Transcript 6 More deaths from heart failure (HF )

Susan George, APRN- CNP, CCNS, CCRN, CHFN
Heart Failure Patients in US
(millions)
Epidemiology of Heart Failure
10
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 6
4.8
4.9
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More deaths from heart failure
(HF )than from all forms of
cancer combined
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4.9 million symptomatic
patients; estimated 10 million
in 2037
3.5
Incidence: About 550,000
new cases/year
 Mortality: 10% within 1st year
& 50% within 5yrs
 The total estimated cost in
2009 was $27.9 billions

1991
2000
2005
2037
Prevalence of HF
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Heart Disease and Stroke Statistics—2012 Update
Hospital discharges for HF
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Heart Disease and Stroke Statistics—2012 Update
Medicare Expenditures for
Heart Failure
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Definition of HF
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 It is a complex clinical syndrome that can result from
any structural or functional cardiac disorders that
impairs ability of the left ventricle to fill with or
ejects blood
HF: Systolic v. Diastolic
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 Systolic dysfunction: Left ventricular ejection fraction (LVEF) of
less than 40% and is generally due to left ventricular
enlargement.
 Diastolic dysfunction: Impaired ventricular relaxation and
distensibility resulting in an increase in ventricular filling
pressures.
Classification of Heart
Failure
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 Functional classification: NYHA class (I-IV)
 Staging of HF: ACC/AHA stages (A,B,C,D)
ACC/AHA staging of HF
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NEJM. 2003;Volume 348:2007-2018
Management of HF
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 Life style modification
 Medications
 Electrical Therapy
 Advanced HF therapy - Transplant/ Mechanical
circulatory support (MCS).
Heart failure and exercise
intolerance
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 Patients with HF have limited exercise capacity because of
dyspnea and fatigue.
 End stage HF patients have structural and functional
abnormality in skeletal muscle secondary to chronic
hypoperfusion and physical deconditioning
 Skeletal muscle dysfunction involving the respiratory
muscles may contribute to dyspnea.
 Heart failure patients have skeletal muscle atrophy and
intrinsic skeletal muscular metabolic defects, leading to
less efficient use high energy phosphates and more rapid
accumulation of lactic acid
 Exercise intolerance is also caused by hemodynamic
disorders
Effects of exercise training
in HF
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Studies have shown that exercise leads to functional,
pathophysiological, and hemodynamic improvement
 Enhanced peak/maximum VO2 (VO2 max) and
possibly peak cardiac output due to a higher
workload achieved, and leg blood flow during
exercise
 Improved muscle energetics so that oxygen
utilization becomes more efficient
 Improvement in HF symptoms such as dyspnea and
fatigue
Effects of exercise training
in HF
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 Restoring autonomic cardiovascular control towards normal by
reducing sympathetic tone and increasing vagal tone
 Reduced neurohormaonal activity
 Improvement in endothelial function leading to vasodilation of
skeletal muscle blood vessel, possibly leading to increase in
exercise capacity
 Reduction in total peripheral resistance
 Reduction in plasma brain natriuretic peptide values
 Significant improvement in six-minute walk distance
 Significant improvement in NYHA functional class
 Exercise training may reduce HF related hospitalization and
improve health related quality of life
Advanced/End Stage HF
Patient
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• Severe exercise intolerance
• Heart failure wasting
syndrome
• Cardiorenal syndrome
• Right heart failure
• Inotrope dependence
Advanced/End Stage HF
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 It is characterized by the presence of structural
myocardial disease and symptoms that limit daily activity
(NYHA III/IV or stage D)
 300,000 to 800,000 advance HF patients in US
 20% stage D patients are younger than 65yrs- that is at
least 60,000 patients
 Cardiac transplantation provides increased longevity and
symptomatic relief
 Only 2200 organ donors in US
 Mechanical circulatory support with LVADs is a rapidly
evolving field and is a life saving therapy for patients
with advanced heart failure
Advanced HF therapy
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 Transplant- When conventional medical therapies
are unsuccessful, cardiac transplantation is an option
for treatment and to prolong life. Unfortunately, only
2200 patients each year receive heart transplants,
because the number of patients awaiting transplants
far exceeds the number of organs available.
 Mechanical Circulatory support
Listing criteria for Heart
transplantation
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 Cardiopulmonary exercise testing: VO2 max
<14ml/kg/min if patients intolerant to BB;
<12ml/kg/min in the presence of BB; or <50% of
predicted VO2 in young patients (<50yrs) and
women.
 Acceptable pulmonary artery pressure
 Age <70
 Diabetes well controlled
 Absence on neoplasm
 Psychosocial support
MCS Applications
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 Bridge to transplantation
 Bridge to decision
 Destination therapy
 Bridge to recovery
MCS landmark Study
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 REMATCH (The Randomized Evaluation of
Mechanical Assistance for the Treatment of
Congestive Heart Failure) trial was the landmark
study that approved the benefit of mechanical
support for patients with end stage HF.
