Download Left Ventricular Assistive Device as a Destination Therapy

Major Case Study:
Heart Failure and Left
Ventricular Assistive
Device as a Destination
Therapy
January 29th, 2013
By: Rachael Woods; dietetic intern
By: Rachael Woods: Dietetic Intern
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Purpose of the Study
S Case was intriguing
S Nutritional implications for left ventricular assistive devices
(LVAD) are not well known among RD’s
About A.S.
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71 y/o retired Caucasian male
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Catholic
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113.90 kg (250.6 lb)
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182.88 cm (72in)
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BMI: 36.1
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IBW: 80.9 kg
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%IBW: 141%
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Admitted with Heart Failure class III Stage IV (D) for LVAD placement
A.S.’s Past Medical History
S Congestive heart failure (heart failure) class III, stage IV (D)
S Cardiomyopathy
S Coronary artery disease
S Chronic kidney disease
S Throat and prostate cancer with radiation
S Hypertension
PMH Continued
S Gastritis
S Atrial fibrillation
S Right bundle branch block
S Ischemic heart disease
S History of myocardial infarction
S Surgeries performed prior to admission: pacemaker placement and
stented coronary artery
Heart Failure and it’s Causes
S Occurs when the heart is unable to pump blood at the rate
sufficient to meet the metabolic demands of the tissues or can only
do so at an elevated filling pressure
S 3 leading causes causes: coronary artery disease, high blood
pressure and diabetes
S Other causes: cardiomyopathy, heart valve disease, arrhythmias
and congenital defects
S A.S.’s was caused by a myocardial infarction in the 1990’s
Nutrition History
S Limits sodium and fat intake at home; does not follow a
particular diet
S Wife does grocery shopping and prepares meals
S Meals are eaten at a dining room table where a television set
is visible
S Eat out 1-2x’s per week
S Does not engage in physical activity regularly
S Participated in Weight Watchers 1 year ago; lost 55 lbs
Classes of Heart Failure
Classes of Heart Disease according to the New York Heart Disease Association
No limitation of physical
activity. Ordinary physical
Class I
Mild
activity does not cause undue
fatigue, palpitation, or dyspnea
(shortness of breath)
Slight limitation of physical
activity. Comfortable at rest but
Class II
Mild
ordinary physical activity
results in fatigue, palpitation, or
dyspnea
Marked limitation of physical
activity. Comfortable at rest,
Class III
Moderate
but less than ordinary activity
causes fatigue, palpitation, or
dyspnea
Unable to carry out any
physical activity without
Class IV
Severe
discomfort. Symptoms of
cardiac insufficiency at rest. If
any physical activity is
undertake, discomfort is
increased
Stages of Heart Failure
Stage A
Stage B
Stage C
Stage D
American Heart Association Stages of Heart Failure
Presence of heart failure risk
High Risk
factors but no heart disease and
no symptoms
Heart disease is present but
there are no symptoms
Asymptomatic
(structural changes in heart
before symptoms occur)
Structural heart disease is
Symptomatic
present and symptoms have
occurred
Presence of advanced heart
disease with continued heart
Advanced Disease
failure symptoms requiring
aggressive medical therapy
Normal Anatomy of the Heart
Biological Adaptations
S Frank-Starling mechanism: increased filling volumes (of blood)
enlarge the heart and increase cross bridge formation of muscle cells
of the heart, which increases contractility
S Hypertrophy: Heart muscle cells (sarcomeres) proliferate to increase
muscle size and enhance force of contractility. Enlarged hearts
secondary to hypertrophy require additional oxygen consumption to
support the demands of additional muscle tissue; therefore
hypertrophied hearts are more susceptible to deterioration
S Neurohormonal Systems
S Norepinephrine
S Activation of renin-angiotensin-aldosterone system
S Release of natriuretic peptide
Healthy vs. Diseased
Nutrition/Medical
Interventions
S Heart healthy diet (such as the TLC diet)*
S Physical activity
S Medications (5 classes)*
S ACE inhibitors & Angiotension
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S
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receptor blockers
Beta-Blockers*
Diuretics*
Aldosterone receptor antagonists*
Nitrates
Surgical Interventions
S Pacemaker Implantations*
S Implantable Cardioverter Defibrillators
S Coronary Artery Bypass Grafts
S LVAD implantation*
S Heart Transplant
What is an LVAD?
