Advanced Heart Failure and the Role of
Mechanical Circulatory Support
Megan Shifrin, RN, MSN, ACNP-BC
Vanderbilt University
Objectives
• Review current recommendations for advanced heart failure
management
• Identify the different types of VADs currently in use
• Identify the indications and contraindications for placement
• Overview of immediate post-operative management and potential
complications
Why Should I Care About Heart Failure or LVADs?
• Prevalence – According to the American Heart Association, there
are close to 6 million Americans living with heart failure.
• Incidence – Almost 550,000 new cases are diagnosed annually.
• About 300,000 people die each year of heart-failure related causes.
• Heart failure is the single most common cause of hospitalization in
the United States for people over the age of 65.
• In 2012 alone, there were 2,066 permanent LVADs placed in
patients.
• These patients live in your community.
The Cost of Heart Failure Management in the
United States
Hospitalization
$20.9
Total Cost
$39.2 billion
53.3%
11.9%
6.4%
10.5%
Lost Productivity/
Mortality*
$4.1
Nursing Home
$4.7
9.7%
Home Healthcare
$3.8
Physicians/Other
Professionals
$2.5
Drugs/Other
Medical Durables
$3.2
8.2%
Heart Disease and Stroke Statistics—2010
Update: A Report From the AHA
Circulation, Feb 2010; 121: e46 - e215
Etiologies of Heart Failure
• Ischemic cardiomyopathy
• Hypertension
• Coronary artery disease
• Myocardial infarction
• Non-ischemic cardiomyopathy
•
•
•
•
•
•
•
•
Valvular disease
Viral/bacterial cardiomyopathy
Peripartum cardiomyopathy
Idiopathic/familial cardiomyopathy
Myocarditis
Connective tissue disorders
Drugs/Toxins
Alcohol
New York Heart Association Functional Classification of Heart Failure
Increasing Severity
Class I
Class II
Class IIIa and IIIb
Class IV
• Cardiac disease
• No symptoms
• No limitation in
ordinary physical
activity
• Mild symptoms
(mild shortness of
breath and/or
angina)
• Slight limitation
during ordinary
activity
• Marked limitation
in activity due to
symptoms
• Comfortable only
at rest
• Severe limitations
• Symptoms even
while at rest
• Mostly bedbound
patients
Goals of Heart Failure Management
1. Improving symptoms and quality of life
2. Slowing the progression or reversing cardiac and
peripheral dysfunction
3. Reducing mortality
Addressing Heart Failure in 2013
Katz AM
Heart Failure
Evidence of Progressing Heart Failure
Decreased end organ perfusion
• Renal function
• Liver function
• Pulmonary function
We need more support!
Ventricular Assist Device (VAD)
A mechanical circulatory device used to partially or completely
replace the function of either the left ventricle (LVAD); the right
ventricle (RVAD); or both ventricles (BiVAD)
Long-Term LVAD
Short-Term LVAD
Implanted surgically with the
intention of support for months
to years
Utilized for urgent/ emergent
support over the course of days
to weeks
Things to Consider Before Placing ANY
type of VAD Support
• Are there any contraindications to VAD support?
•
•
•
•
•
•
End-stage lung, liver, or renal disease
Metastatic disease
Medical non-adherence or active drug addiction
Active infectious disease
Inability to tolerate systemic anticoagulation (recent CVA, GI bleed, etc.,)
Moderate to severe RV dysfunction for some LVADs
• What are our other issues in this particular patient?
• What are the patient’s goals? What are our goals?
• What happens if we don’t meet our goals?
INTERMACS SCORE
Interagency Registry for Mechanically Assisted Circulatory Support
Long-Term LVAD
Ideal candidates are
INTERMACS classes 3-4
Short-Term LVAD
Candidates are
INTERMACS classes 1-2
Not a LVAD Candidate
INTERMACS 1 or those with
multisystem organ failure
Lietz and Miller
Curr Opin Cardiol
2009, 24:246–251
Destination Therapy vs. Bridge to Transplantation
Long-term placement
Bridge to Transplantation (BTT)
•
•
•
Patient is approved and currently
listed for transplant
NYHA IV
Failed maximized medical therapy
Destination Therapy (DT)
•
•
•
•
•
•
Not a heart transplant candidate
NYHA IV
LVEF <25%
Maximized medical therapy >45
of 60 days; IABP for 7 days
Functional limitation with a peak
oxygen consumption of less than
or equal to 14 ml/kg/min
Life expectancy < 2 years
http://www.cms.gov/medicarecoverage-database
Adult FDA Approved LVADs
Bridge to Transplantation (BTT)
HeartMate II (Thoratec)
HeartWare (HeartWare)
PVAD (Thoratec)
IVAD (Thoratec)
Destination Therapy (DT)
HeartMate II (Thoratec)
HeartMate II (Thoratec)
Basics of HM II
Pump Speed (RPM) – How quickly
the pump rotates
Pump Power (Watts) – Measure of
motor voltage and current
Pump Flow (L/min) - Estimated
value of the volume running
through the pump
Pulsitility Index – The measure of
the left ventricular pressure during
systole
Immediate Post-op Management
VS
Management Considerations
• Typically pulseless
• Afterload sensitive
• Preload sensitive
• Anticoagulation
• Should not receive chest compressions during an arrest
• Patients still have heart failure
Potential Device Complications
Outflow graft (kink , leak)
Inflow cannula (poor position,
obstruction)
Drive line infection / fracture
Pump/rotor dysfunction
(thrombus)
Controller malfunction
Battery dysfunction
Hematologic Long-Term Complications
• GI bleed
• 13-40% of LVAD patients
• Constitute 9.8% of LVAD readmissions
• CVA (embolic and hemorrhagic)
• 17% of patients who survived 24 months post-implant
• Hemolysis
• Increases rate of mortality by 25% over six months
“However beautiful the strategy, you
should occasionally look at the results.”
