Heart Failure and VADs

MEHDI BAKHSHI
MSN,PhD
ICNS
 Etiologies of cardiac failure
Coronary artery disease
Idiopathic cardiomyopathy
Peripartum cardiomyopathy
Dilated cardiomyopathy
Ischemic cardiomyopathy
Acute valvular disease
Arrhythmia (supraventricular or ventricular)
Myocarditis
Congenital heart disease
Drug induced
Diabetes mellitus
Hypertension
Pathogenesis of Heart Failure
 NYHA classes
Class Patient Symptoms
Class I (Mild) No limitation of physical activity. Ordinary physical
activity does not cause undue fatigue, palpitation, or
dyspnea (shortness of breath).
Class II (Mild) Slight limitation of physical activity. Comfortable at
rest, but ordinary physical activity results in fatigue,
palpitation, or dyspnea.

Class III Marked limitation of physical activity. Comfortable

(Moderate) at rest, but less than ordinary activity causes fatigue,
palpitation, or dyspnea.
Class IV (Severe) Unable to carry out any physical activity without
discomfort. Symptoms of cardiac insufficiency at
rest. If any physical activity is undertaken,
discomfort is increased.
 CVD deaths vs. cancer deaths by age (US)

1,000
Deaths in Thousands

831
800
560
600

400 315
242
165
200 120 138
48 50 81 101 85
25 21
0
<45 45-54 55-64 65-74 75-84 85+ Total
Ages

CVD Cancer
 CVD and other major causes of death for all males and females

500,000
398,563 432,709
400,000
290,069 269,819
Deaths

300,000

200,000
78,941 59,260 65,323 42,658
100,000 36,006 51,281
0
A B C D E A B D F C

Males Females

A CVD D Chronic Lower Respiratory Diseases

B Cancer E Diabetes Mellitus
C Accidents F Alzheimer’s Disease

NCHS and NHLBI 2006

 Economic Ramifications
Prevalence 1-2% population 5 million individuals

Cost 1-2% total health care $35 billion

spending

Incidence (per year) 550,000 new diagnoses 300,000 deaths

Hospitalizations 6 days (average) 50% rehospitalized

within 6 months

www.americanheart.org
 Options for Advanced CHF
Transplant ($$$$$$)
Assist Device ($$$)
Die($)
– Preceded by 6-12 months of medical therapy
– Multiple hospital re-admissions
– Hospice ($$$)
 Historical Events
1953: Gibbon’s heart-lung
machine successfully used
during ASD repair

1950 1960 1970 1980 1990 2000 2010

John Gibbon
Born in 1903 in Philadelphia
4th generation physician
1931: watched a young woman
postop from cholecystectomy
die from PE
Worked for 20 years on dogs to
refine bypass machine
Received financial and
technical support from Thomas
Watson of IBM
1953: first successful use of
machine on patient during ASD
repair
 Historical Events
1953: Gibbon’s heart-lung
machine successfully used
during ASD repair

1963: DeBakey implants first

VAD in patient with
postcardiotomy shock

1950 1960 1970 1980 1990 2000 2010

 Historical Events
1953: Gibbon’s heart-lung
machine successfully used
during ASD repair

1963: DeBakey implants first

VAD in patient with
postcardiotomy shock

1950 1960 1970 1980 1990 2000 2010

1967: Barnard performs

first heart transplant
 Christian Barnard
Born in South Africa in 1922

Studied heart surgery at the

University of Minnesota then
returned to set up a cardiac unit
in Cape Town.

December 1967: transplanted the

heart of a road accident victim
into a 59 year old patient

Patient only survived 18 days due

to infectious complications
 Historical Events
1953: Gibbon’s heart-lung
machine successfully used
during ASD repair

1963: DeBakey implants first

VAD in patient with
postcardiotomy shock

1968: Shumway
performs first heart
transplant in US

1950 1960 1970 1980 1990 2000 2010

1967: Barnard performs

first heart transplant
 Norm Shumway

Stanford University
1959: transplanted the heart of a
dog into a 2-year-old mongrel
1968: performed the first heart
transplant in the US on a 54 year
old steel worker who lived 14
days
Pioneered immunosuppression
1981: performed the world’s
first successful heart-lung
transplant
 Historical Events
1953: Gibbon’s heart-lung
machine successfully used
during ASD repair

