advanced heart failure and the role of mechanical circulatory support
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Megan Shifrin, RN, MSN, ACNP-BC Vanderbilt University. Advanced Heart Failure and the Role of Mechanical Circulatory Support. Objectives. Review current recommendations for advanced heart failure management Identify the different types of VADs currently in use - PowerPoint PPT PresentationTRANSCRIPT
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Advanced Heart Failure and the Role of Mechanical Circulatory Support
Megan Shifrin, RN, MSN, ACNP-BCVanderbilt University
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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
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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.
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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
$3.8Drugs/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
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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
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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
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Goals of Heart Failure Management
1. Improving symptoms and quality of life
2. Slowing the progression or reversing cardiac and peripheral dysfunction
3. Reducing mortality
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Addressing Heart Failure in 2013
Katz AM Heart Failure
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Pharmacologic Optimization of the Heart Failure Patient with LVEF <40%
(Strength of Evidence = A)• ACE inhibitors
• ARBs• To be utilized when intolerant to
ACE inhibitors due to angioedema or cough
• Patients intolerant to ACE-I due to renal insufficiency or hyperkalemia are likely to experience the same effects with ARBs
• Warfarin• In patients with atrial fibrillation,
pulmonary embolism, or TIA
• Beta Blockers
• Aldosterone Antagonists
• Hydralazine and Isosorbide Dinitrate• In African American population
with stage III and IV heart failure, strength of evidence = A
• Loop Diuretics Lindenfeld, J, et al.J Card Failure2010; 6, 486-491
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Pharmacologic Optimization of the Heart Failure Patient with LVEF <40%
Strength of Evidence = B• Antiplatelet agents (Aspirin)
• Ischemic etiology of HF• Digoxin
• In stage II and III HF• Thiazide diuretics• Warfarin
• MI patients with LV thrombus
Strength of Evidence = C• Digoxin• In stage IV HF
• Metalazone
Lindenfeld, J, et al.J Card Failure2010; 6, 486-491
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Pharmacologic Optimization of the Heart Failure Patient with LVEF <40%
Inotropes• Commonly used on an outpatient basis for stage IIIb – IV
heart failure• Milrinone and Dobutamine are the only FDA approved
drugs for outpatient use• Not recommended for acute heart failure exacerbations in
ischemic patients• Probable benefit in non-ischemic exacerbations
• OPTIME-CHF JAMA 2002; 287:1541-7
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Non-pharmacologic Optimization of the Heart Failure Patient with Low LVEF
Cardiac Resynchronization Therapy (CRT)• LVEF <35%• NYHA class III – IV• QRS > 120 ms• Optimal medical therapy
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Non-pharmacologic Optimization of the Heart Failure Patient with Low LVEF
Implantable Cardiac Defibrillators• Ischemic Etiology • (Strength of Evidence = A)
• Non-ischemic Etiology • (Strength of Evidence = B)
• Primary prevention of ventricular arrhythmias• LVEF <35% Lindenfeld, J, et al.
J Card Failure2010; 6, 486-491
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Evidence of Progressing Heart Failure
Decreased end organ perfusion• Renal function• Liver function• Pulmonary function
We need more support!
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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)
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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?
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Lietz and Miller Curr Opin Cardiol 2009, 24:246–251
INTERMACS SCOREInteragency Registry for Mechanically Assisted Circulatory
Support Long-Term LVAD
Ideal candidates are INTERMACS classes 3-4Short-Term LVAD
Candidates are INTERMACS
classes 1-2Not a LVAD Candidate
INTERMACS 1 or those with multisystem organ failure
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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; OR 14 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
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Adult FDA Approved LVADsBridge to Transplantation
(BTT)HeartMate II (Thoratec)HeartWare (HeartWare)
PVAD (Thoratec)IVAD (Thoratec)
Destination Therapy (DT)HeartMate II (Thoratec)
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HeartMate II (Thoratec)
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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
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Immediate Post-op Management
VS
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Management Considerations• Typically pulseless • Use a doppler or arterial line for BP assessment (Target MAP 60-80)
• Afterload sensitive • An increase against pump propulsion is reflected in decreased
pump flow• Preload sensitive• Anticoagulation status• Correction of coagulopathy immediately post-operatively• At 24-48 hours, Warfarin with goal INR 2-3 +/- Aspirin, Dipiridamole,
Clopidogrel
• Should not receive chest compressions during an arrest• Patients still have heart failure
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Potential Device Complications
Inflow cannula (poor position, obstruction)
Pump/rotor dysfunction (thrombus)
Battery dysfunction
Outflow graft (kink, leak)
Drive line infection / fracture
Controller malfunction
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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
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“However beautiful the strategy, you should occasionally look at the results.”
Winston Churchill
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Medical Management vs. LVAD
Rose, EA; et alNEJM 2001; 345:1435-1443
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Survival Rates
Kirkland, JK, et. alJHLT 2013; 32:141-156
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ADLs of DT Patients
Kirkland, JK, et. alJHLT 2013; 32:141-156
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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
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Variations of Short-Term VADs• Impella 2.5 and 5.0•Tandem Heart•CentriMag•ECMO (V-A)
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Impella 2.5 and 5.0• Utilized for LV support only; not
appropriate to use with RV failure• Impella 2.5 can be inserted through
the femoral artery during a standard catheterization procedure; provides up to 2.5 L of flow
• 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
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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
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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
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ECMO (VA)• 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
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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