 LVAD group showed significant improvement in
survival and quality of life
Indication for BTT
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 Non-reversible systolic HF- NYHA class IV
 Inotropic support, if tolerated
 No contraindication for listing as status 1A or status
1B meet the following
- Pulmonary capillary wedge pressure (PCWP) or pulmonary
artery diastolic pressure (PAD) >20 mm Hg
- Cardiac index < 2.2L/min/m or SBP <90 mm Hg
 Body surface area >1.2m
Indication for DT
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 Advanced HF symptoms (class IIIB or IV) with one of the
following:
- On optimal management, but failing to respond
- Class III or IV HF and dependent on IABP and/or
inotropes
- Intolerant to ACE/ARB or BB
 Body surface are (BSA) >1.2 m
 Ineligible for cardiac transplant
 VO2 max <14ml/kg/min or <50% predicted VO2 max
 LVEF <25%
Exclusion Criteria
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 Active systemic infection
 Uncorrectable aortic insufficiency
 Renal insufficiency that may require dialysis in the
near future
 History of cardiac transplant
 Any condition, other than heart failure, which is
expected to limit survival to less than 2 years
Pre-op MCS evaluation
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 Assessment of RV
function
 Nutrition
 Hemodynamics
 Renal function
 Gastrointestinal
 Hepatic function
 Hematology
 Coagulation
 Peripheral vascular
disease
 Pulmonary function
 Infection
 Neurologic
 Psychosocial
 Psychiatric
MCS candidacy
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 MCS pre-op evaluation data is presented to a
multidisciplinary team and the candidacy s
determined by the team.
Types of Devices
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 Short-term MCS: intended to support a patient with
acute decompensated HF until patient recovers or
until further long-term therapy is indicated based on
recovery of end-organ function. Usually for few hour
to days to less than 2wks.
 Long-term MCS
Types of Long-term MCS
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 Left ventricular assist device (LVAD)
 Biventricular support (BiVAD)
 Total artificial heart (TAH)
Biventricular support
(BiVAD)
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 Thoratec Paracorporeal VAD (P-VAD) – BTT- for
patients with severe biventricular failure
Total artificial heart (TAH)
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 Syncardia TAH – BTT- for patients with severe
biventricular failure
Evolution of Devices
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 1st generation- Pulsatile positive displacement
pumps- HeartMate XVE and Thoratec paracorporeal
ventricular assist device (PVAD)
 2nd generation: Continuous flow axial blood pump
with an internal rotor- HeartMate II LVAD
 Third generation- currently in development
First generation pumps:
HeartMate XVE
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Second generation pumps:
HeartMate II
 HeartMate II is
currently FDA
approved for BTT and
DT
 Axial-flow, rotary
ventricular assist
system
 Capable of flows up
to 10 liters per minute
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HeartMate II
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 High Speed Rotary
 Long Life
 Small
 Flexible Driveline
 Quiet
 Valveless
 Textured Blood
Contacting Surface
 Cost Effective
HeartMate II
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Outflow
Cannula
Inflow
Cannula
Bend
Relief
Percutaneous
Cable
Connection
Blood
Pump
Flex
Section
HeartMate II
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Flow
Outflow
Stator
Inflow
Stator
Rotor
Outflow
Bearings
Inflow
Bearings
HeartMate II
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HeartMate II
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More than 13,000 patients worldwide
have now been
®
implanted with the HeartMate II LVAS.
Over 5,500 patients on ongoing support
Patients supported ≥ 1 year: 1,576
Patients supported ≥ 2 years: 883
Patients supported ≥ 3 years: 412
Patients supported ≥ 4 years: 161
Patients supported ≥ 5 years: 121
Patients supported ≥ 6 years: 26
Patients supported ≥ 7 years: 11
Patients supported ≥ 8 years: 1
HM II system Controller
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Microprocessor that:
Delivers power to the pump
Controls pump speed and power
Monitors, interprets & responds
to system performance
Performs diagnostic monitoring
Indicates hazard and advisory
alarms
Provides complete backup system
Automatic event recording
Data logger capabilities
Common HM II Externals
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Power sources
 - Power Module
- Batteries
System Monitor
Display Module
Battery Charger
HM II Post-op period
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 ICU stay- 3-5 days
 IMC/Tele- 7-14 days
 Rehab- some patients will need inpatient rehab
Post-op period
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 Extensive patient and family education regarding
equipment handling and driveline exit site dressing
change
 Patient completes 7 modules and signs contracts of
commitment and understanding
 Aggressive PT/OT/Cardiac rehab
 Stabilize INR
 Dietary monitoring
 Set up home health if needed
 Discharge planning for community training
HeartMate II
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 The HeartMate II is continuous flow, therefore you
may not feel a pulse
 Heart rate- only detectable by telemetry- there may
not be a palpable pulse!
 Blood pressure- may or may not be detected with
automatic BP cuff
 Arterial line monitoring or Doppler
 At each office visit check mean BP by Doppler
 Goal blood pressure is 70-90mmHg
Transportation/Ambulation
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 Change patient to
batteries
 Take the black bag,
which includes:
 Charged batteriesminimum of one pair
 Backup system
controller
 Disposable
stethoscope
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Activity instructions
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Many patients will need inpatient rehab
Sternal precaution for 3 months
No driving for 3 months
No shower for 3 months
No lifting over 5-10lbs for 2 months; then gradually
increasing
Encourage regular exercise but avoid very strenuous
exercise
Encourage patients get back to their regular hobbies
No swimming or water aerobics
Battery and controller should be secured well at all times
Anti-Coagulation
Guidelines
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 Medications
 Aspirin – prevents platelet aggregation
 Persantine – prevents platelet aggregation
 Plavix/Effient- occasionally used for platelet
inhibition
 Antiplatelets are adjusted based thromboelastography (TEG)
 Coumadin- required, goal INR depends on patients
underlying comorbidities
Complication
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 Bleeding
 Pump thrombus/Hemolysis
 Infection
 Stroke- Ischemic or hemorrhagic
 Right hear failure- usually immediate post-op period
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