1963: DeBakey implants first

VAD in patient with
postcardiotomy shock

1968: Shumway
performs first heart
transplant in US

1950 1960 1970 1980 1990 2000 2010

1969: Cooley implants VAD

as bridge to transplant
1967: Barnard performs
first heart transplant
Willem Kolff
“Father of artificial organs”
1911: Born in the
Netherlands
1940: Established the first
blood bank in Europe
1943: Developed the first
artificial kidney
1957: Developed the first
artificial heart that was
successfully transplanted
into an animal
 Historical Events
1953: Gibbon’s heart-lung
machine successfully used
1984: implantation of Jarvik-7
during ASD repair
artificial heart by DeVries

1963: DeBakey implants first

VAD in patient with
postcardiotomy shock

1968: Shumway
performs first heart
transplant in US

1950 1960 1970 1980 1990 2000 2010

1969: Cooley implants VAD

as bridge to transplant
1967: Barnard performs
first heart transplant
William DeVries
Born in 1943
Trained at the University of
Utah and Duke University
Worked with Kolff to
implant artificial heart in
animals
1982: Implanted first
artificial heart into Seattle
dentist Barney Clark
1985: Implanted 2nd
Jarvik into Bill Schroeder
in Louisville KY
 Historical Events
1953: Gibbon’s heart-lung
machine successfully used
1984: implantation of Jarvik-7
during ASD repair
artificial heart by DeVries

1963: DeBakey implants first 1994: FDA approval

VAD in patient with of LVAD as bridge
postcardiotomy shock to transplant

1968: Shumway
performs first heart
transplant in US

1950 1960 1970 1980 1990 2000 2010

1969: Cooley implants VAD

as bridge to transplant
1967: Barnard performs
first heart transplant
 Historical Events
1953: Gibbon’s heart-lung
machine successfully used
1984: implantation of Jarvik-7
during ASD repair
artificial heart by DeVries

1963: DeBakey implants first 1994: FDA approval

VAD in patient with of LVAD as bridge
postcardiotomy shock to transplant

1968: Shumway
performs first heart
transplant in US

1950 1960 1970 1980 1990 2000 2010

1969: Cooley implants VAD 2004: REMATCH trial

as bridge to transplant
1967: Barnard performs
first heart transplant
 Historical Events
1953: Gibbon’s heart-lung
machine successfully used Heart mate II
1984: implantation of Jarvik-7 approved for
during ASD repair
artificial heart by DeVries destination therapy

1963: DeBakey implants first 1994: FDA approval

VAD in patient with of LVAD as bridge
postcardiotomy shock to transplant

1968: Shumway
performs first heart
transplant in US

1950 1960 1970 1980 1990 2000 2010

1969: Cooley implants VAD 2004: REMATCH trial

as bridge to transplant
1967: Barnard performs
first heart transplant
 What is a VAD?

A single system device that is surgically attached

to the left ventricle of the heart and to the aorta
for left ventricular support

For Right Ventricular support, the device is

attached to the right atrium and to the
pulmonary artery
 Ventricular Assist Device (VAD)

A mechanical pump that is surgically attached to one

of the heart’s ventricles to augment or replace native
ventricular function
Can be used for the left (L VAD), right (R VAD), or
both ventricles (Bi VAD)
Are powered by external power sources that connect
to the implanted pump via a percutaneous lead
(driveline) that exits the body on the right abdomen
Pump output flow can be pulsatile or nonpulsatile
 Indications for VAD
Bridge to transplant (BTT) “Destination” therapy (DT)
– most common – permanent device,
– allow rehab from severe instead of transplant
CHF while awaiting – currently only in
donor transplant-ineligible
patients
Bridge to recovery (BTR) Bridge to candidacy
– unload heart, allow (BTC)/
“reverse remodeling” Bridge to decision (BTD)
– can be short- or long- – when eligibility unclear
term at implant
– not true “indication” but
true for many pts
PATIENT SELECTION
 Types of VADs

Pulsatile
and

Non Pulsatile
 Pulsatile VAD Key Parameters
Pump Rate:
– How fast the VAD is pumping (filling & emptying)
– Can be set at a fixed rate or can automatically
adjust
– Pulsatile VADs are loud and the rate can be
assessed by listening

Output:
– The amount of blood ejected from the VAD
– Measured is liters per minute
– Is dependent upon preload, afterload, and pump
rate
 Non-Pulsatile
Continuous-flow devices
– Impeller (spinning turbine-like rotor blade) propels blood continuously
forward into systemic circulation.
– Axial flow: blood leaves impeller blades in the same direction as it enters
(think fan or boat motor propeller).

