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Who Should Not Receive a VAD: Pragmatism and Futility in Patient Selection

Who Should Not Receive a VAD: Pragmatism and Futility in Patient Selection. INTERMACS 9 th Annual Meeting MCSD: Evolution, Expansion, and Evaluation May 15-16, 2015. Disclosures: None. Joseph G. Rogers, MD Professor of Medicine Duke University.

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Who Should Not Receive a VAD: Pragmatism and Futility in Patient Selection

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  1. Who Should Not Receive a VAD: Pragmatism and Futility in Patient Selection INTERMACS 9th Annual Meeting MCSD: Evolution, Expansion, and Evaluation May 15-16, 2015 Disclosures: None Joseph G. Rogers, MD Professor of Medicine Duke University

  2. Contraindications to VAD Therapy: Clinical Trial Definitions • Mechanical aortic valve without plan to replace or close • Thrombocytopenia • Other condition that limits survival to < 24 months • Uncontrolled, systemic infection • Recent stroke or cerebrovascular disease that increases risk for intra-operative CVA • Contraindication to systemic anticoagulation or antiplatelet therapy • Significant right heart failure • Psychosocial instability (ongoing substance abuse, lack of care giving plan, non-compliance)

  3. Who is (or is not) a VAD Candidate?Duke Criteria • Sick but not too sick • Not too old • Not too much right heart failure • Not too much renal dysfunction • Not too malnourished • Not too septic • Not supported on mechanical ventilation for too long • Not too crazy

  4. The Impact of Illness Severity on MCS Outcomes J Heart Lung Transplant 2008;27:1065-72 Anticipated Survival without VAD X J Heart Lung Transplant 2011;30:155-23 J Heart Lung Transplant 2013;32:141-56 J Heart Lung Transplant 2014;33:555-64

  5. How Old is Too Old? J Am Coll Cardiol 2013;61:313-21 J Am Coll Cardiol 2011;57:2487–95

  6. Issues of Nutrition (Low) Markers of Poor Nutrition • BMI < 20 kg/m2 • Pre-albumin < 15 mg/dl • Transferrin > 250 mg/dl • Total Cholesterol < 130 mg/dl • Lymphocyte Count < 100 Strategies • PO supplements • Enteral nutrition • TPN (last resort) J Heart Lung Transplant 2010: (4 Suppl):S1-39.

  7. Chronic Biscuit Poisoning Obesity not a contraindication • Devices may provide adequate support • Has not impacted outcomes • May be contraindication for transplant • Patients not losing weight on VAD support J Heart Lung Transplant 2010: (4 Suppl):S1-39.

  8. I shall not attempt to further define the kinds of material I understand to be embraced within the short-hand description of hard-core pornography and perhaps I should never succeed in intelligibly doing so. But I know it when I see it… Uh…. I think that fella is too frail for a VAD. Joseph Rogers, MD Potter Stewart , Associate Supreme Court Justice

  9. The Importance of Frailty in LVAD Patient Selection Circ Heart Fail 2012;5:286-93

  10. Decision-Making in Advanced Heart Failure VT Right heart failure Infection risk Urgency Malignancy Infection risk Renal insufficiency Older Age DT VAD ECTx

  11. The Importance of RV Function in MCS • Pre-implant diagnosis is challenging • Definition • Need for inotropic support > 14 days • Need for RVAD • Limits device function by reducing pre-load • Associated with end-organ dysfunction and prolonged LOS • Important cause of post-implant morbidity and mortality • MSOF • New description of “late” RV failure, etiology unknown J ThoracCardiovascSurg 2010;139:1316-24

  12. Predictors of Post-LVAD RV Failure Clinical • Pre-implant mechanical ventilation • Pre-implant renal or hepatic dysfunction • Need for vasopressors Hemodynamic • High RA, low PA • CVP:PCWP pressure > 0.63 • RVSWI < 300 mmHgxml/m2 Echocardiographic • RV size and function • Tricuspid insufficiency • TAPSE • RV Strain

  13. Hepatic Function & Coagulopathy • Determine etiology of hepatic dysfunction • LFT’s • Serologies • Liver biopsy to r/o cirrhosis • If labs are normal the liver disease may be well compensated • The minimum screen for coagulation abnormalities should include: • PT/INR, PTT • Platelet count • Platelet aggregation studies • HIT assay (Heparin induced thrombocytopenia, platelet antibody) Clinical Management of Continuous-flow LVADs JHLT 2010: 1-39.

  14. The Impact of LVAD on Ventricular Arrhythmias • 100 consecutive VAD patients • Mean age=51 yrs, 63% ischemic J Am Coll Cardiol 2005;45:1428-34

  15. Neurologic, Psychosocial, and Psychiatric Considerations • Assess candidates’ ability to: • Care for equipment • Exercise • Comply • Consider history of psychiatric disorders, drug abuse • Psychosocial support team • Address advanced directives Clinical Management of Continuous-flow LVADs JHLT 2010: 1-39.

  16. Who Should not be Treated with a VAD • It is often not evidence-based or entirely clear. • Be mindful of • The aged and frail • The under- and over-nourished • Those with VT • Those with right heart failure • Those with primary coagulopathy and liver disease • The crazy people whose mothers don’t love them

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