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LVAD BASICS HEART MATE II

LVAD BASICS HEART MATE II. Continuous flow axial pump FDA approved for BTT , DT, BTD Valve less system Generates 10 liters of output (4-7L) Runs in fixed mode RPM 8-13 (8-10)

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LVAD BASICS HEART MATE II

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  1. LVAD BASICSHEART MATE II • Continuous flow axial pump • FDA approved for BTT , DT, BTD • Valve less system • Generates 10 liters of output (4-7L) • Runs in fixed mode RPM 8-13 (8-10) • Continuous unloading of LV throughout cardiac cycle this eliminates arterial pulse Use of doppler for b/p measurement MAP 70-90

  2. BENEFITS OVER PULSATILE PUMPS • Lighter and smaller than pulsatile pumps • May be used in smaller patients • Quiet • Increased durability • Better suited for long term support • Improve hemodynamics, end organ function quality of life and functional capacity

  3. SURGICAL PROCEEDURE • Median Sternotomy • Inflow cannula apex of LV • Outflow cannula anastomosed to ascending aorta • Pump placed in pre peritoneal position, intra abdominal placement can also be used • Driveline positioned in a gentle loop with punch or slit through muscle and stabilized with a suture

  4. CRITICAL ELEMENTS FOR SUCCESSFUL LVAD • Patient Selection • Pre op preparation • Timing of implant • In a word RESPECT the RV

  5. PATIENT SELECTION Appropriateness for VAD support based on degree of illness Ability to successfully undergo surgery Family support Implant prior to end organ damage Class IIIB IV Maximal medical therapy Peak VO2< 14ml/kg/min. Heart failure survival score/Seattle Heart Failure Model estimates HF survival 1-2 years

  6. PRE OPERATIVE PREPARATION • OPTIMIZE RV as RV failure leading cause of morbidity and mortality with LVAD • Echo to assess RV size, function and tricuspid regurg. • RHC initially and prior to implant for diuresis and unloading with inotropes IABP • RVSWI may be a predictor of RV function • Ie CVP<15, PVR<4 wood units, transpulmonary gradient < 15mmHg, RVEDV 200cc RVESV <177

  7. TIMING OF IMPLANT • Prior to end organ damage renal liver malnutrition • Opt to delay until co morbidities can be reversed or controlled • Prior to RV dilatation/decreased function • Trend towards earlier implant and referral

  8. CASE STUDY • Mr. MO is a 46 year old African American male with a history of MI at the age of 26 with normal EF, PVD s/p fem pop bypass 2005 diabetes 2007 and HLD. Treated appropriately and. was compliant • Admitted to hosp Jan 09 for decompensated HF Echo showed an EF of 20% normal RV size and function Diuresed and placed on appropriate medications.

  9. MEDICATIONS • Coreg 6.25 bid • Hydralazine 25 tid • Imdur 30 qd • Januvia 100 qd • Digoxin .125 • Lasix 40 qd • Aldactone 25 • Lipitor 80 qd

  10. FURTHER TREATMENTS • ICD implanted for Primary prevention 2/9 echo with EF 15% • 5/10 Upgraded to BIVICD 6/24 • Much improved post BIV implant Walking 3 miles a day • Further Medication titration Coreg 25 • Echo repeated 9/13 improvement in EF to 20-25% RV normal new wall motion abnormality

  11. Angiogram mid LAD occlusion distal filling mod pulmonary HTN Admitted post angiogram for diuresis secondary to elevated pressures RA 23 PCWP 31 BNP 2550 diuresed and felt better • 9/10 Seen in office stable but decreased activity tolerance CPX ordered Prelim VAD transplant discussion initiated

  12. CPX 8.6 unable to complete test • Zaroxolyn added twice a week • Family meeting with VAD coordinator • W/U initiated • 11/18 RHC RA 26 PCWP 23 CI 1.9 Echo mod TR EF 25 normal RV • 12/10 Lengthy discussion re VAD/Transplant he feels he is too healthy and wants to think about

  13. 1/11 Admitted for decompensated HF abd distension wt gain able to walk 100 feet BNP 2550 ECHO EF 20% RV mildly dilated • 2/11VAD discussion intensify still feels he is too healthy despite medical evidence to contrary. • 3/16 Admitted for decompensated HF PICC line placed for home dobutamine continues to refuse VAD • 4/9 Admitted with fever chills Creat 4 MRSA from PICC Paracentesis for 3 L Agrees to go for VAD eval • 5/17 Denied VAD/Transplant due to severe RV failure

  14. DISCUSSION • Paucity of effective therapies for advanced heart failure which led to evolution of assist devices. • REMATCH TRIAL pivotal trial • Increase in number of LVADS implanted past 3 years in large part due to HMII • 6 Pulsatile and 9 continuous flows in trials not approved YET. • Learning curve as with anything More you implant the better you do.

  15. STATISTICS • Survival Rematch trial one year 23% with pulsatile • Transition from pulsatile to continuous dramatic beginning in 2008 98% of adult LAVD implanted • One year survival 74% 2 year 66%(cont) 67% one year 46% 2 year pulsatile • Increase in DT and decrease in implants for C shock 35 to 17% • DT accounts for 15% of all implants

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