Heartware HVAD Ventricular Assist System Last edited 9/12/13

About the Pump Miniaturized circulatory support system for treatment of advanced heart failure Can achieve up to 10L/min cardiac output Designed to be placed only in pericardium, no abdominal access as in competitors FDA approved Utilized as “Bridge to Transplantation” and as “Destination Therapy” Last edited 11/28/12

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Cannulation The inflow cannula is housed within the Pump Helps decrease pump size Patient is cannulated in LV apex and Ascending AO Last edited 11/28/12

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Always defaults to AC/DC power supply if that is plugged in Last edited 11/28/12

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HeartWare®Back-up Controller Keep a back-up controller and extra fully charged batteries with the patient at all times in case of an emergency Verify that the back-up controller parameters match the primary controller parameters verify by looking at the settings sticker on the backside of the back-up controller Alarm parameters should be documented on sticker and updated when changed MD to update sticker when any changes to settings made The back-up controller should be programmed before the implant procedure, upon any parameter change to the primary controller, and when the primary controller is replaced Done by MD and documented in note Last edited 11/28/12

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Only use bags provided from vendor Last edited 11/28/12

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This will be spot checked on 8E This will be spot checked on 8E. Patient does not go home with this monitor. Last edited 11/28/12

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This does not shut down the device Last edited 11/28/12

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Parameters Monitored Speed = RPMs Work = Watts Flow = Cardiac Output Normal 2400-3200 (capable of 1800-4000) Set rate by MD Measured number Work = Watts Measured Number 2.5-7.0 Alarm should be set 2 greater than what patient is running at Flow = Cardiac Output Calculated Number ( roughly Speed + work + HCT) Responsible that HCT programmed in device is within 5 of patients current HCT Alarm should be set 2L/min lower than patient current CO, but never less than 2 L/min Should be >2 L/min Last edited 11/28/12

Management post-operatively and beyond Control hypertension –maintain MAP < 90mmHg*** Continuous flow pumps are preload dependent and sensitive to increased afterload. ALWAYS : Consider clinical (patient) related changes when assessing changes in pump flow Fluids are given to maintain pump flow index at greater than 2.0 L/min/m2 with central venous pressure and left atrial pressure less than 20 mmHg Vasopressors and/or vasodilators can be used as required to adjust vascular tone Patients may require inotropic assistance of right ventricular function Last edited 11/28/12

Daily Care Essentials Always ensure that the controller is plugged into two power sources (red outlet on wall + battery or 2 batteries) A backup controller, programmed to the patient’s current settings, should always be available. Sticker on back of backup controller with patient information (MR, DOB) and settings Batteries should be changed when the battery shows 1 bar left (~25% battery life). Obtaining a blood pressure Continuous flow device, based on native function, may not have pulsatility BP obtained via art line tracing or with Doppler + manual cuff Doppler at brachial pulse to hear continuous flow Inflate cuff around upper arm Pressure at which you first hear flow = approximate MAP Can attempt BP with automated cuff but must confirm with doppler/manual Attempt pleth measurement if pt has pulsatility RVAD and BiVAD: Never open venous lines directly to air No trips to MRI! Listen & document heart sounds every shift Notify MD if changes noted Device is preload-driven: Consider potential causes for decreased preload: Tamponade Hypovolemia Changes in intrathoracic pressure Increased PVR R heart failure Device is afterload-sensitive, consider potential causes for increased afterload Pulmonary vs. systemic hypertension Consider afterload reduction, pulmonary vasodilators, analgesia/sedation Mobilize pt ASAP  Last edited 11/28/12

Nursing considerations Notify MD of suction events, even if intermittent Check Alarm Limits (on sticker; changed by MD in system) High Power alarm 2 watts above average power Low flow alarm 2L/min below average flow (minimum set 2L/min) Assure correct HCT is programmed for CO calculation Last edited 11/28/12

Arrhythmias/Emergency Procedures Arrhythmias may occur in the post-operative period OK to defibrillate HeartWare® System patients Anti-arrhythmic drugs, pacemakers, and ICDs are compatible with the HeartWare System Institute appropriate PALS/ACLS protocols If chest compressions have been administered, confirm function and positioning of HVAD® pump Last edited 11/28/12

Anticoagulation Anticoagulation should be individualized for each patient In general, begin low-dose heparin at 10 units/kg/hr on postoperative day one target PTT of 50-60 seconds Heparin gtt to be freshly made by Pharmacy and changed Q12 hours As patients tolerate oral medication, they should be started on warfarin and aspirin Warfarin should be titrated to maintain the INR of 1.7 to 3 Discontinue heparin when the INR is in therapeutic range. Use low dose Other Labs: Unfractionated heparin levels (0.35-0.5) PTT TEG ATIII Last edited 11/28/12

Dressing Care Good hand-washing technique Always use sterile technique: hats, masks & sterile gloves Initially daily and prn if saturated After 1 week, QOD and prn After 14 days, 2 x per week and prn Dressing: Cleanse site & surrounding tissue with chlorhexidine 2% wand Place 2 x 2 gauze over site & cover any area on drive line with exposed velour coating with gauze (tegaderm that is placed directly on velour coating is a significant infection risk) Cover with tegaderm & date dressing Securement device needed for drive line Document in Powerchart Last edited 11/28/12

Performs safety checks for Heartware system At bedside Back up controller programmed with current patient’s settings Battery charger with back up batteries charging and labeled Doppler and manual BP cuff In Cardiac Storage room, 3rd floor, OR Surgical Back-up equipment Drive line extension cable Outflow graft for pump Another pump Necessary surgical insertion tools 2 monitors 4 batteries and battery charger 2 controllers 2 AC adapters Another patient pack (Velcro holder) Last edited 11/28/12

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Trouble shooting Page “LVAD” for heart failure team www.heartware.com cs@heartwearinc.com Heartware 205 Newbury Street, Suite 101 Framingham, MA 01701 24- Hour Clinical Support 888.494.6365 Last edited 11/28/12