Objec've
• Par'cipantwillbeabletoiden'fytheprogressionofadvancedheartfailurestagesandcurrenttherapies.
HeartFailure
• Heartfailureiswhentheheartspumpingabilityisinsufficientinmaintainingbloodflowtomeetthebody’sneeds
LeBVentricle
RightVentricle
CardiacAbnormali'es
• Restric'veMyopathy-heartmuscleisrigidandlackflexibilitytoexpandnormally.(goodexampleisamyloidosis).
• HypertrophicMyopathy-thickmyocardium(smallventricularcavity).
CardiacAbnormali'es
• Congenitalheartdisease-birthdefectoftheheartand/orvessels.(ExampletetralogyofFallot)
• DilatedMyopathy-weakenedandenlargedventricle,poormuscletone.
CardiacAbnormali'es
• Valvularheartdisease-poorfunc'oningvalvecausingpoormovementofbloodinoroutofthechambers.
HeartFailure(HF)
• TheleadingcauseofHFiscoronaryarterydisease,highbloodpressureanddiabetes.
• 2.4%oftheadultpopula'onareaffectedwithHF.– GreaterDesMoinespopula'onis~599,789.Thiswouldmean~14,394ofadultsintheDesMoinesareamayhaveheartfailure.
Allen,L.(2012)DecisionMakinginAdvancedHeartFailure
Systolicvs.DiastolicHF
• Normallytheheartejects50-75%ofthebloodfromtheleBventricle.
• DiastolicHeartFailure-LeBventricleisnotabletofillproperlyduringthediastolic(filing)phase.Lessbloodisejectedfromtheheartthanwhatshouldbe. – HFpEF(preservedejec'onfrac'on>50%).
• SystolicHeartFailure-LeBventricleisnotabletosqueezehardenoughtopushbloodouttotherestofthebodyduringsystole.(heartdamagefromMI,thin/narrowmusclelining).– HFrEF(reducedejec'onfrac'on<50%).
TherapyOp'ons
• Diet• Exercise• Diabetesmanagement• Bloodpressurecontrol• Op'onsforstructuralissues(parachute,TAVR,MitraClip,surgery)
• Coronaryinterven'on(sten'ng,balloonangioplastyand/orcoronaryarterybypassgraB(CABG))
• Pacemaker/resynchroniza'ontherapy/ICD• Mechanicalcirculatorysupport/Cardiactransplant
PaBentswithAdvancedHeartFailure
• RepeatedhospitalizaBons(greaterorequalto2withintheyear)• ProgressivedeterioraBoninrenalfuncBon(riseinBUNandCr)• Weightlosswithoutothercause(cardiaccachexia)• IntolerancetoACEinhibitorsorb-blockersduetohypotensionand/or
worseningHF.• Frequentsystolicbloodpressure<90mmHg• PersistentdyspneawithdailyacBviBes(bathinganddressing)• Inabilitytowalk1blockonthelevelgroundduetodyspneaorfaBgue• FrequentICDshocks(arrhythmias)• IncreaseescalaBonofdiureBcs(examplefurosemideequivalentto>160
mgperday).• Progressivedeclineinserumsodium(<133)
B189-0312
INTERMACSPROFILES4–7:AmbulatoryHeartFailure
StevensonLW,PaganiFD,YoungJB,etal.INTERMACSprofilesofadvancedheartfailure:thecurrentpicture.JHeartLungTransplant.2009;28:535-41.
INTERMACS PROFILES AND OTHER CLASSIFICATION SYSTEMS
Profile # Description NYHA Class Time to MCS therapy AHA/ACC Stage
INTERMACS 1 Crashing and burning IV Within hours D
INTERMACS 2 Progressive decline on inotropic support IV Within a few days D
INTERMACS 3 Stable but inotrope dependent IV Within a few weeks D
INTERMACS 4 Recurrent advanced heart failure; resting symptoms at home on oral
therapy Ambulatory IV Within weeks to
months D
INTERMACS 5 Exertion intolerant Ambulatory IV Variable D
INTERMACS 6 Exertion limited or walking wounded Ambulatory IV Variable C-D
INTERMACS 7 Advanced NYHA III IIIB Variable C
A depiction of the clinical course of heart failure with associated types and intensities of available therapies.
