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

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
Hospitalization $20.9
Total Cost $39.2 billion
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
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

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 Isosorbide Dinitrate
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,

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,

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,

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. Interagency Registry for Mechanically Assisted Circulatory Support
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

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

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 ManagementVS

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 hours, Warfarin with goal INR /- 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:

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

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

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. 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

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