Winston Churchill
Medical Management vs. LVAD
Rose, EA; et al
NEJM 2001;
345:1435-1443
Survival Rates
Kirkland, JK, et. al
JHLT 2013; 32:141-156
ADLs of DT Patients
Kirkland, JK, et. al
JHLT 2013; 32:141-156
What Happens to These Patients?
• Shock Team Evaluation for
mechanical circulatory
support (MCS)
• Try to avoid the bridge to
decision or the bridge to
nowhere
Variations of Short-Term VADs
• Impella 5.0
• Tandem Heart
• CentriMag
• ECMO (V-A)
Impella 5.0
• Utilized for LV support only; not appropriate to
use with RV failure
• Impella 5.0 inserted via femoral or axillary
artery cut down; provides up to 5L of flow
• The catheter is advanced through the ascending
aorta into the left ventricle
• Pulls blood from an inlet near the tip of the
catheter and expels blood into the ascending
aorta
• FDA approved for support of up to 6 hours
TandemHeart pVAD
• Used for LV support; not
appropriate in RV failure
• Cannulas are inserted
percutaneously through the
femoral vein and advanced across
the intraatrial septum into the left
atrium
• The pump withdraws oxygenated
blood from the left atrium and
returns it to the femoral arteries
via arterial cannulas
• Provides up to 5L/min of flow
• Can be used for up to 14 days
CentriMag
• Can be used for LV and/or RV
support
• Cannula are typically
inserted via a midline
sternotomy
• Capable of delivering flows
up to 9.9 L/min
• Can be used for up to 30
days
ECMO (V-A)
• Used for patients with a
combination of acute cardiac
and respiratory failure
• A cannula takes deoxygenated
blood from a central vein or the
right atrium, pumps it past the
oxygenator, and then returns
the oxygenated blood, under
pressure, to the arterial side of
the circulation
• Can be used for days to weeks
Summary
• The management of advanced heart failure is a dynamic process
that requires frequent re-evaluation
• Timing of LVAD placement is critical
• LVADs for DT have been shown to improve mortality rates and
quality of life
• There are short-term VAD options available for emergent situations
Case Study
LN is a 34 year old female with a past medical history of peripartum
cardiomyopathy following the vaginal delivery of her first child nine
months ago. Her LVEF is 20%, and she has NYHA class IV symptoms.
She has been on optimal medical therapy including carvedilol,
captopril, aldactone, and lasix. In addition, she was started on an
outpatient milrinone infusion at 0.25 mcg/kg/min one month ago.
She has been listed for heart transplantation, but due to her blood
type of A- and her body habitus, it is unlikely that a donor heart will
be found quickly.
Case Study
Based on the cast study presented, LN’s peripartum cardiomyopathy
would fall into which of the following categories:
A) Ischemic cardiomyopathy
B) Non-ischemic cardiomyopathy
Case Study
LN is undergoing evaluation for LVAD placement. Based on the case
study, LN would fall into which LVAD category?
A) Destination therapy
B) Bridge to transplantation
C) Bridge to nowhere
D) Bridge to decision
Case Study
LN asks about the benefits of having an LVAD placed. Which of the
following statements is TRUE regarding LVAD placement as a bridge
to transplantation?
A) Patients are guaranteed a transplant if they get a LVAD
B) Most LVAD patients see an improvement in their ability to carry
out their usual activities of daily living
C) A LVAD will make her heart failure resolve
D) She will be able to stop all of her heart failure medication shortly
after LVAD placement
Case Study
Some of the long-term risks associated with LVAD placement include
which of the following:
A) Infection
B) GI bleed
C) CVA
D) All of the above
Case Study
As the ACNP preparing to care for LN in the immediate post-operative
period, you recognize that the following issues will likely be present:
A) LN may be afterload sensitive
B) LN may be preload sensitive
C) LN will likely be pulseless due to her continuous flow LVAD
D) All of the above
Case Study
True/False: If LN’s heart failure continues to advance, you know that
it’s an easy decision to throw her on a short-term VAD such as a
TandemHeart or CentriMag.
A) True
B) False