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Download 2nd talk: Short Term MCS
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The Rise of the Machines: Cardiac Mechanical Assist in the ICU Disclosures We WILL be discussing off label use of various mechanical circulatory support devices and medications Jason A. Gluck, DO Director, Mechanical Circulatory Support Program Director, Emergency Cardiac Care Program Heart Failure and Transplant Cardiologist Center for Advanced Heart Failure and Transplant Hartford Hospital (860) 545545-1212 Nicole Chomick, Chomick, RN VAD Coordinor Center for Advanced Heart Failure and Transplant Hartford Hospital (860) 545545-1212 Case 35 y/o M admitted to CCU with acute bibi-V systolic HF, EF of 15% on a Friday at 4 PM BP: 78/58 HR: 110 reg RR: 24 O2 sat: 88% Physical: lethargic, elevated JVD, rales b/l, b/l, tachy w/ gallop, II/VI SM, anuric, anuric, cool and clammy Started on Dopamine, Lasix SWAN: RA: 24 PAP: 44/34 PAWP: 32 MVO2: 48% CI: 1.6 Dobutamine added, started making urine Overnight becomes hypotensive and suffers a 25 minute PEA cardiac arrest Resucitated, Resucitated, intubuated on Epi, Epi, Dopamine, Dobutamine, Dobutamine, Vasopressin Ring… Ring….Ring… .Ring…Ring… Ring… Doc… Doc… What should we do? Optimize meds IABP LVAD RVAD BiBi-VAD Operative vs transcutaneous approach • Which device? • Which device? • Which devices? Objectives Brief Review of Mechanical Circulatory Support Define ECMO and types of ECMO History of ECMO Current use of ECMO Revew of Literature Future potential of ECMO and role of perfusionist 1 Mechanical Circulatory Support Salvage/Emergency Therapy Anatomy Model Maintenance Therapy TV R A PV R V MV Lungs PA PV L A AV L V Aorta Vena Cava Cap Bed Veins Arteries IntraIntra-Aortic Balloon Pump TV R A PV R V MV Lungs PA PV L A AV L V Aorta Vena Cava Cap Bed Veins IntraIntra-Aortic Balloon Pump IntraIntra-Aortic Balloon Pump ECG or pressure triggered Increases Coronary Perfusion Pressure Increases Systemic Perfusion Deflates in Systole Indications Inflates in Diastole Inflation/Deflation of helium balloon Cardiogenic Shock Reversible intracardiac mechanical defects Contraindications Weaning of pump Shock Percutaneous coronary Angioplasty High Risk CABG Absolute Acute MR Post MI septal perf Unstable Angina Post Cardiotomy Decreases afterload Increases Cardiac Output Believed to augment flow by up to 0.5 L Arteries Severe Aortic Insufficiency Aortic Dissection Severe aortoiliac occulusive disease Relative Prosthetic vascular aortic graft Aortic Aneurysm Aortofemoral graft 2 IABP Abbreviations IABP Tracings Inflation Goal To produce a rapid rise in aortic pressure (optimize PDP/DA) Increase O2 supply to coronaries PAEDP/UEDP: Patient Aortic End Diastolic Pressure PSP: Peak Systolic Pressure PDP/DA: Peak Diastolic Pressure/Diastolic Augmentation BAEDP/AEDP: Balloon Aortic End Diastolic Pressure APSP: Assisted Peak Systolic Pressure (Systole after IABP deflation) DN: Dicrotic Notch Deflation Goal To reduce aortic end diastolic pressure (afterload) afterload) Decreasing MVO2 while improving CO IABP Timing Three 1) 2) 3) Inflate just prior to DN which should result in PDP/DA > PSP BAEDP/AEDP < PAEDP/UEDP APSP < PSP What timing issue to you see? Poor Afterload Reducation with IABP - Causes Balloon not inflated to full volume causing a decrease in volume displacement Compliant aortic walls which allow for only small changes in volume Improper balloon placement Partial obstruction of gas lumen Improper timing What timing issue to you see? IABP is inflated before DN Result Early Inflation Violate rule 1 Premature closure of Aortic Valve Reduced SV and CO Increased LV end diastolic volume Early Inflation 3 What timing issue to you see? What timing issue to you see? DN is visible between