Managing the LVAD patient in Cardiac Rehabilitation 2012 NWCVPR Annual Conference MultiCare Health System Tacoma General Hospital Cardiac Health and Rehabilitation Program

Enrolling the LVAD Patient Start program 6+ weeks after hospital discharge Talk with VAD Coordinator prior to contacting patient Typical diagnosis for reimbursement Tricuspid Valve Annuloplasty – v43.3 May have CAD co-morbidity

Program Overview Intake Interview – RN 1:1 Exercise Evaluation – CES Montana Outcomes Minnesota Living with Heart Failure® Questionnaire (VAD study) 1:1 Exercise Evaluation – CES 6 Minute Walk Test (VAD study) – potential for separate billing Exercise Equipment Orientation Exercise Prescription Monitored Exercise and Education Classes ECG monitoring – typically PACED Case management – risk factor /lifestyle modification Exercise tolerance – heart failure patient No blood pressure readings

Program Considerations Measurement of specific parameters (signs and symptoms, functional limitations, quality of life) determine specific patient benefit and overall program outcomes assess and treat as heart failure patient Help monitor overall medical plan optimization of medication use monitoring of daily weights compliance with sodium restriction surveillance for potential exacerbations Education program designed for heart failure patients Report signs and symptoms of infection (area of drive insertion)

Exercise Training Considerations Cycling should be assessed for on an individual basis because of the location of the external drive Hip flexion may be somewhat limited – important to include activities that prevent disuse and to facilitate the return to functional activities Symptoms of lightheadedness or dizziness Device has internal sensor that increases flow rate as needed during exercise, sensor may fail, can be manually increased Symptom limited exercise

LVAD Function with Exercise LVAD rate can increase automatically as the device senses the volume of blood in the pump chamber, or rate may be controlled manually The native left ventricle (LV) continues to contract during LVAD function Rest – LVAD contributes virtually all the cardiac output Exercise – native LV contributes varying amount of the total cardiac output Degree of LV contribution is dependant upon degree of LV dysfunction

Our Experience at Tacoma General Hospital In-service from VAD Coordinator prior to enrolling patients Developed emergency procedure (modified Sacred Heart’s) First Patient in October 2009 5 total patients 3 Medicare, 2 Medicaid 4 completed program, 1 current patient

Emergency Procedures – Heartmate II RED HEART DEVICE IS RUNNING Call CT Surgeon on call Page VAD Coordinator Treat Arrythmia Fluid Resuscitate DEVICE HAS STOPPED CHECK CONNECTIONS DO NOT CONNECT to Power Base Unit Replace Controller at direction of Surgeon or VAD Coordinator Leave Device Alone Assess/Treat Patient (Volume, Rhythm, HTN Obstruction: inflow/outflow) IF TIGHT

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