Professional Documents
Culture Documents
Therapy Update-
TCH experience
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Objectives
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Indications for MCS intervention
•All states of cardiac failure that are either reversible (variable
period of time) or that require transplantation
•Patient population
-CMO/Myocarditis
-Malignant arrhythmia
-TCAD- re-transplant?
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Current MCS Protocol at TCH
Child in need of Cardiopulmonary VA ECMO
Respiratory mechanical support support
only Cardiac only
NO BiVAD
YES Expected Recovery biventricular • HeartWare ®
Lung (<2 weeks) support needed
• Syncardia® TAH 50cc: BSA >1.2
Transplant Acute process:
Chronic and <1.8
• Myocarditis NO
only LV process: • Syncardia® TAH 70cc: BSA >1.7
• Acute graft support
rejection • DCM
needed
• Unknown process • End stage CHD
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Individualized VAD Strategy
üCareful evaluation of the patient’s disease process
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Contraindications
•Catastrophic neurologic injury/ intracranial hemorrhage
•Hypercoagulable
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Assist Devices utilized at TCH
Berlin Heart® HeartWare® Heartmate II®
Heartmate III®
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Device Variations
•HeartWare ® (Long term), Heartmate 3 ® (Long term), and Rotaflow ® (Short term)
- Centrifugal Flow (Mag- Lev)- 3rd Generation
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Short Term VAD Support
Indications
- Need for post operative support
•Failure to wean from bypass
•Bridging between forms of MCS
•Temporary RV Support ( w/ LVAD)
- Low cardiac output state
•Not related to surgery
•Myocarditis
•Cardiomyopathy
•Acute transplant rejection
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Impella (Axial flow)
ØMotor size is 12 fr.
ØPlacement is key
Ø (N: 31)
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Maquet Rotaflow (Centrifugal flow)
Constrained Vortex
-Negative Pressure at Inlet of pump
Complications:
-Hemolysis/Thrombosis
-Bleeding
-Temperature maintenance
-Air entrapment
Use: 2009 - present N: 48
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Long Term VAD Support:
Centrifugal Pumps
A magnetically levitated pump rotates and causes
fluid to accelerate before being released at the
outflow port.
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Ø Magnetically suspended Impeller- Hydrodynamic-no bearings,
HeartWare ® made of Titanium- Continuous Flow
Ø Operating speeds of 1800 to 4000 RPM
Ø Can Flow up to 10 LPM
Ø Recommended BSA ≥0.7
Ø Power sources: Battery/Wall/Car adaptors
Ø 6 hrs to charge fully depleted batteries
Ø No Pump Pocket
Ø Smallest patient @ TCH: 13.2kg
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HeartWare® Used to adjust device parameters
Clinical screen Monitor Displays real time and historical
pump information (flow/power,
alarms)
(Password Protected)
Controller
Regulates pump function and
monitors the system
Indicates alarms and battery life
Displays alarms/intervention
Controller has 30 day data storage
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HeartWare® Pump Waveform Characteristics
Flow Waveform
Heart Rate
Maximum value of the HVAD flow waveform (PEAK) Beginning of
> 2 liters above trough) Diastole
Waveform
Peak
• Minimum value of the HVAD flow waveform (TROUGH)
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Long Term VAD Support:
Axial Flow Pumps
Works off of the same principle as
the Archimedes screw.
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Heartmate II ®
Ø Most widely used ventricular assist device in
the world, made of Titanium
Ø Limiting factor is the pump size because a
pump “pocket” must be created for
implantation
Ø Recommended for patients w/ BSA >1.3
Ø Delivers up to 12 liters flow
Ø Power sources: Battery/wall
Ø Battery support: 10-12hrs (pair)
Ø 4 hr recharge time (fully depleted batteries)
Ø Controller supplies 15minutes emergency
power (accidental power d/c)
Ø Controller displays speed/flow/power,
records alarms/data-event recording
Ø Use: 2008-2014 (N: 17)
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Clinical Screen
•Access to:
- Setting adjustments
- (Speed/alarm limits)
- Alarm log file
- Save/transfer data
•Displays:
- Primary operating parameters
- Information updated every second
- Alarms color coded
(red-high priority, yellow- low priority)
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LONG TERM VAD Support:
Pneumatic (Pulsatile) Pumps- Berlin Heart ®
ØFirst generation of ventricular assist devices
Ø(N: 55)
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Driver (IKUS®)-Pump Console
Ø A sturdy mobile driving unit called the IKUS controls the Berlin
pump
Ø Houses compressors (3) and pressure/suction regulators
Ø Displays information about the pump parameters
Ø Access for pump setting adjustments (Password protected)
Ø Computer logs alarms
Ø 30 minute battery supply (hours of service)
Ø Alert every 10 minutes (when on battery)
Ø Power display/hours of service
Ø Hand pump (loss of power)
Ø Weight: 219 pounds
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Long Term VAD Support: Pneumatic (Pulsatile)
Pumps: SynCardia® Total Artificial Heart (TAH)
Size limitation: (10cm AP measured at T10; Pump size: 50mls / 70-mls)
(N: 2)
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SynCardia® TAH System
70cc TAH 50cc TAH
400 ml 270 ml
Implantable TAH
Drivelines
External
Driver
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What we have learned…
VAD Operating Characteristics
• Conditions that may lead to a decrease in preload:
