common
Coronary Artery Disease Hypertension Diabetes
Cardiomyopathy-(disease of the heart muscle)
Heart Valve Disease
Arrhythmias
Congenital
Treatments for cancer-radiation and chemotherapy
Alcohol abuse or cocaine and other illicit drug use
Medical Treatment Options
for Advanced Heart Failure Optimal Medical Therapy
Beta Blockers, ACE Inhibitors, ARBs, Aldosterone Antagonists, Diuretic Therapy, Oral Nitrates and Hydralazine, etc.
Electrophysiologic Testing and the Use of Devices in Heart Failure
Prophylactic ICD Placement Bi-ventricular Resynchronization Pacing
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Cardiac Transplantation: The “Gold Standard” Remains the most effective treatment for end-stage heart
disease, although donor shortage limits it use Approximately 2,000 hearts are available each year
1-year survival: 85%
5-year survival: 71%
10-year survival: 46%
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Surgical Interventions forEnd-Stage Heart Failure
Contraindications for Cardiac Transplantation
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General Specific Relative
Any condition limiting a successful transplant outcome, i.e. non-compliance, lack of social support.
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
Surgical Intervention
for End-Stage Heart Failure Ventricular Assist Device A ventricular assist device (VAD) is an implantable device designed to partially replace the
function of the failing heart, restoring circulation of blood flow to the body through mechanical circulatory support.
Decreases cardiac workload Increases systemic circulation & tissue perfusion Decreases preload
VADs are designed to assist the right (RVAD) or left (LVAD) ventricle, or both at once (Bi-VAD). The type of VAD used depends on the underlying heart disease and the pulmonary arterial resistance that determines the load on the right ventricle.
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Indications
Bridge to Transplant (BTT)Must be UNOS listed at time of implant
Destination TherapyPermanent support for those ineligible for heart transplantSome may convert to BTT
Bridge to Decision/Bridge to Recovery
Patients with acute cardiac failure with the anticipation of recovery of their native heart function (i.e. cardiogenic shock)Post-cardiotomy patients with failure to wean from bypass
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How does an LVAD work?LVADs are implanted through open-heart surgery. Unlike a pacemaker or defibrillator, the pump is powered by a controller and batteries that are outside of the body. The VAD acts like a bypass for the weak ventricle. It continuously sucks blood out from the left ventricle and into the pump, where it is then pushed through the outflow graft that is connected to the ascending aorta.
Most Common Implantable LVADs on the Market
Thoratec HeartMate IIFDA approved for BTT and Destination TherapyApproved for Destination Therapy in 2010
HeartWare HVAD Can be used as an RVAD & LVADOnly for BTT indication
Patient Selection for Destination Therapy: CMS Requirements
New York Heart Association (NYHA) Functional Class IV
Failure to respond to optimal medical management (including beta-blockers, ACE inhibitors, if tolerated) for at least 45 of 60 days,
or IABP dependent for 7 days or IV inotrope dependent for 14 days and
Left Ventricular Ejection Fraction ≤ 25%
Peak VO2 < 14 ml/kg/min (If able to participate in test)
Ineligible for heart transplant
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Multidisciplinary Team and
Selection Committee Cardiac Surgeon Heart Failure/Transplant Cardiologist Pulmonary Critical Care/ Infectious Disease VAD Nurse Practitioner/Physician Assistant VAD Coordinator RN Transplant Coordinator RN Social Worker Finance Nutritionist Psychiatrist Pharmacist Physical Therapy/ Occupational Therapy
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Blood PressureDue to the continuous flow of the LVAD, most patients are what we call “non-pulsatile”. MAP vs. Systolic/DiastolicMost accurate measure of blood pressure is obtained by: Doppler and manual cuff Arterial line
DO NOT rely on automatic/non-invasive blood pressure cuffs!Typical MAP goal is 65-85
Forget What You Know: Physical Assessment
Forget What You Know: Physical Assessment
Heart Rate These patients typically do not have a palpable pulse, as the aortic
valve does not always open and close. Most accurate measure of heart rate is obtained by:
-12-Lead EKG-Telemetry rhythm strip
DO NOT rely on pulse oximetry for measure of heart rate!
Special Nursing Considerations
VAD DrivelineThe “driveline” is the percutaneous cord that connects to the patient’s external controller. This powers the pump internally. All patients must have their driveline covered by a “dressing” at all times.
The VAD/driveline exit dressing is specific to the patient’s implanting center.
Special Nursing Considerations
VAD DrivelineIt is important for the patient and health care practitioners to assess the external driveline and power cords for damage on a routine basis.Most common complications are:
-Driveline related infection (can lead to bacteremia and sepsis)-Wear and tear of driveline (can lead to pump malfunction or death)
Special Nursing Considerations
Anticoagulation LVAD patients must be anticoagulated with Warfarin (Coumadin) and
enteric-coated aspirin. No other anticoagulants have been approved for use in LVAD patients at this time.
INR goals are patient specific but typically range anywhere from 1.5-3.0. Most frequent complications are:
• GI bleeding• Epistaxis• CVA
Forget What You Know: Arrhythmias
LVAD patients can maintain perfusion even in the presence of VT/VF. The patient may even be walking and talking.
However, arrhythmias must be treated as the patient will eventually decompensate.
Can be cardioverted or defibrillated
LVAD patients are volume sensitive, especially those with right ventricular dysfunction and/or aortic insufficiency. Take caution with fluid resuscitation, even in the presence of sepsis. Aggressive volume resuscitation can cause the patient to go into heart failure/respiratory distress.
Forget What You Know:Fluid/Volume Imbalance
Emergency EquipmentAll VAD patients have a black emergency travel bag that should be with patient at all times!Bag should contain back up controller, batteries, battery clips, EMS/alarm guide.
Never Leave Home Without It!
Can you perform CPR on a patient with an LVAD?
Yes, but DO NOT perform chest compressions.
May treat with ACLS medications, cardioversion, defibrillation Notify and transfer patient to implanting VAD center when stable!
Non urgent: Contact outpatient VAD Clinic Urgent: Contact VAD Hospital to speak with Transfer Center All health care members are permitted to contact us for a
consult. Only a VAD team member can determine if a patient is an
eligible candidate.
Advanced Heart Therapy Consults