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Ventricular Assist Device (VAD) Patients in the Community

This presentation discusses the available ventricular assist devices for home use and reviews the clinical indications for placement of VADs. It also covers the care requirements for VAD patients in the home environment, with case studies.

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Ventricular Assist Device (VAD) Patients in the Community

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  1. Ventricular Assist Device (VAD) Patients in the Community Liz Amerman, RN, BSN IU Health Methodist VAD Program Manager April 18, 2012

  2. 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 Objectives

  3. 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

  4. Disease Progression Jessup, NEJM 2003

  5. Heart Transplants in US

  6. Volume of VAD Patients 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

  7. 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 Device

  8. 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 Use

  9. Central Nervous System damage before or during operative procedure Body Surface Area (BSA) < 1.2m² for some assist devices Contraindications for VAD

  10. 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

  11. 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 VAD

  12. Abiomed Thoratec – IVAD and PVAD HeartMate – XVE and HM II HeartWare Types of VAD’s

  13. 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 Abiomed

  14. 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 IVAD

  15. Thoratec

  16. 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 II

  17. HeartMate XVE

  18. HeartMate II

  19. Heartware • Left ventricular assist device only • Long term use • BSA must be >1.2 • Centrifugal pump • Bridge to transplant • Destination therapy

  20. HeartWare

  21. Blood Pump Differences • HeartMate/Heartware • Continuous flow pump • Valveless • Afterload sensitive – retrograde flow • Follows native pulse • Pump output varies over cardiac cycle Thoratec/Abiomed • Pulsatile pump • Valves allowing unidirectional flow • Vacuum assist filling • Asynchronous pulsatile VAD • Need to start anticoagulation earlier

  22. Comparison of Pulsatile and Axial Flow (Both have average flow between 4-5 L/min)

  23. Pump Rotor and Stators Flow Rotor Outflow Stator Inflow Stator Outflow Bearings Inflow Bearings

  24. HeartMate II • Blood pump rotor is the only moving part • Rotor spins on blood –lubricated bearings designed for long life

  25. Recovery Education Excursions Discharge – home environment What it takes to get a patient home!

  26. Recovery Hemodynamic stability Nitric Oxide or Flolan Dobutrex or Milrinone Cardiac Tamponade Anticoagulation Pain management Infection

  27. Education Process Driveline Dressing change Learning the VAD Alarms and troubleshooting VAD Handling an emergency Excursions What it takes to get a patient home!

  28. 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 Checks

  29. Advance Heart Care Clinic has 24/7 on call Local ER Fire station Electric company Caregiver/Ambulance/Lifeline transfer if needed Emergency Resources

  30. 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

  31. Down the line…… Right Heart Failure Debilitation Cardiac Arrhythmias Device Failure Co-Morbidities Infection Hospice/End of Life Cost

  32. A 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

  33. Survival Rates June 2006-Q4 2012 n=158 IU Health Pagani INTERMACS • *Patient survival post implant • Kaplan-Meier Survival Analysis • Pagani et. al, JACC, 2009

  34. Survival Rates 2011-2012 n = 60 IU Health Pagani INTERMACS • *Patient survival post implant • Kaplan-Meier Survival Analysis • Pagani et. al, JACC, 2009

  35. New York Heart Association

  36. Quality of LifeFunctional status six months post-implant NYHAClass 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 *All patients are Class III or IV before VAD implantation 32 Patients evaluated 25 patients reached 6 months 7 patients NOT Included. 4 deceased, 1 transferred care and 2 transplanted. • Benchmark: NYHA Class I & II = 89% at 6 months • Pagani et. al, JACC, 2009 • Data Source: MCCM

  37. "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 References

  38. 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’s

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