Most implanted devices are LVADs only

Are quite and cannot be heard outside of the patient’s body. Assess VAD
status by auscultation over the apex of the LV. The VAD should have a
continuous, smooth humming sound.

The Patient may have a weak, irregular, or non-palpable pulse

The Patient may have a narrow pulse pressure and may not be
measurable with automated blood pressure monitors. This is due to the
continuous forward outflow from the VAD.

The Mean Arterial Pressure is the key in monitoring hemodynamics.

Ideal range is 65-90 mmHg.
Non Pulsatile VAD Key Parameters
Flow:
– Measured in liters per minute
– Correlates with pump speed (speed=flow,
↓speed=↓flow)
– Dependent on Preload and Afterload

Speed:
– How fast the impeller of the internal pump spins
– Measured in revolutions per minute (rpm)
– Flow speed is set and determined by VAD clinical
team and usually cannot be manipulated outside of
the hospital
Non Pulsatile VAD Key Parameters
Power:
– The amount of power the VAD consumes to
continually run at a set speed
– Sudden or gradual sustained increases in the
power can indicate thrombus inside the VAD

Pulsatility Index (PI):

– A measure of the pressure differential inside the
internal VAD pump during the native heart’s cardiac
cycle
– Varies by patient
– Indicates volume status, right ventricle function, and
native heart contractility
Non Pulsatile VAD Key Parameters

The device parameters are displayed numerically on

the VAD console or Controller

Will vary with each individual patient and VAD device

 Thoratec VAD (pVAD/iVAD)

 Pneumatic, external(pVAD) or internal (iVAD), pulsatile pump(s)

 right-, left-, or bi-ventricular support (RVAD/LVAD/BiVAD)
 up to ~7.2 lpm flow
 Short- to medium-term use (up to ~1-2 years)
 bridge to recovery
 bridge to transplant
 hospital discharge possible

iVAD
pVAD
Thoratec pVAD
 HeartMate XVE LVAS
 Internally implanted, electric pulsatile pump
 left heart support only
 up to 10 lpm flow
 Medium- to long-term therapy (months to years)
 bridge to transplant
 destination therapy (only FDA-approved DT device)
 HeartMate II LVAS
 Internally implanted, axial-flow (non-pulsatile) device
 left heart support only
 speed: 8000-15000 rpm
• flow: ~3-8 lpm
 Medium- to long-term therapy (months to years)
 bridge to transplant (FDA-approved)
 destination therapy (investigational)
 Jarvik 2000 LVAD
 Axial-flow (non-pulsatile)
pump
 electric, intra-ventricular
 left heart support only
 Speed: 8000-12000 rpm
 flow: ~3-5 lpm
 Medium- to long-term therapy
(months to years)
 bridge to transplant
(investigational)
Jarvik 2000 LVAD
 Basic VAD Management
 ALL VADs are:
 Preload-dependent

 EKG-independent

 Afterload-sensitive

 Anticoagulated

 Prone to:

• infection
• bleeding
• thrombosis/stroke
• mechanical malfunction
 Key differences depend on pulsatile vs. non-

pulsatile device
 Criteria for patient selection
Class IV HF
Failing hemodynamics
Persistent pulmonary edema
Neurologic impairment or renal failure due
to low perfusion
Fluid and electrolyte imbalance related to
low cardiac output
Severe arrhythmias despite medical
therapy
 Indications for support
SBP<80 mm Hg
MAP<65 mm Hg
CI<2.0 L/min/m2
PCWP>20 mm Hg
SVR>2100 dynes-sec/cm

