Ventricular Assist Device VAD Patients in the Community

Ventricular Assist Device (VAD) Patients in the Community Liz Amerman, RN, BSN IU Health Methodist VAD Program Manager April 18, 2012 11/25/2020 1

Learning Objectives § Discuss available ventricular assist devices for home use § Review clinical indications for placement of ventricular assist devices § Understand VAD patient care requirements in the home environment § Case studies 11/25/2020 2

Heart Failure in the US • Heart failure accounts for 34% of cardiovascular-related deaths • 670, 000 new cases of heart failure are diagnosed in the US every year • 277, 000 deaths are caused by heart failure each year • Heart failure is the most frequent cause of hospitalization in patients older than 65 years, with an annual incidence of 10 per 1, 000 • Rehospitalization rates during the 6 months following discharge are as much as 50% • 2010 estimated total cost of heart failure in US $39. 2 billion, representing 1 -2% of all health care expenditures 11/25/2020 3

Disease Progression Jessup, NEJM 2003 11/25/2020 4

Heart Transplants in US 11/25/2020 5

Volume of VAD Patients Year 2012 Patient Volume 34 BTT 12 BTD 4 DT Device Types 22 29 HM II, 5 Heartware, 4 Abiomed Replaced 2 HM II 2011 27 11 0 16 20 HM II, 5 Heartware, 2 Thoratec, 1 Abiomed 1 patient had a HM II and Abiomed 2010 2009 31 32 18 17 4 11 9 (1 replaced) 4 (2 replaced) 19 HMII; 4 Heart Ware; 3 L P/I-VAD, 5 Abiomed 17 HMII, 15 Abiomed, 1 Thoratec 1 patient had a HM II and Abiomed Additional Device Implants: 2012: 19 - 2 Tandem. Hearts, 17 Impella ( 10 – 5. 0, 7 – 2. 5) 2011: 7 Impella and 3 Tandem. Heart 2010: 4 Impella We had a total of 52 patients and 57 devices for 2012 11/25/2020 6

Defining A Ventricular Assist Device • A VAD is designed to circulate the blood in the pulmonary and/or systemic circulation when the natural heart is unable to maintain normal blood flows and pressures. 11/25/2020 7

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Indications for Use • Bridge to Recovery/Decision (BTR/BTD) – Postcardiotomy Shock – Acute MI – Cardiac Disorders such as Viral Myocarditis • Bridge to Transplant (BTT) – Cardiomyopathies – Failed Cardiac Transplant • Destination Therapy (DT)– improve quality of life when not a transplant candidate 11/25/2020 9

Contraindications for VAD • Central Nervous System damage before or during operative procedure • Body Surface Area (BSA) < 1. 2 m² for some assist devices 11/25/2020 10

Criteria Evaluated Before Getting A VAD • Physical and psychosocial evaluation • Good support group • BTT requirements • DT requirements • Pre-VAD meeting with the VAD team • Presented to Advance Heart Failure Board for acceptance Not everyone can get a VAD!! 11/25/2020 11

Choosing the appropriate VAD § Does the patient need a Left, Right, or Biventricular Assist Device. § Size of the patient. § Short or long term use needed. § What hospital the patient is in. 11/25/2020 12

Types of VAD’s • Abiomed • Thoratec – IVAD and PVAD • Heart. Mate – XVE and HM II • Heart. Ware 11/25/2020 13

Abiomed § Left, Right, or Biventricular § Short term use - months § Patient size irrelevant § Bridge to Recovery § Bridge to Transplant § NOT for Destination Therapy § Outlying hospitals can implant emergently – Patient then transferred to Methodist by Lifeline 11/25/2020 14

Thoratec – PVAD or IVAD § Left, Right, or Biventricular support § Short or long term use § Patient size irrelevant § Bridge to Recovery § Bridge to Transplant § NOT for Destination Therapy Implantable or Paracorpeal 11/25/2020 15

Thoratec 11/25/2020 16

Heart. Mate XVE and II § Left ventricular assist device only § Long term use § BSA must be >1. 2 for HM II and >1. 5 for HM XVE Pulsatile or axial flow § Bridge to transplant § Destination therapy 11/25/2020 17

Heart. Mate XVE 11/25/2020 18

Heart. Mate II 11/25/2020 19

Heartware l l l Left ventricular assist device only Long term use BSA must be >1. 2 Centrifugal pump Bridge to transplant § Destination therapy 11/25/2020 20