- Compromised right ventricular volume (e.g. RVF, Tamponade)
- Low intravascular volume
Preload
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Protocol Tests Result/Range/Indication
PT-INR (Coumadin) HeartWare/Jarvik: 2-3 (often 2.5-3)
Berlin/TAH : 2.5-3.5
PTT 60-80 (VAD- Heparin- varies with patient)
PTT Hepzyme 70-80 (VAD- BiVAL- varies with patient)
ACT 180-200 (ECMO)
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TCH VAD program approach ~
Benefits of Extended VAD Support
ØNutritional Optimization (BSA growth)
ØStability of home, care system-support system
ØMedication/care/clinic compliance
ØBetter Transplant Candidacy
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Potential Complications
associated w/ VAD therapy…
•Driveline infections
•Epistaxis
•Thromboembolic events
(Improvement w/ BiVAL)
•Renal failure
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Mechanical updates~ New Devices
Jarvik 2015® Pump (Axial flow)
Pumpkin Clinical Trial
Afterload sensitive
No Inflow
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Jarvik 2015® Pump (Axial flow)
Used for >8kg and <30kg (Fits 6 kg)
Jarvik supported-
see controller and batteries
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System Components Overview
Lithium-ion Battery
FlowMaker Controller
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Jarvik 2015 Performance (HQ curve)
Typical MAP (via arterial pressure line or doppler) = 60 mmHg
Typical CVP (via venous pressure line or estimated) = 10 mmHg
Pressure drop across VAD (outlet P – inlet P) = 60 – 10 = 50 mmHg
Pump speed = 16,000 rpm
DP = 50 mmHg
PO = 2.4 LPM
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Mechanical updates ~ New Devices
Heartmate III® (Centrifugal flow)
• Made of Titanium-Fully Magnetically Levitated
• Large pump gap-space designed to reduce blood trauma across rotor
• Artificial pulse (automatic speed ramp every 2 seconds by 2000rpm)
• Textured blood contacting surfaces (creates pseudo-neo-intima)
• Full support (2 – 10 L/min)
• Modular Driveline (replacement of portion if damaged)
• Pocket Controller displays 6 recent alarms, flow/speed/power/PI
• Battery supply 10-12 hrs/mobile power unit
• Requires BSA ≥ 1.2
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Power Module (Hmate II)
System Components
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TCH VAD program approach…
Ø VAD evaluation protocol checklist
Ø VAD training pre -> post implant
Ø Close the Pre-implant education loop
with patient/families meeting (VAD
Ambassadors)
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HeartWare® Placement Techniques
•The standard Intra-
pericardial placement often
results in unfavorable inflow
arrangement
•Infra-diaphragmatic
placement decreases angle
of inlet to septum
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Adachi, I. A modified implantation technique of the HeartWare ventricular assist device for pediatric patients.
J Heart Lung Transplant 2015 Jan;34(1):134-6
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HeartWare® HVAD
Driveline Placement Technique
“Rectus Sparing Approach”
Ø Driveline is the Achilles’ Heel of
implantable VAD’s
Ø Less developed abdominal wall
muscles in sick children
Ø Reduce trauma to tunneling track
Ø Reduces postoperative
pain/inflammation
Ø Assists in prevention of driveline
infections
Ø Better “seeding” “ingrowth” of the
driveline (anchored!)
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Image © 2014 Texas Children’s Hospital
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TCH VAD approach~
Complicated Anatomy
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TCH VAD approach ~
Can a heart remodel / recover?
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TCH VAD program
approach…individualized care
Some dressings/vad packs too big, some too smallà find the size that works
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TCH VAD program ~ Dedicated VAD Clinic
-Regimented Outpatient protocol
-Labs
-Doppler BP management
-Screening speed adjustment ECHO
-RHC
-Cardiac CT
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Community Integration- Outreach back
to local area
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Home discharge locations of
current TCH VAD supported
patients as of 4/2019
Snyder Dallas
Round Rock
Austin Orange
Houston LaPorte
Clear Lake
Laredo
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Patients return to home, school,
celebrating family and life...
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Camp Pump it Up….
(Letting kids be kids)
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1st Annual TCH
VAD Celebration Day 6/30/2018
Coming to 8/9/2019- 2nd Annual TCH SUPER-HERO VAD CELEBRATION DAY…save the
date…details to come…
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Key Points
•Pediatric VAD patients have good outcomes and can be discharged home safely
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Challenges
Program development-financial support-education
Availability of technology
Sizing of device to fit child - inflow cannula placement
Timing of device implant, transitioning to adult program
Anatomic/Congenital challenges/Prior Surgery
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Future Directions…..
üSmaller device “Miniaturized”
ü“Water Proof”
üDurable components
ü“Cordless” driveline
ü“Pediatric friendly”
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Future Developments
Synergy (CicuLite)®
Heart Assist 5 ®
Pedia Flow®
HeartWare® MVAD
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If I only had a
“Heart” -VAD
Thank you !!
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