Download Mechanical Circulatory Support for the Advanced Heart Failure Patient

Mechanical Circulatory Support for the
Advanced Heart Failure Patient
Carrie E Weaver RN, BSN, CCRN-CMC/CSC
Minnesota Academy of Physician Assistants Spring Conference
March 17, 2016
Disclosures
• I have none
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Objectives
• Understand Advanced Heart Failure Treatments
• Understand Mechanical Circulatory Support Options
• Proper Management of Patients with Mechanical Circulatory Support
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What is Heart Failure?
• Definition: The inability of the heart to fill with or eject blood sufficient to meet metabolic demands as a result of either a structural or functional disorder of the myocardium, endocardium or pericardium
• Majority of patients with Heart Failure (HF) have dysfunction of the left ventricular myocardium, leading to a change in the geometry (dilatation) and sometimes structure (hypertrophy), a process known as remodeling
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Heart Failure—Structural Changes
Heart Failure happens when the heart cannot pump enough blood and oxygen to support other organs within the body.
CDC, 2014
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Heart Failure: A Global Epidemic
• Heart Failure is a global problem
• Estimated 38 million patients worldwide, 5.1 million of those in the US
• 650,000 new diagnosis annually
• HF accounts for 1 million hospital admissions each year
• Most common diagnosis for hospital admission in patients 65 years of age or older • Despite progress in the field, the prognosis is worse than most cancers
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AHA, 2015
Clinical Manifestations of Heart Failure
• Dyspnea
• Fatigue
• Impaired functional capacity (NYHA Class)
• Fluid retention leading to peripheral and/or pulmonary edema
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Heart Failure Classification
Class
Class I
Patient Symptoms
No limitation of physical activity. Ordinary physical activity
does not cause undue fatigue, palpitation (feeling heart
beats), or dyspnea (shortness of breath).
Class II
(Mild)
Slight limitation of physical activity. Comfortable at rest, but
ordinary physical activity results in fatigue, palpitation, or
dyspnea.
Class III
(Moderate)
Marked limitation of physical activity. Comfortable at rest,
but less than ordinary activity causes fatigue, palpitation, or
dyspnea.
Class IV
(Severe)
Unable to carry out any physical activity without discomfort.
Symptoms of cardiac insufficiency at rest. If any physical
activity is undertaken, discomfort is increased.
Source: The American College of Cardiology and the American Heart Association Stages of Heart Failure
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Stages of Heart Failure
Stage
Stage A
Definition
Presence of heart failure risk factors but no heart disease
and no symptoms
Stage B
Heart disease is present but there are no symptoms
(structural changes in heart before symptoms occur)
Stage C
Structural heart disease is present AND symptoms have
occurred
Presence of advanced heart disease with continued heart
failure symptoms requiring aggressive medical therapy
Stage D
Source: The American College of Cardiology and the American Heart Association Stages of Heart Failure
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Treatment Options for Heart Failure
• Early onset HF Treatments (NYHA I‐II)
– Oral medications
• Beta‐blockers, ACEi/ARB, Aldosterone Antagonists, Diuretics, Anti‐arrhythmics, Vasodilators/Nitrates
– Heart‐healthy lifestyle
• Fluid & Sodium restrictions
• Diet & Exercise
• Advanced HF Treatment Options (NYHA III‐IV)
– CRT, ICD implant
– Continuous IV medications
• Inotropes (increases squeeze of heart muscle)
– Mechanical Circulatory Support (VAD—Ventricular Assist Device)
• Short‐term
• Long‐term
– Heart Transplant
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Seattle Heart Failure Model
•
Seattle Heart Model looks at:
– NYHA Class
– EF
– Weight
– PO meds
– Inotrope usage
– ICD/PPM
– Labs
– Interventions
•
Determines life expectancy of a Heart Failure patient with/without interventions
Case Study: 62 yo Male, Class IV, EF 20%
Without LVAD Mortality & proper Medical Management
– 1 yr—74%
– 2 yr—93%
– 5 yr—99% – Mean life expectancy: 0.7 yrs
•
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•
With LVAD (only) Mortality
– 1 yr—33%
– 2 yr—56%
– 5 yr—90% – Mean life expectancy: 2.3 yrs
•
With LVAD & proper Medical Management
– 1 yr—13%
– 2 yr—25%
– 5 yr—56% – Mean life expectancy: 5.2 yrs
http://depts.washington.edu/shfm/
Mechanical Circulatory Support
Systems
• VAD—Ventricular Assist Device
– An implantable mechanical circulatory device “heart pump” that assists a failing heart by increasing blood flow to the rest of the body.
