1. Mechanical Circulatory Support for Advanced Heart Failure Speakers: Lynne A Benish, ACNP-BC Mechanical Assist Device Nurse Practitioner, Cardiac Surgery Yesabel Bustos, RN, CCRN VAD Coordinator

2. Objectives  Overview of End-Stage Heart Failure  Treatments for End Stage Heart Failure  Heart Transplantation  Mechanical Circulatory Support

3. What is Heart Failure?  Physiologic state in which cardiac output is insufficient in meeting the needs of the body Can involve the left side, right side or both sides Typically, begins in left side since left ventricle is the main pumping chamber  Chronic, progressive disease.  Not curable, but treatable.  Broadly defined as a clinical syndrome characterized by dyspnea and fatigue, at rest or with exertion, diminished quality of life, and shortened life expectancy. 3

4. Heart Failure Prevalence and Incidence  Incidence in the U.S. 5.7 million  More than 280,000 patients die of heart failure in the US each year 2 nd highest mortality at one year with optimal medical management  More than 600,000 new cases are diagnosed each year in the United States.  Patients that have advanced end-stage heart failure are characterized by: - frequent hospitalizations - reduced quality of life - a complex therapeutic regimen, and a high mortality rate  Heart failure costs the nation an estimated $32 billion each year. This total includes the cost of health care services, medications to treat heart failure, and missed days of work.

6. Causes of Heart Failure  Most common  Coronary Artery Disease  Hypertension  Diabetes  Cardiomyopathy-(disease of the heart muscle)  Heart Valve Disease  Arrhythmias  Congenital  Treatments for cancer-radiation and chemotherapy  Alcohol abuse or cocaine and other illicit drug use

8. Medical Treatment Options for Advanced Heart Failure  Optimal Medical Therapy  Beta Blockers, ACE Inhibitors, ARBs, Aldosterone Antagonists, Diuretic Therapy, Oral Nitrates and Hydralazine, etc.  Electrophysiologic Testing and the Use of Devices in Heart Failure  Prophylactic ICD Placement  Bi-ventricular Resynchronization Pacing 8

9. Cardiac Transplantation: The “Gold Standard”  Remains the most effective treatment for end-stage heart disease, although donor shortage limits it use  Approximately 2,000 hearts are available each year 1-year survival: 85% 5-year survival: 71% 10-year survival: 46% 9 Surgical Interventions for End-Stage Heart Failure

10. Contraindications for Cardiac Transplantation 10 GeneralSpecificRelative  Any condition limiting a successful transplant outcome, i.e. non- compliance, lack of social support.  Elevated pulmonary vascular resistance  Active infection  Renal or pulmonary disease  Diabetes with end-organ damage  Cross-match incompatibility  Active psychiatric disease  Substance abuse  Smoking  Age  Peripheral vascular disease  Malignancy  Size/Obesity

11. Surgical Intervention for End-Stage Heart Failure Ventricular Assist Device  A ventricular assist device (VAD) is an implantable device designed to partially replace the function of the failing heart, restoring circulation of blood flow to the body through mechanical circulatory support.  Decreases cardiac workload  Increases systemic circulation & tissue perfusion  Decreases preload  VADs are designed to assist the right (RVAD) or left (LVAD) ventricle, or both at once (Bi- VAD). The type of VAD used depends on the underlying heart disease and the pulmonary arterial resistance that determines the load on the right ventricle. 11

12. Indications  Bridge to Transplant (BTT)  Must be UNOS listed at time of implant  Destination Therapy  Permanent support for those ineligible for heart transplant  Some may convert to BTT  Bridge to Decision/Bridge to Recovery  Patients with acute cardiac failure with the anticipation of recovery of their native heart function (i.e. cardiogenic shock)  Post-cardiotomy patients with failure to wean from bypass 12

13. 13 The Implantable Heart Pump: LVAD

14. How does an LVAD work?  LVADs are implanted through open-heart surgery.  Unlike a pacemaker or defibrillator, the pump is powered by a controller and batteries that are outside of the body.  The VAD acts like a bypass for the weak ventricle. It continuously sucks blood out from the left ventricle and into the pump, where it is then pushed through the outflow graft that is connected to the ascending aorta.