LVAD: Heart Mate II
S LVAD Video
Laboratory Values 12/5
Laboratory findings (12/5)
Electrolytes
K: 3.3 (3.6-5 mEq/L)
Glucose
124 (70-99 mg/dL)
BUN, Creatinine
WNL
Laboratory Values 12/16
Laboratory findings (12/16)
Electrolytes
Cl: 94 (101-111 mEq/L)
Glucose
94 (70-99 mg/dL)
BUN, Creatinine
32(5-20 mg/dL); 1.48(0.6-1.2 mg/dL)
Medications
S Albuterol
S Lactobacillus Acidophillus
S Amiodarone
S Pantoprazole
S Bumetanide
S Ranolazine
S Carvedilol
S Spironolactone
S Docusate-Senna
S Coumadin
S Humulin
S Humalog
Typical Intake for A.S.
S Cereal for breakfast at around 9:00 am
S A typical lunch for A.S. is an unspecified sandwich, hot dog,
or peanut butter and jelly sandwich at around 1:30 pm
S A typical dinner for A.S. consists of turkey breast, meatloaf,
chicken, hamburgers, or pizza if he and his wife go out to
dinner
Hospital 24-Hour Recall
Table 1.6 24-hour recall
Food Product
Kcals
Carbohydrate
Protein
Fat
Ensure Plus
350 kcals
15g
13g
11g
Pudding
140 kcals
24g
4g
4g
Jello
64 kcals
16g
1g
0g
Ensure Plus
350 kcals
13g
51g
11g
0 kcals
0g
0g
0g
904 kcals
68g
69g
26g
Diet Tea
Total
Nutrition Care Process:
Assessment
S At the time of A.S.’s first visit, he was on a full liquid diet
and was eating roughly 25% of his meals due to his lack of
interest in the foods being served
Nutrition Care Process:
Diagnosis
S At the time of A.S.’s first visit, his diagnosis was:
S Inadequate protein energy intake related to decreased ability
to consume sufficient protein and energy as evidenced by
intake less than recommended needs
S This diagnosis was formulated on the premises of the full
liquid diet that was only fractionally consumed
Calculations for Estimated
Needs (ASPEN)
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Basal energy expenditure calculated using the Harris-Benedict Equation
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Add to basal value an additional 15%-25% for minimal physical activity
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Add another 10%-20% for hypermetabolism of severe heart failure
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Determine carbohydrate (40%-60%), protein (10%-15%), and fat (30%-40%)
adjust based on concurrent conditions
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Major surgery or sepsis increases energy requirements by 20%-50%
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Based on the above criteria A.S.’s estimated energy needs during the visit on
December 5th were 3,200 kcals: (BEE =2050kcals + 20% for minimal activity
= 2500 + 10% for hypermetabolism = 2700 + 20% for surgery= ~ 3200
kcals/day and 80-120g protein/day
Nutrition Care Process:
Intervention
S The importance of adequate calories and protein
consumption for wound healing was discussed since he was
only consuming ~25% of each meal
S The topic of fat, sodium, and fluid restriction were not
discussed at the time because A.S. was on a full liquid diet
Nutrition Care Process:
Monitoring/Evaulation
S Follow up visit was scheduled
Nutrition Care Process:
Assessment
S At the time of A.S.’s second visit, A.S.’s diet was advanced
to a Solid Regular Coumadin/Warfarin Cardiac diet with
Wolk Shake TID
S A.S. was much more receptive to this diet than the
previously prescribed diet consuming 100%
Nutrition Care Process:
Diagnosis
S During the second visit of the study A.S. did not have any
acute nutrition related problems and so a formal nutrition
diagnosis was not made secondary to 100% food/beverage
intake and 100% Wolk Shake intake TID
Nutrition Care Process:
Intervention/Monitoring/Evalu
ation
S No intervention, monitoring criteria, or evaluation was
formulated as a formal diagnosis was not made
Observable Physiological and
Psychological advancements
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A.S. was feeling lethargic, experiencing shortness of breath and was not able
to carry on the daily activities of life prior to surgery
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A few days post surgery A.S. was not ambulating and appeared to be very
tired and frail. His wife was present in the room and was able to assist with
the interview process. Throughout A.S.’s stay at the hospital, his physical and
psychological changes were evident; with each visit, his physical and mental
status greatly improved.