PSP and PDP/DA Result Late Inflation What timing issue to you see? Late Inflation Violates rule 1 PDP/DA less than optimum Less blood displacement due to decreased aortic blood volume Decreased perfusion pressure and volume to coronary arteries What timing issue to you see? APSP = PSP Volates rule 3 May see ‘U’ shape at BAEDP/AEDP Result No afterload reduction Early Deflation Early Deflation What timing issue to you see? What timing issue to you see? BAEDP/AEDP > PAEDP/UEDP Result Late Deflation Violates rule 2 Increased workkload of LV Increased MVO2 Decreased CO Late Deflation 4 What is a Left Ventricular Assist Device (LVAD)? Ventricular Assist Device TV R A PV R V MV Lungs PA PV L A AV L V Mechanical circulatory support system to assist with cardiac output in patients with advanced heart failure Functions as a blood pump Aorta Vena Cava Can be used for several reasons: Bridge to: • Decision • Recovery • Transplantation Destination Therapy Most LVADs provide CONTINUOUS FLOW Cap Bed Veins Arteries pump to assist the ventricle in blood flow which augments cardiac output A Implications of continuous flow devices: Often times patients will NOT have a pulse Implications of continuous flow devices: Absence of pulses does NOT indicate device malfunction or change in patient health status Often times patients will NOT have a pulse Blood pressure measurement may be unreliable or inaccurate Best measured with Doppler First sound observed is often mean arterial pressure Goal MAP for LVAD patients is 6565-85 mmHg Absence of pulses does NOT indicate device malfunction or change in patient health status Patients should be assessed for signs of circulation to determine adequate perfusion Implications of continuous flow devices: Placed in series or parallel to the native left ventricle (native (native blood circulation) Always assume patient is dependant on LVAD (in series) Mental status or Loss of Consciousness Capillary refill Skin Color and Temperature Cyanosis Implications of continuous flow devices: Pulse oximeter readings may be inaccurate if there is difficulty assessing pulsatility 5 Medication implications of continuous flow devices: Implications of continuous flow devices: Flow is dependant on preload and afterload Anticoagulation Flow can decrease with: • Decreased preload Dehydration • Increased afterload Hypertension Flow can increase with: • Increased preload • Decreased afterload What a LVAD does NOT… NOT… Does NOT completely take over patient’ patient’s cardiac function Does NOT require removal of patient’ patient’s heart It is NOT an artificial heart Does NOT circulate blood outside the body AntiAnti-Hypertensive Agents Heart Failure Medications ACE/ARB Beta Blockers Diuretics Hydralazine/NTG Hydralazine/NTG Disease specific medications Diabetic Medications • Insulin • Oral Hypoglycemics Statins Steroids Others Most common adverse reactions with LVAD Bleeding GI bleed (AVM, others) Infection Drive line infection Pocket infection CVA It’ It’s as easy as driving a car… car… Warfarin ASA Dipyridamole (occasionally) / Stroke Can come from VAD Reason for baseline anticoagulation Abiomed – Impella 2.5/5.0 LPM 6 Impella TV R A Tandom Heart PV R V MV Lungs PA PV L A AV L V Aorta Vena Cava Cap Bed Veins Arteries Placed across the aortic valve and pumps blood from LV to Aorta Continuous Flow LVADs Tandom Heart - Percutaneous TV R A PV R V MV Lungs PA PV L A AV L V Aorta Vena Cava Cap Bed Veins Arteries Rotaflow CentriMag Tandom Heart - Operative TV R A PV R V MV Lungs PA PV L A Tandom Heart - Operative AV TV L V R A PV R V MV Lungs PA PV L A AV L V Aorta Vena Cava Aorta Vena Cava Cap Bed Veins Cap Bed Arteries Veins Arteries 7 Biventricular support TV R A PV R V MV Lungs PA PV L A AV L V Temporary MCS Practical Aorta Vena Cava Cap Bed Veins Arteries 8