Circulation 2005; 112: 438-448

 INTERMACS: Patient Selection

1. Critical cardiogenic shock

2. Progressive decline
3. Stable but inotrope dependent
4. Recurrent advanced HF
5. Exertion intolerant
6. Exertion limited
7. Advanced NYHA III
 Short term Device options
ECMO

IABP

Tandem Heart

Bridge to recovery
Bridge to decision

Centrimag
AbioMed 5000

Impella
Intraaortic Balloon Pump (IABP)
Developed in late 1960s
Counterpulsation is synchronized to the EKG or
arterial waveforms
Increase coronary perfusion
Decrease left ventricular stroke work and
myocardial oxygen requirements
Most widely used form of mechanical circulatory
support
Indications for its use include
– Failure to wean from cardiopulmonary bypass
– Cardiogenic shock after MI
– Heart failure
– Refractory ventricular arrhythmias with
ongoing ischemia
 Bridge to bridge: ECMO
Immediately stabilize circulation
Improve end organ perfusion
Overall survival comparable
between ECMO + LVAD versus
LVAD alone
Clinical indicators of poor outcome
after ECMO: consider VAD
implantation carefully
– Elevated blood lactate levels
– Elevated LFTs
 Centrifugal pumps
Acute hemodynamic support
Continuous flow
Extracorporeal
LV, RV or biventricular
support
Wide availability
Ease of use
Relatively low cost
Limited duration of support
Bridge to recovery
Bridge to decision

Hoy et al. Ann Thorac Surg 2000; 70:1259-63

 Tandem hearts

Acute hemodynamic support

Centrifugal pump
Percutaneous placement
LV support via transseptal
cannula
Used in high risk cardiac
catheterization procedures
Risk of vascular injuries due to
cannula size
 Levitronix Centrimag
Newer generation
Centifugal pump
Continuous flow
Extracorporeal
Impellar within the
pump rotates in
contact-free manner
Increased durability
Minimal thrombus
formation and
hemolysis of RBCs
 Abiomed 5000
Extracorporeal
Pneumatic pulsatile pumps
Uni- or biventricular
support
Bridge to transplant
Easy to insert and operate
so used in community
hospitals
Flows 6L/min

Circulation. 2005;112:438-448.
 Impella
Axial flow pumps
Acute hemodynamic
support
Miniaturized impellar pump
in catheter
Helical catheter tip placed
across aortic valve and left
ventricle
Percutaneous or direct
placement
Flow 4.5L/min
Bridge to recovery
Long term Device options

Heartmate XVE Heartmate II

Bridge to transplant Thoratec

Jarvik 2000 CardioWest TAH

Circulation 112 (3): 438

 Thoratec
Pneumatic pump
LVAD, RVAD or
biventricular support
Durable
Can be used in smaller
patients
Flows 7L/min
Bridge to recovery
Bridge to transplant

Circulation. 2005;112:438-448.
Long term Device options

Heartmate II
Heartmate XVE

Bridge to transplant
Destination therapy
Heartmate XVE
(vented electric)
Pneumatic or vented electric
plates
Textured internal surfaces
Only left-sided support
Flows 10L/min
Bridge to transplant
First device to be approved
for destination therapy
Need BSA>1.5
Limited durability: half life 18
months
Infection risk with
percutaneous drive line

Circulation. 2005;112:438-448.
Heartmate II
Axial flow
LV support
Flows 10L/min
Long term durability
Bridge to transplant
Approved January 2010
for destination therapy
Over 4000 devices
implanted to date
 Implantation of device

N Engl J Med 2007;357:885-96

Implantation
Implantation
Implantation
Implantation
Implantation
Implantation
Implantation
Implantation
 Device complications
Early
– Bleeding
– Right sided heart failure
– Progressive multiorgan system failure
Late
– Infection
Nosocomial
Device related
– Thromboembolism
– Failure of device
 Problems/Complications
 Major VAD Complications

 Bleeding

 Thrombosis

 Infection

• sepsis is leading cause of death in long-term VAD support

 RV dysfunction/failure

 Suckdown (low preload causes a nonpulsatle VAD to collapse

the ventricle)

 Device failure/malfunction (highly variable by device type)

 Hemolysis (the VAD destroys blood cells)

