Transcript 2013 VAD Lecture Rehab Final Without Pics (Powerpoint)

Ventricular Assist Device (VAD)
Patients in the Community
Liz Amerman, RN, BSN
IU Health Methodist
VAD Program Manager
April 18, 2012
3/26/2016
1
Learning Objectives
 Discuss available ventricular assist devices
for home use
 Review clinical indications for placement
of ventricular assist devices
 Understand VAD patient care requirements
in the home environment
 Case studies
3/26/2016
2
Heart Failure in the US
• Heart failure accounts for 34% of cardiovascular-related deaths
• 670,000 new cases of heart failure are diagnosed in the US every
year
• 277,000 deaths are caused by heart failure each year
• Heart failure is the most frequent cause of hospitalization in
patients older than 65 years, with an annual incidence of 10 per
1,000
• Rehospitalization rates during the 6 months following discharge are
as much as 50%
• 2010 estimated total cost of heart failure in US $39.2 billion,
representing 1-2% of all health care expenditures
3/26/2016
3
Disease Progression
Jessup, NEJM 2003
3/26/2016
4
Heart Transplants in US
3/26/2016
5
Volume of VAD Patients
Year
2012
Patient Volume
34
BTT
12
BTD
4
DT
Device Types
22
29 HM II, 5 Heartware,
4 Abiomed
Replaced 2 HM II
2011
27
11
0
16
20 HM II, 5 Heartware,
2 Thoratec, 1 Abiomed
1 patient had a HM II and Abiomed
2010
2009
31
32
18
17
4
11
9
(1 replaced)
4
(2 replaced)
19 HMII; 4 Heart Ware;
3 L P/I-VAD, 5 Abiomed
17 HMII, 15 Abiomed,
1 Thoratec
1 patient had a HM II and Abiomed
Additional Device Implants:
2012: 19 - 2 TandemHearts, 17 Impella ( 10 – 5.0, 7 – 2.5)
2011: 7 Impella and 3 TandemHeart
2010: 4 Impella
We had a total of 52 patients and 57 devices for 2012
3/26/2016
6
Defining A Ventricular Assist Device
• A VAD is designed to
circulate the blood in the
pulmonary and/or systemic
circulation when the natural
heart is unable to maintain
normal blood flows and
pressures.
3/26/2016
7
3/26/2016
8
Indications for Use
• Bridge to Recovery/Decision (BTR/BTD)
– Postcardiotomy Shock
– Acute MI
– Cardiac Disorders such as Viral Myocarditis
• Bridge to Transplant (BTT)
– Cardiomyopathies
– Failed Cardiac Transplant
• Destination Therapy (DT)– improve quality of life
when not a transplant candidate
3/26/2016
9
Contraindications for VAD
• Central Nervous System damage
before or during operative procedure
• Body Surface Area (BSA)
< 1.2m² for some assist devices
3/26/2016
10
Criteria Evaluated Before Getting A VAD
•Physical and psychosocial evaluation
•Good support group
•BTT requirements
•DT requirements
•Pre-VAD meeting with the VAD team
•Presented to Advance Heart Failure Board for
acceptance
Not everyone can get a VAD!!
3/26/2016
11
Choosing the appropriate VAD

Does the patient need a
Left, Right, or Biventricular
Assist Device.

Size of the patient.

Short or long term use
needed.

What hospital the
patient is in.
3/26/2016
12
Types of VAD’s
• Abiomed
• Thoratec – IVAD and PVAD
• HeartMate – XVE and HM II
• HeartWare
3/26/2016
13
Abiomed
 Left, Right, or Biventricular
 Short term use - months
 Patient size irrelevant
 Bridge to Recovery
 Bridge to Transplant
 NOT for Destination Therapy
 Outlying hospitals can
implant emergently
– Patient then transferred to
Methodist by Lifeline
3/26/2016
14
Thoratec – PVAD or IVAD
 Left, Right, or Biventricular
support
 Short or long term use
 Patient size irrelevant
 Bridge to Recovery
 Bridge to Transplant
 NOT for Destination Therapy
Implantable or Paracorpeal
3/26/2016
15
Thoratec
3/26/2016
16
HeartMate XVE and II
 Left ventricular assist
device only
 Long term use
 BSA must be >1.2 for HM
II and >1.5 for HM XVE
Pulsatile or axial flow
 Bridge to transplant
 Destination therapy
3/26/2016
17
HeartMate XVE
3/26/2016
18
HeartMate II
3/26/2016
19
Heartware