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The second time A.S. was seen, he was able to answer all of his questions
himself, and was ambulating. As the visits continued, A.S. became more
talkative and began telling more personal stories about his life; such as the
hardships he faced struggling with heart failure until he had the LVAD
placement, rather than just talking about his eating patterns.
Medical Prognosis
S Based on A.S.’s length of stay at the hospital and the
physiological and psychological advancements that were
observed, it appears that the prognosis for A.S. is quite good
S The most common complications post LVAD implantations
are infection and sepsis (18%-59% of recipients)
S Stroke is another common risk factor associated with
LVAD therapy; the risk increases as long as the device
remains in the patient’s body
Nutritional Prognosis
S With increasing BMI, the risk for mortality decreases (good
for A.S. as his BMI was 36.1) post LVAD implantation
S Metabolites such as glucose and lactate will restore to
normal levels post LVAD implantation
S Changes in myocardial metabolism occur in heart failure,
resulting in decreased amino acid levels in cardiac tissues;
LVAD therapy does not allow for the recovery of these
amino acid stores
References
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WebMD. Heart Failure Health Center. Available at: http://www.webmd.com/heartdisease/heart-failure/left-ventricular-assist-device. Accessed January 2nd, 2014.
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Fregmen BF, Frucht SS. Medical Terminology: A Living Language. 4th ed. Upper Saddle
River, NJ: Pearson; 2009:132-137.
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Tool Loop. Veins in the Cardiovascular System. Available at:
http://www.tooloop.com/veins-in-the-cardiovascular-system/. Accessed January 9th,
2014.
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Kumar V, Abbas AK, Fausto N, Aster JC. Pathologic Basis of Disease. 8th ed. Philadelphia,
PA: Sunders Elsevier; 2010:533-537.
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National Heart, Lung, and Blood Institute. What is Heart Failure? Available at:
http://www.nhlbi.nih.gov/health/health-topics/topics/hf/. Updated January 9th 2012.
Accessed January 9th, 2014.
References continued
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Emory Healthcare. Heart Failure Stages & Functional Classifications.
Available at: http://www.emoryhealthcare.org/heart-failure/learn-aboutheart-failure/stages-classification.html. Accessed January 11th 2014.
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Heart Failure Society of America. Questions About HF. Available at:
http://www.abouthf.org/questions_stages.htm. Accessed January 11th, 2014.
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Schwartz DB, DiMaria, RA. The A.S.P.E.N. Nutrition Support Core Curriculum a
Case-Based Approach-The Adult Patient. 1st ed. Silver Spring, MD: American
Society for Parenteral and Enteral Nutrition; 2007:495-501.
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Mahan KL, Escott-Stump S, Raymond, JL. Krause’s Food and the Nutrition Care
Process. 13th ed. St. Louis, MO: Elsevier Saunders; 2012:194;897.
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Mayo Clinic. Diseases and Conditions. Available at:
http://www.mayoclinic.org/diseases-conditions/diabetes/expertblog/diabetes-blog/BGP-20056560. Accessed January 11th, 2014
References continued
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Mayo Clinic: Mayo Medical Laboratories. Test ID: Cl. Available at:
http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/8460.
Accessed January 11th, 2014.
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Rizzieri, A., Verheijde, J., Rady, M., & McGregor, J. (2008). Ethical challenges with the left
ventricular assist device as a destination therapy. Available at
http://www.ncbi.nih.gov/pmc/articles/PMC2527574/. Accessed December 17th, 2013.
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American Dietetic Association. Nutrition Care Manual®. Heart Failure: Nutrition
Prescription. http://nutritioncaremanual.org/topic. Accessed December 17th, 2013.
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Medline Plus Trusted Health Information for You. Drugs, Supplements, and Herbal
Information. Available at: http://www.nlm.nih.gov/medlineplus/druginformation.html.
Accessed January 9th, 2014.
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Florida Hospital. Enteral Nutrition Formulary. 2013
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Weitzel LB, Ambardekar AV, Brieke A, Cleveland JC, Serkova NJ, Wischmeyer PE, Lowes
BD. Left Ventricular Assist Device Effects on Metabolic Substrates in the Failing Heart. April
2013; 8(4):1-6