Stanford Hospital & Clinics Pre-VAD Education VAD team Lisa Guertin, NP VAD Coordinator

Introduction A VAD is one of the treatment options for advanced Heart Failure Stanford invented the first VAD - Novacor It was the first VAD implanted and the first Bridge to transplant in 1984 You and your loved ones play an active role in the VAD implant process Beyond the implant surgery, we have a multidisciplinary team that has lifelong relationship with our VAD patients offering support, education and medical management

5 million Americans have heart failure Heart failure is when the heart muscle becomes impaired The weak heart cannot keep up with the body’s need to pump out blood This can be sudden, or may occur over time

What is a VAD A Ventricular Assist Device is a mechanical pump that helps a weakened heart pump blood throughout the body. The VAD device does not replace the heart. It assists the heart to pump blood, decreasing the workload of the heart. There are both short and long term VADs, single or biventricular devices as well as VADs that must stay in the hospital or that you can go home with.

Bridge to Transplant vs. Destination therapy The team had decided to place you on the transplant list You will be eligible for transplant when the team feels you are ready The VAD will be removed and you will have a new heart implanted You can resume a normal and active lifestyle This is a designation that may change depending on patient status Destination Therapy The team has decided that you are not a candidate for transplant You will live out your life with the VAD You can resume a normal and active lifestyle This is a designation that may change depending on patient status

VAD Evaluation Echocardiogram. Ultrasound of your heart Exercise (VO2) test. Shows the amount of oxygen your heart and lungs can provide to your muscles Right Heart Catheterization. Measures pressures in your heart Left Heart Catheterization. Uses a dye to look at your coronary arteries EKG. Evaluates your heart rhythm Laboratory Tests. Determine blood type, other organ function and exposure to certain diseases Chest Xray. Images heart and lungs Pulmonary Function Test. Determines lung function if you are/were a smoker Carotid and peripheral ultrasounds. Looks for blockages in certain blood vessels Colonoscopy. To ensure you do not have colon cancer Mammogram. To ensure you do not have breast cancer Dental exam. To evaluate your oral health Eye exam Psychosocial evaluation Insurance clearance. This includes covering the cost of the surgery as well as testing and medications after transplant Your doctors may decide if other studies are needed to ensure you are a good candidate for heart transplant

Psychosocial/Psychiatric Evaluation A specialized VAD/transplant social worker will perform a detailed psychosocial evaluation of your candidacy as a VAD recipient Some of the things that will be assessed Your understanding of the VAD process Availability of caregivers before and after implant Coping and stress management barriers/challenges Your compliance with previous medical regimen Mental health history Substance use history

Selection Once all testing and psychosocial evaluation is complete the entire VAD/transplant team comprised of surgeons, cardiologists, nurses, social workers, psychiatrists, financial counselors, and more meet to review your case. The team carefully reviews all of the your information in order to determine if VAD therapy is safe and appropriate for you. Your cardiologist will inform you of the committee’s decision and of alternate therapies in the event that you are not deemed a VAD candidate.

The Surgery An incision is made in the midline of your chest A heart-lung bypass machine will take over the work of the heart and lungs Your VAD will be implanted into your diseased heart to help support it.

Immediately after your VAD implant You will be taken to a bed in North ICU to recover immediately after the implant You will be connected to a ventilator to help you breathe while you awaken from your surgery. This will be discontinued when you can breathe independently You may need a special catheter in one of the big veins in your neck that will monitor the pressure in your heart You will have many IVs and IV pumps delivering medications Chest Tubes will be present to drain fluids from your chest You will have a catheter in your bladder to drain your urine Most patients are in the ICU for 4-5 days after your VAD implant depending on the pace of your recovery You will have a procedure called an Echocardiogram to evaluate how your heart and VAD are working together