Short‐term Devices
Long‐term Devices
Goals of Therapy
• Improve Survival
• Improve Quality of Life
St Jude Medical (previously Thoratec), HeartMate II
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Short-term Mechanical Circulatory
Support
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1st Generation: Pulsatile Pumps
HeartMate XVE By Thoratec
Corporation
Novacor LVAS By WorldHeart
Corporation
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2nd Generation: Axial Flow Pump
HeartMate II by St. Jude (formerly Thoratec Corporation)
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2nd Generation: Axial Flow Pump
Heart Assist 5
by Reliant Heart
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3rd Generation: Centrifugal Pumps
HeartWare HVAD
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Short-Term & Long-Term Mechanical
Circulatory Support
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Syncardia Total Artificial Heart
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Indications for use
• Bridge to Transplant (BTT)—Patients who are listed for transplant, but may die before a transplant becomes available
• Destination Therapy (DT)—Patients who do NOT qualify for transplant at time of implant. Those with advanced age (>70 yrs) & other co‐morbidities will live with device for their lifetime
• Bridge to Recovery—Not a diagnosis code, but cardiac recovery has been noted in a small percentage of VAD patients over time
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Patient Selection
• Full review of all medical/surgical history
• Psycho‐social Evaluation done by Social Worker
– Must identify support person(s) available to provide assistance
– Neuropsychological Evaluation if warranted
– Palliative Care (for Destination Therapy)
• Insurance Coverage
• All info then reviewed at the Advanced Heart Failure Team Selection Meeting
– Who attends?
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How Do We Choose a VAD?
• What’s the Indication for the VAD?
– Bridge to Transplant or Destination Therapy
• How much support do they need?
– LVAD, RVAD, BiVAD, TAH
• What anatomic reasons may contra‐indicate one device over another?
– Thick myocardium
– Body Habitus
– Non‐dilated ventricle
• What is their compliance history?
– With Medications—anticoagulation
– Making appointments—frequent follow‐up
– Following directions—dietary, sodium & fluid restrictions
• Previous Medical History
– GI bleeding
– Aortic Root repair or aortic calcification
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HeartMate II
• Axial flow, rotary pump
• FDA approved for use as BTT or DT
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HeartWare
• Centrifugal flow pump
• FDA approved for use as BTT
• Clinical trial for DT
Surgical Procedure
HeartWare
HeartMate II
Driveline
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Continuous Blood Flow
• Blood Flows through the heart normally –
– From the right atrium, tricuspid valve into the right ventricle, pulmonic valve, pulmonary system, into the left atrium, mitral valve, into the left ventricle, inflow cannula, LVAD pump, outflow cannula into the aorta.
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Key points Unique to VAD Patients
• Pulse: Difficult to palpate due to continuous flow of VAD
• Blood Pressure: Preferred method is to use a doppler to obtain a “MAP”
– 1st sound heard is an “approximate” equivalent to the mean arterial pressure, goal range 60‐90, but patient dependent
– Automatic cuff may work and provide an estimated pressure (do not focus on systolic/diastolic)
– Narrow pulse pressure (i.e. 87/75, MAP=79)
• MAP=(2 X diastolic) + systolic/3
• Oxygen Saturation: Difficult to obtain related to lack of pulse
• EKG—Not affected by VAD
• Most are on Anticoagulation (Coumadin & Aspirin)
• Look, Listen, and Feel
– Pulseless does not mean pressure‐less
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Common Complications
• Bleeding – Nose bleed
– Gastrointestinal
– Intra‐cranial
• Right‐sided heart failure
• Thrombo‐emboli (PE, MI, CVA) – IV anticoagulation
– Supportive treatment
• Arrhythmia
• Pump Malfunction
– Inotropes
– Pump exchange
• Infection (at the Driveline site)
– Prophylactic antibiotics with any trauma to the driveline
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Restrictions
• No excessive bending or twisting • No contact sports
• No MRI
• No swimming
• No chest compressions
• Avoid Pregnancy
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Most Common Complications
• Bleeding • Common areas: nose, GI, head
• Treat bleeding as you would with any other patient
• Consult with VAD Coordinator BEFORE reversing anticoagulation.