Allen L A et al. Circulation. 2012;125:1928-1952
Copyright © American Heart Association, Inc. All rights reserved.
TriggersTriggersbelowhelpthehealthcareproviderevaluatethepa'entsdeclineinheartfunc'onthereforepromptcollabora'onwithheartfailurecardiologist.• Hospitaliza'onforheartfailure• FirstICDshock• UpgradetoCRT-Ddevicewithnoimprovementinheartfailuresymptoms
• Developmentofcardiorenalsyndrome• WithdrawalofACE
Timing• Heartfailureisaprogressivedisease.Theartofcaringforadvanceheartfailurepa'entsishelpingthemmakedecisionsonnextbesttreatmentop'onsandeduca'ngthemonselfcareandsymptommanagement.
• Fiveyearsurvival,50%.• Best'metotalkaboutop'onsisintheambulatoryselng.
• Hospitaladmissionshouldbea'metoreviewandpossiblyupdatecareop'onsratherthanintroduceadvancedtherapycaredecisionop'ons.
• Advancedtherapiesisaboutimprovingqualityoflife.
Lesny,P.etal.(2013).JournalofHeartandLungTransplant
AdvancedHeartFailureTeam
• Physicians/ARNP• HeartFailureCaseManagers• VADCoordinator• VADSocialWorker• Pallia'veCareCoordinator• TransplantpartnersatUIHC
WhatdoesaVADdo?• TheVADassiststheheartby
helpingpumpmorebloodtotherestofthebody,fromtheleBventricleuptotheaorta.
• VentricularAssistDevicecanbecalledothernames:– LVAS(LeBVentricularAssistSystem)– MCS(MechanicalCirculatory
Support)• HeartMateIIistheonlylong
termmechanicalassistdeviceapprovedbytheFDA(pa'entliveswiththedeviceathome).
Thoratec©
PictureaboveistheVADpumpapachedtotheheart(internally).
Power
Battery
Heart Pump (inside body)
Driveline, exits the body here
Power Cord
Battery
Power Cord
Pocket Controller
Thoratec©
FDAApproval
• BridgetoTransplant– Non-reversibleleBheartfailure– Imminentriskofdeath– Candidateforcardiactransplanta'on
• Des'na'onTherapy– Notacandidatefortransplant– Allothertreatmentop'onshavebeenexhausted.– GoalistoimprovequalityoflifeanddecreaseHFsymptoms.
CriteriaforDesBnaBonTherapy
End-Stageheartfailure(NewYorkHearAssocia'onClassIV)whoarenotcandidatesforhearttransplanta'on,andmeetallofthefollowingcondi'ons:• Havefailedtorespondtoop'malmedicalmanagement(IncludingBeta-blockersandACEInhibitors)foratleast45ofthelast60days,orhavebeenballoonpump-dependentfor7days,orIVinotrope-dependentfor14days;and
• HavealeBventricularejec'onfrac'on(LVEF)<25%;and• Havedemonstratedfunc'onallimita'onwithapeakoxygenconsump'onof<14ml/kg/minunlessballoonpumporinotropedependentorphysically
unabletoperformthetest(cardiopulmonarytreadmill-CPX).
Evalua'onPhaseTesBngforcardiactransplantandLVAD• Labs• LeBheartcath(angiogram)toevalcoronaries• Rightheartcath-toevaluateincreasedfillingpressures/backupoffluidon
therightside.• CTofchestifprevioussternotomy• CPX-Cardiopulmonaryexercisestresstest-VO2lessthan14• Echocardiogram-BubblestudyneededifmaygetLVAD• 6minwalktest• Ultrasounds-Caro'dandAbdominal• ABI-toruleoutPVD• Colonoscopy• Mammogram,Pap,prostateeval(persex)• Pallia'veRN(evaluatesPOA/Will,5wishesandcopingwithdiseaseprocess)• SocialWorker(evaluatessocialsupportathomeandinsurancecoverage)
HeartMateII
RegistryInformaBontodate(fromThoratec)• Pa'entsimplanted:20,000+worldwide• 100+pa'entsonsupportforover5years,withmul'plepa'entsover8years
• Longestsupportedpa'entonasingledevice(8+years)
• Agerange:10-91years
Pa'entEquipment
• Pa'entmusthavebackupequipmentwiththematall'mes!