Heart. Ware 11/25/2020 21

Blood Pump Differences Thoratec/Abiomed • Pulsatile pump • Valves allowing unidirectional flow • Vacuum assist filling • Asynchronous pulsatile VAD • Need to start anticoagulation earlier 11/25/2020 Heart. Mate/Heartware §Continuous flow pump §Valveless §Afterload sensitive – retrograde flow §Follows native pulse §Pump output varies over cardiac cycle 22

Comparison of Pulsatile and Axial Flow (Both have average flow between 4 -5 L/min) 11/25/2020 23

Pump Rotor and Stators Flow Outflow Stator 11/25/2020 Rotor Outflow Bearings Inflow Stator Inflow Bearings 24

Heart. Mate II ØBlood pump rotor is the only moving part ØRotor spins on blood –lubricated bearings designed for long life 11/25/2020 25

What it takes to get a patient home! • Recovery • Education • Excursions • Discharge – home environment 11/25/2020 26

Recovery • Hemodynamic stability • Nitric Oxide or Flolan • Dobutrex or Milrinone • Cardiac Tamponade • Anticoagulation • Pain management • Infection 11/25/2020 27

What it takes to get a patient home! • Education Process –Driveline Dressing change –Learning the VAD –Alarms and troubleshooting VAD –Handling an emergency –Excursions 11/25/2020 28

Daily Checks § Recording VAD settings § Monitoring trends § Assessing preload and afterload § Alarm tests § Dressing change § Monthly assessing VAD equipment for any problems – i. e. - exposed wires 11/25/2020 29

Emergency Resources • Advance Heart Care Clinic has 24/7 on call • Local ER • Fire station • Electric company • Caregiver/Ambulance/Lifeline transfer if needed 11/25/2020 30

Emergency Situations • Assess patient and VAD monitor • Check connections • OK to intubate, defibrillate, and give medications • If need to defibrillate NO disconnection required • Can DO chest compressions if you cant get pump running • Close monitoring of fluid status and MAP

Down the line…… • Right Heart Failure • Debilitation • Cardiac Arrhythmias • Device Failure • Co-Morbidities • Infection • Hospice/End of Life • Cost 11/25/2020 32

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A Successful VAD Program • MD’s – Surgeon and Cardiologist • VAD Coordinator • Nurse Practitioners • Social Worker • Bedside Nurse • Pharmacist • Dietician • Respiratory Therapist • Physical and Occupational Therapist • Transplant Coordinators • Research Nurse’s • Chaplin 11/25/2020 34

Survival Rates June 2006 -Q 4 2012 n=158 IU Health Pagani INTERMACS *Patient survival post implant Kaplan-Meier Survival Analysis Pagani et. al, JACC, 2009 11/25/2020 35

Survival Rates 2011 -2012 n = 60 IU Health INTERMACS Pagani *Patient survival post implant Kaplan-Meier Survival Analysis Pagani et. al, JACC, 2009 11/25/2020 36

New York Heart Association NYHA Class Symptoms I II IV 11/25/2020 No symptoms and no limitation in ordinary physical activity, e. g. shortness of breath when walking, climbing stairs etc Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e. g. walking short distances (20– 100 m). Comfortable only at rest. Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients. 37

Quality of Life Functional status six months post-implant NYHA Class assessed for every patient at 6 month visit June 2011 – June 2012, n=25* Class I 17 patients 68% 92% Class II 6 patients 24% Class III 2 patients 8% Class IV *All patients are Class III or IV before VAD implantation 32 Patients evaluated 25 patients reached 6 months 7 patients NOT Included. 4 deceased, 1 transferred care and 2 transplanted. Benchmark: NYHA Class I & II = 89% at 6 months 11/25/2020 Pagani et. al, JACC, 2009 Data Source: MCCM 38

References "Advanced Practice Guidelines for Heart. Mate Destination Therapy. " Guidelines 2(2004): 1 -38. American Heart Association (2009). Heart disease and stroke statistics 2009 update at a glance (Our guide to current statistics and the supplement to our heart and stroke facts). Retrieved January 2009 from http: //wwwamericanheart. org. Thoratec Corporation, "Your Guide to Successful LVAS Patient Discharge. " Heart. Mate Left Ventricular Assist System (LVAS) Community Living Manual. 1 st Ed. 2004. United Network For Organ Sharing (2011). Heart transplant statistics for 2011. Retrieved February 2012 http: //www. unos. org Mariell Jessup, M. D. , and Susan Brozena, M. D. Heart Failure. N Engl J Med 2003; 348: 2007 -2018 May 15, 2003 11/25/2020 39

To Learn More About VAD’s • www. abiomed. com • www. thoratec. com • www. americanheartassociation. org • www. heartcenteronline. com • www. optn. org • www. healthatoz. com • www. nlm. nih. gov 11/25/2020 40