• Thrombo‐embolic (clot)
• Common areas: pump, head, PE
• Consult with VAD Coordinator PRIOR to thrombolytics
• Infection
• Treat as normal
• Right‐sided Heart Failure
• Consult with VAD Coordinator
• Pump Malfunction
• VAD alarming • Consult with VAD Coordinator
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Unique Factors with Vital Signs
Due to continuous flow . . .
• Pulse
• May or may not be present
• Blood Pressure
• May be difficult to obtain – use other signs of perfusion
• Treat MAP (Mean Arterial Pressure only). • Do not focus on systolic/diastolic pressures.
• Goal MAP 60‐90 mmHg
• Preferred method is using a Doppler to obtain a MAP
• Oxygen Saturation
• May be difficult to obtain due to lack of pulse
• EKG
• Not typically affected by VAD, may get artifact
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Emergency Procedure
• Contact VAD Coordinator
• ANW VAD Emergency # 612‐916‐6638
• Available 24/7
• Assess Perfusion • May or may NOT be a palpable pulse
• Assess device for any alarms (VAD Coordinator will advise how to treat)
• Indicators of Perfusion
1.
2.
3.
4.
Mental Status
Breathing – intervene if necessary
Skin color/temperature
Determine Mean Arterial Pressure (MAP), do not focus on systolic/diastolic pressure
– Normal MAP range 60‐90 mmHg
– NIBP (automatic cuff) not always able to read
5.
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ETCO2 < 20
Emergency Procedure
• Treatment of Inadequate Perfusion
(remember, no palpable pulse does NOT always mean no perfusion)
• Start Chest Compressions – OK to use LUCAS device if > 6 weeks from surgery
– Assume > 6 weeks if alone and/or chest incision is healed
• AED (automated external defibrillator)
– Not affected by VAD
– Does NOT harm VAD
– Use per protocol
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Emergency Procedure
• Rhythm Disturbance with Perfusion
– Assess stability of patient – VAD patients with an arrhythmia typically do NOT present with the same amount of compromise as a regular patient
– Patient may tolerate an arrhythmia for long periods of time
• Does not necessarily indicate inadequate perfusion
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Emergency Procedure
• Look to Treat Underlying Cause of Emergency
– May NOT necessarily be fixed with chest compressions
– VADs need volume
• Consider 500‐1000 cc fluid
– Common Complications with VADs include •
•
•
•
•
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Bleeding
Clotting
Stroke
Infection
Malfunction
Exposing the Patient
• Be EXTREMELY careful when removing clothing
– DO NOT cut driveline (line exiting patient’s abdomen)
VAD Driveline exit site
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VAD Equipment
HeartMate II Equipment
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HeartWare HVAD Equipment
Emergency Bag
• VAD Patients are REQUIRED to carry an emergency bag at ALL TIMES.
Contains:
• Extra Controller
• Extra Batteries
• Emergency Contacts
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Transporting VAD Patients
• Stabilize patient in closest facility
• Then transport to implanting facility for admission
• Bring EMERGENCY BAG
• Secure equipment to the stretcher (controller and 2 batteries)
• Avoid kinking or twisting the driveline when strapping patient
• DO NOT allow equipment to fall from stretcher or exam table
• OK for ground or air transport
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Questions???
[email protected]
VAD Coordinators
Abbott Northwestern Hospital
Transplant Department
612‐863‐5638
Jessica Boughton, RN
Lisa Lundquist, RN
Kristy McHugh, RN
Carrie Weaver, RN
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