Left ventricular assist
device only
Long term use
BSA must be >1.2
Centrifugal pump
Bridge to transplant
 Destination therapy
3/26/2016
20
HeartWare
3/26/2016
21
Blood Pump Differences
Thoratec/Abiomed
• Pulsatile pump
• Valves allowing
unidirectional flow
• Vacuum assist filling
• Asynchronous pulsatile VAD
• Need to start anticoagulation
earlier
3/26/2016
HeartMate/Heartware
Continuous flow pump
Valveless
Afterload sensitive –
retrograde flow
Follows native pulse
Pump output varies over
cardiac cycle
22
Comparison of Pulsatile and Axial Flow
20
15
10
5
0
-5
-10
30
Pump speed = 10,000 RPM
25
Outflow (L/min)
Outflow (L/min)
30
25
20
15
10
5
0
-5
-10
(Both have average flow between 4-5 L/min)
3/26/2016
23
Pump Rotor and Stators
Flow
Outflow
Stator
3/26/2016
Rotor
Outflow
Bearings
Inflow
Stator
Inflow
Bearings
24
HeartMate II
Rotor Magnet
Rotor
Bearings
Blood pump rotor is
the only moving part
Rotor spins on
blood –lubricated
bearings designed for
long life
Inlet Stator
Outlet Stator
3/26/2016
Motor Winding
25
What it takes to get a patient home!
•Recovery
•Education
•Excursions
•Discharge – home environment
3/26/2016
26
Recovery
• Hemodynamic stability
• Nitric Oxide or Flolan
• Dobutrex or Milrinone
• Cardiac Tamponade
• Anticoagulation
• Pain management
• Infection
3/26/2016
27
What it takes to get a patient home!
•Education Process
–Driveline Dressing change
–Learning the VAD
–Alarms and troubleshooting VAD
–Handling an emergency
–Excursions
3/26/2016
28
Daily Checks
 Recording VAD settings
 Monitoring trends
 Assessing preload and afterload
 Alarm tests
 Dressing change
 Monthly assessing VAD equipment
for any problems – i.e.- exposed wires
3/26/2016
29
Emergency Resources
•Advance Heart Care Clinic has 24/7 on
call
•Local ER
•Fire station
•Electric company
•Caregiver/Ambulance/Lifeline transfer
if needed
3/26/2016
30
Emergency Situations
• Assess patient and VAD monitor
• Check connections
• OK to intubate, defibrillate, and give
medications
• If need to defibrillate NO disconnection
required
• Can DO chest compressions if you cant
get pump running
• Close monitoring of fluid status and MAP
Down the line……
• Right Heart Failure
• Debilitation
• Cardiac Arrhythmias
• Device Failure
• Co-Morbidities
• Infection
• Hospice/End of Life
• Cost
3/26/2016
32
3/26/2016
33
A Successful VAD Program
• MD’s – Surgeon and Cardiologist
• VAD Coordinator
• Nurse Practitioners
• Social Worker
• Bedside Nurse
• Pharmacist
• Dietician
• Respiratory Therapist
• Physical and Occupational Therapist
• Transplant Coordinators
• Research Nurse’s
• Chaplin
3/26/2016
34
Survival Rates June 2006-Q4 2012
n=158
IU Health
Pagani
INTERMACS
*Patient survival post implant
Kaplan-Meier Survival Analysis
Pagani et. al, JACC, 2009
3/26/2016
35
Survival Rates 2011-2012
n = 60
IU Health
Pagani
INTERMACS
*Patient survival post implant
Kaplan-Meier Survival Analysis
Pagani et. al, JACC, 2009
3/26/2016
36
New York Heart Association
NYHA Class
I
No symptoms and no limitation in ordinary physical activity,
e.g. shortness of breath when walking, climbing stairs etc
II
Mild symptoms (mild shortness of breath and/or angina)
and slight limitation during ordinary activity.
III
Marked limitation in activity due to symptoms, even during
less-than-ordinary activity, e.g. walking short distances
(20–100 m).
Comfortable only at rest.
Severe limitations. Experiences symptoms even while at
rest. Mostly bedbound patients.
IV
3/26/2016
Symptoms
37
Quality of Life
Functional status six months post-implant
NYHA Class assessed for every patient at 6 month visit
June 2011 – June 2012, n=25*
Class I 17 patients 68%
Class II 6 patients
24%
Class III 2 patients
8%
92%
Class IV
*All patients are Class III or IV before VAD implantation
32 Patients evaluated
25 patients reached 6 months
7 patients NOT Included. 4 deceased, 1 transferred care and 2 transplanted.
Benchmark: NYHA Class I & II = 89% at 6 months
3/26/2016
Pagani et. al, JACC, 2009
Data Source: MCCM
38
References
"Advanced Practice Guidelines for HeartMate Destination Therapy." Guidelines 2(2004):
1-38.
American Heart Association (2009). Heart disease and stroke statistics 2009 update at a glance
(Our guide to current statistics and the supplement to our heart and stroke facts). Retrieved January 2009
from http://wwwamericanheart.org.
Thoratec Corporation, "Your Guide to Successful LVAS Patient Discharge." HeartMate
Left Ventricular Assist System (LVAS) Community Living Manual. 1st Ed. 2004.
United Network For Organ Sharing (2011). Heart transplant statistics for 2011. Retrieved February 2012
http://www.unos.org
Mariell Jessup, M.D., and Susan Brozena, M.D. Heart Failure. N Engl J Med 2003; 348:2007-2018 May 15, 2003
3/26/2016
39
To Learn More About VAD’s
• www.abiomed.com
• www.thoratec.com
• www.americanheartassociation.org
• www.heartcenteronline.com
• www.optn.org
• www.healthatoz.com
• www.nlm.nih.gov
3/26/2016
40