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Susan George, APRN- CNP, CCNS, CCRN, CHFN. Epidemiology of Heart Failure 6 More deaths from heart failure (HF )than from all forms of cancer combined.

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Presentation on theme: "Susan George, APRN- CNP, CCNS, CCRN, CHFN. Epidemiology of Heart Failure 6 More deaths from heart failure (HF )than from all forms of cancer combined."— Presentation transcript:

1 Susan George, APRN- CNP, CCNS, CCRN, CHFN

2 Epidemiology of Heart Failure 6 More deaths from heart failure (HF )than from all forms of cancer combined 4.9 million symptomatic patients; estimated 10 million in 2037 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 Heart Failure Patients in US (millions)

3 Heart Disease and Stroke Statistics2012 Update Prevalence of HF

4 Heart Disease and Stroke Statistics2012 Update Hospital discharges for HF

5 Medicare Expenditures for Heart Failure

6 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 Definition of HF

7 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. HF: Systolic v. Diastolic

8 Functional classification: NYHA class (I-IV) Staging of HF: ACC/AHA stages (A,B,C,D) Classification of Heart Failure

9 ACC/AHA staging of HF NEJM. 2003;Volume 348:

10 Life style modification Medications Electrical Therapy Advanced HF therapy - Transplant/ Mechanical circulatory support (MCS). Management of HF

11 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 Heart failure and exercise intolerance

12 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

13 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 Effects of exercise training in HF

14 Advanced/End Stage HF Patient Severe exercise intolerance Heart failure wasting syndrome Cardiorenal syndrome Right heart failure Inotrope dependence

15 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/End Stage HF

16 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 Advanced HF therapy

17 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 Listing criteria for Heart transplantation

18 Bridge to transplantation Bridge to decision Destination therapy Bridge to recovery MCS Applications

19 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 MCS landmark Study

20 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 BTT

21 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% Indication for DT

22 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 Exclusion Criteria

23 Pre-op MCS evaluation Assessment of RV function Nutrition Hemodynamics Renal function Gastrointestinal Hepatic function Hematology Coagulation Peripheral vascular disease Pulmonary function Infection Neurologic Psychosocial Psychiatric

24 MCS pre-op evaluation data is presented to a multidisciplinary team and the candidacy s determined by the team. MCS candidacy

25 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 Devices

26 Left ventricular assist device (LVAD) Biventricular support (BiVAD) Total artificial heart (TAH) Types of Long-term MCS

27 Thoratec Paracorporeal VAD (P-VAD) – BTT- for patients with severe biventricular failure Biventricular support (BiVAD )

28 Syncardia TAH – BTT- for patients with severe biventricular failure Total artificial heart (TAH)

29 1 st generation- Pulsatile positive displacement pumps- HeartMate XVE and Thoratec paracorporeal ventricular assist device (PVAD) 2 nd generation: Continuous flow axial blood pump with an internal rotor- HeartMate II LVAD Third generation- currently in development Evolution of Devices

30 First generation pumps: HeartMate XVE

31 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

32 HeartMate II High Speed Rotary Long Life Small Flexible Driveline Quiet Valveless Textured Blood Contacting Surface Cost Effective

33 1 HeartMate II Percutaneous Cable Connection Bend Relief Outflow Cannula Blood Pump Flex Section Inflow Cannula

34 HeartMate II Flow Outflow Stator Outflow Bearings Rotor Inflow Bearings Inflow Stator

35 HeartMate II

36 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 HeartMate II

37 HM II system Controller 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

38 Power sources - Power Module - Batteries System Monitor Display Module Battery Charger Common HM II Externals

39 ICU stay- 3-5 days IMC/Tele days Rehab- some patients will need inpatient rehab HM II Post-op period

40 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 Post-op period

41 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 HeartMate II

42 Transportation/Ambulation Change patient to batteries Take the black bag, which includes: Charged batteries- minimum of one pair Backup system controller Disposable stethoscope

43 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 Activity instructions

44 Medications Aspirin – prevents platelet aggregation Persantine – prevents platelet aggregation Plavix/Effient- occasionally used for platelet inhibition Antiplatelets are adjusted based thrombo- elastography (TEG) Coumadin- required, goal INR depends on patients underlying comorbidities Anti-Coagulation Guidelines

45 Bleeding Pump thrombus/Hemolysis Infection Stroke- Ischemic or hemorrhagic Right hear failure- usually immediate post-op period Complication


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