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Ventricular Assist Device (VAD) Patients Ventricular Assist Device (VAD) Patients in the Communityin the Community

Liz Amerman, RN, BSNIU Health Methodist

VAD Program ManagerApril 18, 2012

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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

Learning ObjectivesLearning Objectives

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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

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Disease Progression

Jessup, NEJM 2003

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Heart Transplants in US

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Volume of VAD Patients

Year Patient Volume BTT BTD DT Device Types

2012 34 12 4 2229 HM II, 5 Heartware,

4 AbiomedReplaced 2 HM II

2011 27 11 0 1620 HM II, 5 Heartware,

2 Thoratec, 1 Abiomed 1 patient had a HM II and Abiomed

2010 31 18 49(1

replaced)

19 HMII; 4 Heart Ware; 3 L P/I-VAD, 5 Abiomed

2009 32 17 114(2

replaced)

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

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• 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.

Defining A Ventricular Assist DeviceDefining A Ventricular Assist Device

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• 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

Indications for UseIndications for Use

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• Central Nervous System damage

before or during operative procedure

• Body Surface Area (BSA)

< 1.2m² for some assist devices

Contraindications for VADContraindications for VAD

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Not everyone can get a VAD!!Not everyone can get 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

Criteria Evaluated Before Getting A VAD

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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.

Choosing the appropriate VADChoosing the appropriate VAD

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• Abiomed

• Thoratec – IVAD and PVAD

• HeartMate – XVE and HM II

• HeartWare

Types of VAD’sTypes of VAD’s

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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

AbiomedAbiomed

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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

Thoratec – PVAD or IVADThoratec – PVAD or IVAD

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Thoratec

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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

HeartMate XVE and IIHeartMate XVE and II

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HeartMate XVEHeartMate XVE

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HeartMate IIHeartMate II

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Left ventricular assist device only

Long term use BSA must be >1.2 Centrifugal pump Bridge to transplant

Destination therapy

HeartwareHeartware

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HeartWareHeartWare

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Blood Pump Differences

Thoratec/Abiomed

• Pulsatile pump

• Valves allowing unidirectional flow

• Vacuum assist filling

• Asynchronous pulsatile VAD

• Need to start anticoagulation earlier

HeartMate/Heartware

Continuous flow pump

Valveless

Afterload sensitive – retrograde flow

Follows native pulse

Pump output varies over cardiac cycle

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Comparison of Pulsatile and Axial Flow

-10

-5

0

5

10

15

20

25

30

Ou

tflo

w (

L/m

in)

Pump speed = 10,000 RPM

-10

-5

0

5

10

15

20

25

30

Ou

tflo

w (

L/m

in)

(Both have average flow between 4-5 L/min)

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Pump Rotor and Stators

Inflow Bearings

Inflow Stator

Rotor

Outflow Bearings

Outflow Stator

Flow

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HeartMate II

Rotor Magnet Rotor

Bearings

Inlet Stator

Motor WindingOutlet Stator

Blood pump rotor is the only moving part

Rotor spins on blood –lubricated bearings designed for long life

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•Recovery

•Education

•Excursions

•Discharge – home environment

What it takes to get a patient home!What it takes to get a patient home!

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RecoveryRecovery• Hemodynamic stability

• Nitric Oxide or Flolan

• Dobutrex or Milrinone

• Cardiac Tamponade

• Anticoagulation

• Pain management

• Infection

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•Education Process–Driveline Dressing change –Learning the VAD–Alarms and troubleshooting VAD–Handling an emergency–Excursions

What it takes to get a patient home!What it takes to get a patient home!

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Recording VAD settings

Monitoring trends

Assessing preload and afterload

Alarm tests

Dressing change

Monthly assessing VAD equipment

for any problems – i.e.- exposed wires

Daily ChecksDaily Checks

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•Advance Heart Care Clinic has 24/7 on call

•Local ER

•Fire station

•Electric company

•Caregiver/Ambulance/Lifeline transfer if needed

Emergency Resources Emergency Resources

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

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Down the line……Down the line……• Right Heart Failure

• Debilitation

• Cardiac Arrhythmias

• Device Failure

• Co-Morbidities

• Infection

• Hospice/End of Life

• Cost

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A Successful VAD ProgramA 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

Survival Rates June 2006-Q4 2012

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IU Health Pagani INTERMACS

*Patient survival post implantKaplan-Meier Survival Analysis

Pagani et. al, JACC, 2009

n=158

Survival Rates 2011-2012

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n = 60

*Patient survival post implantKaplan-Meier Survival Analysis

Pagani et. al, JACC, 2009

IU Health Pagani INTERMACS

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New York Heart Association

NYHA Class

Symptoms

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.

IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

Quality of LifeFunctional status six months post-implant

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Benchmark: NYHA Class I & II = 89% at 6 months Pagani et. al, JACC, 2009

Data Source: MCCM

*All patients are Class III or IV before VAD implantation

NYHA Class assessed for every patient at 6 month visit

June 2011 – June 2012, n=25*

Class I 17 patients 68% 92%

Class II 6 patients 24%

Class III 2 patients 8%

Class IV

32 Patients evaluated

25 patients reached 6 months

7 patients NOT Included. 4 deceased, 1 transferred care and 2 transplanted.

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"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

ReferencesReferences

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• www.abiomed.com

• www.thoratec.com

• www.americanheartassociation.org

• www.heartcenteronline.com

• www.optn.org

• www.healthatoz.com

• www.nlm.nih.gov

To Learn More About VAD’sTo Learn More About VAD’s