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Advanced Heart Failure and the Role of Mechanical Circulatory Support

Megan Shifrin, RN, MSN, ACNP-BC Vanderbilt University. Advanced Heart Failure and the Role of Mechanical Circulatory Support. Objectives. Review current recommendations for advanced heart failure management Identify the different types of VADs currently in use

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Advanced Heart Failure and the Role of Mechanical Circulatory Support

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  1. Megan Shifrin, RN, MSN, ACNP-BC Vanderbilt University Advanced Heart Failure and the Role of Mechanical Circulatory Support

  2. 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

  3. 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.

  4. The Cost of Heart Failure Management in the United States Total Cost $39.2 billion Hospitalization$20.9 53.3% Nursing Home$4.7 11.9% 6.4% 10.5% Physicians/Other Professionals$2.5 8.2% Lost Productivity/Mortality* $4.1 9.7% Drugs/Other Medical Durables$3.2 Home Healthcare$3.8 Heart Disease and Stroke Statistics—2010 Update: A Report From the AHA Circulation, Feb 2010; 121: e46 - e215

  5. 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

  6. New York Heart Association Functional Classification of Heart Failure Increasing Severity Class I Class II Class IIIa and IIIb Class IV • Mild symptoms (mild shortness of breath and/or angina) • Slight limitation during ordinary activity • Cardiac disease • No symptoms • No limitation in ordinary physical activity • Marked limitation in activity due to symptoms • Comfortable only at rest • Severe limitations • Symptoms even while at rest • Mostly bedbound patients

  7. Goals of Heart Failure Management • Improving symptoms and quality of life 2. Slowing the progression or reversing cardiac and peripheral dysfunction 3. Reducing mortality

  8. Addressing Heart Failure in 2013 Katz AM Heart Failure

  9. Pharmacologic Optimization of the Heart Failure Patient with LVEF <40%(Strength of Evidence = A) • ACE inhibitors • ARBs • To be utilized when intolerant to ACE inhibitors due to angioedema or cough • Patients intolerant to ACE-I due to renal insufficiency or hyperkalemia are likely to experience the same effects with ARBs • Warfarin • In patients with atrial fibrillation, pulmonary embolism, or TIA • Beta Blockers • Aldosterone Antagonists • Hydralazine and IsosorbideDinitrate • In African American population with stage III and IV heart failure, strength of evidence = A • Loop Diuretics Lindenfeld, J, et al. J Card Failure 2010; 6, 486-491

  10. Pharmacologic Optimization of the Heart Failure Patient with LVEF <40% Strength of Evidence = B • Antiplatelet agents (Aspirin) • Ischemic etiology of HF • Digoxin • In stage II and III HF • Thiazide diuretics • Warfarin • MI patients with LV thrombus Strength of Evidence = C • Digoxin • In stage IV HF • Metalazone Lindenfeld, J, et al. J Card Failure 2010; 6, 486-491

  11. Pharmacologic Optimization of the Heart Failure Patient with LVEF <40% Inotropes • Commonly used on an outpatient basis for stage IIIb – IV heart failure • Milrinone and Dobutamine are the only FDA approved drugs for outpatient use • Not recommended for acute heart failure exacerbations in ischemic patients • Probable benefit in non-ischemic exacerbations • OPTIME-CHF JAMA 2002; 287:1541-7

  12. Non-pharmacologic Optimization of the Heart Failure Patient with Low LVEF Cardiac Resynchronization Therapy (CRT) • LVEF <35% • NYHA class III – IV • QRS > 120 ms • Optimal medical therapy

  13. Non-pharmacologic Optimization of the Heart Failure Patient with Low LVEF Implantable Cardiac Defibrillators • Ischemic Etiology • (Strength of Evidence = A) • Non-ischemic Etiology • (Strength of Evidence = B) • Primary prevention of ventricular arrhythmias • LVEF <35% Lindenfeld, J, et al. J Card Failure 2010; 6, 486-491

  14. Evidence of Progressing Heart Failure • Decreased end organ perfusion • Renal function • Liver function • Pulmonary function We need more support!

  15. 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 Implanted surgically with the intention of support for months to years Short-Term LVAD Utilized for urgent/ emergent support over the course of days to weeks

  16. 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?

  17. 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 CurrOpinCardiol 2009, 24:246–251

  18. Destination Therapy vs. Bridge to Transplantation Long-term placement • Destination Therapy (DT) • Not a heart transplant candidate • NYHA IV • LVEF <25% • Maximized medical therapy >45 of 60 days; IABP for 7 days; OR 14 days • Functional limitation with a peak oxygen consumption of less than or equal to 14 ml/kg/min • Life expectancy < 2 years • Bridge to Transplantation (BTT) • Patient is approved and currently listed for transplant • NYHA IV • Failed maximized medical therapy http://www.cms.gov/medicare-coverage-database

  19. Adult FDA Approved LVADs Destination Therapy (DT) HeartMate II (Thoratec) Bridge to Transplantation (BTT) HeartMate II (Thoratec) HeartWare (HeartWare) PVAD (Thoratec) IVAD (Thoratec)

  20. HeartMate II (Thoratec)

  21. 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

  22. Immediate Post-op Management VS

  23. Management Considerations • Typically pulseless • Use a doppler or arterial line for BP assessment (Target MAP 60-80) • Afterload sensitive • An increase against pump propulsion is reflected in decreased pump flow • Preload sensitive • Anticoagulation status • Correction of coagulopathy immediately post-operatively • At 24-48 hours, Warfarin with goal INR 2-3 +/- Aspirin, Dipiridamole, Clopidogrel • Should not receive chest compressions during an arrest • Patients still have heart failure

  24. Potential Device Complications Outflow graft (kink , leak) Inflow cannula (poor position, obstruction) Drive line infection / fracture Pump/rotor dysfunction (thrombus) Controller malfunction Battery dysfunction

  25. 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

  26. “However beautiful the strategy, you should occasionally look at the results.” Winston Churchill

  27. Medical Management vs. LVAD Rose, EA; et al NEJM 2001; 345:1435-1443

  28. Survival Rates Kirkland, JK, et. al JHLT 2013; 32:141-156

  29. ADLs of DT Patients Kirkland, JK, et. al JHLT 2013; 32:141-156

  30. 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

  31. Variations of Short-Term VADs • Impella 2.5 and 5.0 • Tandem Heart • CentriMag • ECMO (V-A)

  32. Impella 2.5 and 5.0 • Utilized for LV support only; not appropriate to use with RV failure • Impella 2.5 can be inserted through the femoral artery during a standard catheterization procedure; provides up to 2.5 L of flow • 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

  33. TandemHeartpVAD • 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 atriumand returns it to the femoral arteries via arterial cannulas • Provides up to 5L/min of flow • Can be used for up to 14 days

  34. 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

  35. ECMO (VA) • 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

  36. 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

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