16. Most Common Implantable LVADs on the Market  Thoratec HeartMate II FDA approved for BTT and Destination Therapy Approved for Destination Therapy in 2010  HeartWare HVAD Can be used as an RVAD & LVAD Only for BTT indication

17. HMII vs. HVAD

18. HMII patient vs. HVAD patient

19. HMII equipment vs. HVAD equipment

20. Patient Selection for Destination Therapy: CMS Requirements  New York Heart Association (NYHA) Functional Class IV  Failure to respond to optimal medical management (including beta- blockers, ACE inhibitors, if tolerated) for at least 45 of 60 days,  or IABP dependent for 7 days  or IV inotrope dependent for 14 days and  Left Ventricular Ejection Fraction ≤ 25%  Peak VO2 < 14 ml/kg/min (If able to participate in test)  Ineligible for heart transplant 20

21. Multidisciplinary Team and Selection Committee  Cardiac Surgeon  Heart Failure/Transplant Cardiologist  Pulmonary Critical Care/ Infectious Disease  VAD Nurse Practitioner/Physician Assistant  VAD Coordinator RN  Transplant Coordinator RN  Social Worker  Finance  Nutritionist  Psychiatrist  Pharmacist  Physical Therapy/ Occupational Therapy 21

22. Blood Pressure  Due to the continuous flow of the LVAD, most patients are what we call “non-pulsatile”.  MAP vs. Systolic/Diastolic  Most accurate measure of blood pressure is obtained by:  Doppler and manual cuff  Arterial line  DO NOT rely on automatic/non-invasive blood pressure cuffs!  Typical MAP goal is 65-85 Forget What You Know: Physical Assessment

23. Heart Rate  These patients typically do not have a palpable pulse, as the aortic valve does not always open and close.  Most accurate measure of heart rate is obtained by: -12-Lead EKG -Telemetry rhythm strip  DO NOT rely on pulse oximetry for measure of heart rate!

24. Special Nursing Considerations VAD Driveline  The “driveline” is the percutaneous cord that connects to the patient’s external controller. This powers the pump internally.  All patients must have their driveline covered by a “dressing” at all times. The VAD/driveline exit dressing is specific to the patient’s implanting center.

25. Special Nursing Considerations VAD Driveline  It is important for the patient and health care practitioners to assess the external driveline and power cords for damage on a routine basis.  Most common complications are: -Driveline related infection (can lead to bacteremia and sepsis) -Wear and tear of driveline (can lead to pump malfunction or death)

26. Special Nursing Considerations Anticoagulation  LVAD patients must be anticoagulated with Warfarin (Coumadin) and enteric-coated aspirin. No other anticoagulants have been approved for use in LVAD patients at this time.  INR goals are patient specific but typically range anywhere from 1.5-3.0.  Most frequent complications are: GI bleeding Epistaxis CVA

27. Forget What You Know: Arrhythmias  LVAD patients can maintain perfusion even in the presence of VT/VF. The patient may even be walking and talking.  However, arrhythmias must be treated as the patient will eventually decompensate.  Can be cardioverted or defibrillated

28.  LVAD patients are volume sensitive, especially those with right ventricular dysfunction and/or aortic insufficiency.  Take caution with fluid resuscitation, even in the presence of sepsis.  Aggressive volume resuscitation can cause the patient to go into heart failure/respiratory distress. Forget What You Know: Fluid/Volume Imbalance

29. Emergency Equipment  All VAD patients have a black emergency travel bag that should be with patient at all times!  Bag should contain back up controller, batteries, battery clips, EMS/alarm guide. Never Leave Home Without It!

30. Can you perform CPR on a patient with an LVAD? Yes, but DO NOT perform chest compressions.  May treat with ACLS medications, cardioversion, defibrillation  Notify and transfer patient to implanting VAD center when stable!

31.  Non urgent: Contact outpatient VAD Clinic  Urgent: Contact VAD Hospital to speak with Transfer Center  All health care members are permitted to contact us for a consult.  Only a VAD team member can determine if a patient is an eligible candidate. Advanced Heart Therapy Consults