• AllVADpa'entshaveaprimarycaregiverwhoisfullytrainedtotroubleshoottheequipment.
• Bagwillcontainemergencycallnumberandalarmtroubleshoo'ngguide.
Typicalcarrycaseholdingextraequipment.
BloodPressureMonitoring• Lesspulsa'lityofna'vepressureduetocon'nuous-flownatureoftheHeartMateII
• Bloodpressuremeasurement– DopplerultrasoundonceA-lineremoved– Automa'ccuffsareinaccurate
• Targe'ngMAPwithagoalof:– Mean≈70-90mmHg
• Hypertension– Effectsonpumpsupport
• Maydecreaseforwardflow• Decreaseinpumpflowandpower
– Inan'-coagulatedpa'ents,mayincreaseriskofhemorrhagicstroke
Titra'ngAn'coagula'on• WarfarindoseforINRtargetof2.0±0.5• Aspirin81to325mg/day• Considerincreasingan'coagula'onduringlowflowstates
– LVADFlow<3.0L/minute
• Gastrointes'nalbleeding– vonWillebranddisease– Reducedpulsa'lity
• TypicallyhighINR’swillnotrequirereversalagent,pa'entmaybeadmipedformonitoringwhiletrendingdown.
Emergencies• Intheoccurrencethatthepa'entbecomesunresponsive,DO
NOTperformchestcompressionsasthismaydislodgethedevice.
• Allothermeasurestoresuscitatethepa'ent(medica'onsandairway)shouldbeperformed(checkcodestatus).
• Mostpa'entshaveapacer/ICD.IfshockadvisedandcurrentICDisnotshockingthepa'ent,externaldefibrilla'oncanbeperformedwithoutdisconnec'ngtheVAD.
• Ifthedevicehasanyalarms,seekaVADcompetentorVADtrainedpersonrightaway.
• Aheartfailurephysicianisoncall24/7.AllpumprelatedemergenciesshouldbedirectedtoVADcoordinatoroncall.Theyaredirectedtocall515-633-3770,IHCheartfailureline.
Risks
• Bleeding– Duetononpulsi'lity,pa'ents
areatriskforAVM’s– GIbleedingismostcommon
• Stroke– Pa'entsmustbean'-
coagulated.– TypicalINRgoalis2.0-3.0
• Powerdisconnect– Neverdisconnectboth
sourcesofpoweratthesame'me(i.e.bothbaperies).
• InfecBon– Mustmaintainsterile
dressingtodrivelinesite– Assessforinfec'on
• SucBonevents– Wheninflowcannulacontacts
ventricularwallcancauseectopicbeats.
– Evaluatepa'entfordehydra'onorarrhythmias
SuccessStory• July2007acutepulmonaryedemaPTCA/stentstoRCAandOM1andramus.Afew
hourslatercodedandrequiredastenttotheRCAagain.• June2012seenbyDr.Frazier,beganverbalizingdepressiveconversaBons.NYHAIII.• September21,2012JerrywasreferredtoDr.WickemeyerforanadvancedHFconsult• May3,2013LVADimplantedbyDr.PrabhakarwithDr.BatesattheUniversityof
Iowa.• May21,2013Mercyacuterehabfor2weeks• June7,2013firstvisittotheIHCadvancedheartfailureclinicwithnewLVAD.• July25,2013firstroadtriptoKansasCity.
SupportGroup
VADsupportgroupbringsotherVADpaBentsandtheircaregiversfromthe
communitytogethertotalkaboutlivinglifewithanLVAD.
*NYHA functional class was determined by an independent clinician at the time points shown. Improvements were statistically significant in both trials (p<0.001).Rogers JG, Aaronson KD, Boyle AJ et al, JACC, 2010;55:1826-34.
Six Month Follow-up for BTT Patients
Two Year Follow-up for DT Patients
Func'onalCapacityaBerHMIILVAD