 Problems/Complications
 Other Common Issues
 Arrhythmias
• A patient can be in a lethal arrhythmia and be asymptomatic. Treat the
patient not the monitor.
• Do not cardiovert/ defib. unless the patient is unstable with the arrhythmia.
• Do not initiate chest compressions unless instructed by a physician or VAD
coordinator. Chest compressions can disrupt the implanted equipment
causing bleeding and death
• Electrical shock from cardiovert/ defib. will not damage any of the VAD
equipment
 Problems/Complications
 Other Common Issues
 Hypertension
• High afterload can limit VAD flow/ output
• Do not administer antihypertensive medications or nitrates unless instructed
by a physician or VAD Coordinator
 Hypotension/ loss of Preload
• All VADs are preload dependent. A loss or reduction in preload will
compromise VAD function and limit flow/ output
 Problems/Complications
 Other Common Issues
 Depression/ Adjustment Disorders
• Living with a VAD is difficult to management for a lot of patients.
• A large percentage of patients experience symptoms of depression
 Portability/ Ergonomics
• The external VAD equipment is heavy and cumbersome limiting a patient’s
mobility and greatly impacting their quality of life.
 Problems/Complications

 Bleeding & Thrombosis

 Careful control of anticoagulation is
imperative
• Patients are often on both anticoagulants and
platelet inhibitors
• Device thrombosis
 rare in pulsatile devices
 typically revealed by increased power and signs and symptoms of
hemolysis
 Problems/Complications
Bleeding & Thrombosis Tx
– Assess for signs and symptoms of bleeding
– Neuro Assessment to rule out CVA
– Initiate IV therapy and administer fluid slowly
to maintain preload
– Device Thrombus is treated with low dose
lytics and/ or increasing anticoagulation
therapy
 Problems/Complications
 Infection
*The leading cause of mortality in VAD
patients

*Higher incidence in pulsatile VADs

*The driveline provides direct access into

the body and into the blood stream

*Often recurrent and difficult to treat

 Problems/Complications
Preventing Infection
* Always observe clean/ sterile
technique when able

* Make sure driveline exit site is

covered with a clean, dry gauze
dressing
 Problems/Complications

 Suckdown
 LV collapse due to
hypovolemia/hypotension or VAD
overdrive
 nonpulsatile devices only
 indicators: hypotension, PVCs/VT, low
VAD flows.
 Problems/Complications

Treating Suckdown
– Initiate a peripheral IV and slowly give
volume to increase preload
– If able and instructed by the VAD
Coordinator, reduce the speed of the
VAD
– Assess for signs and symptoms of
bleeding and sepsis
 Problems/Complications
 Device Failure
 This is a true emergency requiring immediate
transport to the implanting VAD center
 Most common in pulsatile devices
 Patients & caregivers are trained to identify
signs and symptoms of device failure
 May require the VAD to be replaced
 Problems/Complications

 Hemolysis

 Blood cells are destroyed as they travel

through the VAD

 More common in non pulsatile devices

 Problems/Complications
Treating Hemolysis
– Initiate a peripheral IV and slowly give
volume
– If able and instructed by the VAD
Coordinator, reduce the speed of the VAD
– If thrombus is suspected to be causing
hemolysis, administer lytics and
anticoagulants as able/ ordered
 Next generation of VADs
Miniaturized
Improved durability
– Bearing-less technology
Blood compatible surfaces
– Nonthrombogenic
Transcutaneous
– Drive line
– Power sources
 Indicators of poor clinical
outcome

Diabetes mellitus
– 4-fold increased risk of early death
– Associated with end organ failure
Renal failure
– Increased allograft vasculopathy after transplant
– Type I DM is contraindication to transplant
Low preoperative serum albumin
– Surrogate measure of nutritional status
– Increased infections and impaired wound healing
– For every 1 mg/dL increase in albumin, had 19.2 times increased
likelihood for bridge to transplant

JCTS 2005:130;5: 1302-1311

Parameters to predict recovery
Echo
– Decreased LV diameter
– Improved EF (>40%)
Histology
– Resolution of myocyte fibrosis and necrosis
Hemodynamics
– Decreased PCWP
– Decreased PVR
– Improved peak oxygen exercise consumption