Once stable you will be transferred to the step down ICU You will most likely be in a private room once on the step down unit so family can visit, or even spend the night in your room with you You will receive your own set of VAD equipment, and the VAD coordinator will start to teach you and your caregiver about the equipment, how to recognize complications and how to contact the VAD team. Physical and occupational therapists will work with you to build up your strength A dietician will meet with you to discuss a heart healthy diet now that you have a VAD You will continue with blood draws and chest x-rays that monitor response to medications and your recovery

Discharge You will generally be in the hospital for 2 - 3 weeks after implantation. Once you are doing well medically and have learned your equipment, you will be discharged to an apartment/motel located very near Stanford hospital. You will stay in that apartment/motel for a minimum of 2 weeks Sometimes it becomes necessary for you to stay in the area longer if you are experiencing any complications or if your provider deems it necessary You must have a caregiver/support person staying with you for the entire 2 week duration Please ensure you have an alternate person available should your primary caregiver become sick Our social workers will work with you to find accommodations that are affordable for you

Home Monitoring You will need a scale, upper arm blood pressure cuff and thermometer when you are discharged You will chart your weight, blood pressure, temperature and VAD data daily and report these findings to the VAD team at clinic or if there are any changes. It is important that you take these measurements at the same time every day Make sure when doing your daily weight that you have the same amount of clothes on or no clothes on

Clinic Follow Up As a new VAD patient you will be seen very frequently by the VAD team Weekly for 1 month Every 2 weeks for 2 months And monthly thereafter or as needed depending on your status At each clinic visit, you will get lab work done We may ask you to come in for an extra clinic visit if you are not feeling well or we are concerned about your heart function in any way.

VAD Complications Sometimes patients experience complications related to VAD therapy Bleeding Gut Brain Clot Stroke Infection Right heart dysfunction Hemolysis Damage to blood cells due to the pump

Lifestyle change You may not have a palpable pulse or blood pressure by conventional methods You must always wear your VAD equipment! Plan ahead to ensure you will always have an adequate electrical supply Carry a bag with extra supplies with you at all times The VAD exit site will require daily sterile dressing changes Static may interfere with your pump function Modified activity for sternal precautions for 6-8 weeks after surgery

Restrictions No swimming, bath tubs or hot tubs No activities that you run the risk of submersing yourself in water. No jumping No contact sports No MRI

No smoking or drinking

Anticoagulation While on the VAD you will need to take blood thinning medication called Warfarin to decrease your chance of getting a blood clot This medication requires frequent blood draws a few times a week You will also need to take Aspirin, this also thins your blood You will need to take precautions to ensure your safety Protect yourself from injury, you are at an increased risk for bleeding Watch for increased or abnormal bleeding or bruising Use an electric razor You should not take medications containing Ibuprofen You may need to modify your diet There are multiple medication interactions with Warfarin

Precautions Protect your driveline at all times Protect cables connected to your system controller Must always have a power source

Compliance The VAD is a device that requires commitment to living healthily and safely Take all drugs as prescribed Monitor vital signs, weights and VAD data daily Attend all clinic visits Regular exercise Healthy eating Health care maintenance The Stanford VAD team has a lifelong commitment to you to get you through this process by providing information and support.

Routine Health Care It is essential that you have a primary care provider before implant You will continue to have other health needs outside of your VAD that you will need to see a general internist for You will need to keep up regular health maintenance screenings such as colonoscopy, mammogram, prostate exam, pap smear, skin checks If you live a long distance from Stanford, it may be in your best interest to have a cardiologist closer to home. We can often communicate with the cardiologist to help guide care Dental health is important to avoid infection. Ensure you have regular dental check ups and you may need antibiotics before any dental work

General Points You will likely be discharged on 5-10 medications that you will take one or multiple times a day Your list of medications will likely change through out the time you have the VAD NEVER stop or change the doses of your medications unless instructed by the VAD team Take all your medications exactly as directed You will have an individualized regimen Your medications will be reviewed at every clinic visit. Make sure you bring an updated list with you Do not take any new medications or supplements without the VAD teams approval Report any adverse effects of your medications Notify the VAD team if there is any reason you are unable to take your medications REMEMBER – The VAD and medications keep your heart functioning!!