Echocardiographic Structural Assessment Pre- LVAD
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- Charlotte Brooke Simpson
- 5 years ago
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2 None Disclosures
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5 Echocardiographic Structural Assessment Pre- LVAD LVEF ( 25% for DT LVAD) Right ventricle Valvular disease Intra- cardiac shunts Intra- cardiac thrombi Ascending aorta
6 Case 1 50 yo M transferred from OSH with acute decompensated HF and cardiogenic shock 2 Prior bypass surgeries Stage III CKD with a baseline Cr 1.7 Renal failure and volume overload on inotropes Transferred for considera/on of advanced heart failure therapies
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12 Case 1 HM II BTT LVAD Prophylac/c post- op CentriMag RVAD support Post- opera/ve course: RVAD weaned Milrinone for 2 weeks Stable, persistent RV failure Listed for Heart Transplant
13 Consequences of Post LVAD RV Failure Increased periopera/ve mortality Worse end- organ func/on Increased cost of hospitaliza/on and LOS Decreased survival to transplanta/on Peura, et al. Circula(on 2012;126:
14 Predic/ng RV Failure? Clinical and biochemical characteris/cs Echocardiographic characteris/cs Pre- procedure hemodynamics
15 Sample Risk Scores RV Failure Risk Score (Michigan) Heartmate 2 Risk Score Vasopressors (4 points) AST > 80 (2 pts) Bilirubin > 2 (2.5 pts) Scr > 2.3 (3 pts) CVP/PCWP > 0.63 Pre- op ven/latory support BUN > 39 OR of 7.6 (95% CI 3.4 to 17.1) with score > 5.5 J Am Coll Cardiol 2008;22: J Thorac Cardiovasc Surg 2010;139:
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21 LVAD Management
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26 Selec/ng an Op/mal LVAD Speed
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36 LVAD Troubleshoo/ng
37 LVAD Troubleshoo/ng Pericardial effusions +/- tamponade RV dysfunc/on Under- filled LV Inflow cannula malposi/on AV Insufficiency Intra- cardiac thrombus Pump failure Adopted from Table 3 from J Am Coll Cardiol Img 2010;3:
38 LVAD Troubleshoo/ng Heart Failure HF with increased power HF with normal power High Flows with Normal Power Aor/c Insufficiency Arrhythmias Cannula Posi/on Suc/on Events GI Bleeding
39 LVAD Troubleshoo/ng Heart Failure HF with increased power HF with normal power High Flows with Normal Power Aor/c Insufficiency Arrhythmias Cannula Posi/on Suc/on Events GI Bleeding
40 Heart Failure with Increased Power Increased MAP Pump Thrombus Kink in the Ouqlow Cannula
41 Case 2 Heart Failure with Increased Power 41 yo M with NICM s/p HM II LVAD in 2011 doing well for 2 years un/l he develops new heart failure symptoms, power spikes to 13W, and dark urine. LDH 1728.
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47 LVAD Troubleshoo/ng Heart Failure HF with increased power HF with normal power High Flows with Normal Power Aor/c Insufficiency Arrhythmias Cannula Posi/on Suc/on Events GI Bleeding
48 Heart Failure with Normal Power RV failure Tricuspid Valve Insufficiency Inflow Obstruc/on Mitral Stenosis
49 Case 3 Heart Failure with Normal Power 53 F with NICM and BMI 48.2 kg/m 2 HM II LVAD implanted 3 months prior Admired from clinic with volume overload despite up- /tra/on of diure/cs as an outpa/ent Speed 9200, Power 5.8 W, PI 3.3, Flow 4.6 L/min
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53 Heart Failure with Normal Power Right Heart Cath RA: 19 RV: 33/16 PA: 33/15 (25) PCWP: 10 Aorta: 140/60 (87) CO 4.4 CI: 2.1 with a PA sat: 42%
54 LVAD Troubleshoo/ng Heart Failure HF with increased power HF with normal power High Flows with Normal Power Aor/c Insufficiency Arrhythmias Cannula Posi/on Suc/on Events GI Bleeding
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56 Case 4 High flows with normal power 69 M s/p HM II LVAD for ICM Unevenqul Peri- Opera/ve Course Trivial AR on Pre- Op Echo
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63 LVAD Troubleshoo/ng Heart Failure HF with increased power HF with normal power High Flows with Normal Power Aor/c Insufficiency Arrhythmias Speed drops / Suc/on Events Cannula Posi/on GI Bleeding
64 Case 5 Arrhythmia with speed drops 54 yo M with NICM Intermirent palpita/ons and lightheadedness HM II LVAD speed drops ( rpm) mul/ple /mes per minute ECG shows frequent PVC s
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66 Case 6 Cannula posi/on and Arrhythmias 67 yo M with NICM HM II LVAD planned for Des/na/on Therapy 5 months post LVAD implanta/on Recurrent low flow and hypotensive episodes INR 1.7 on admission Frequent PVC s and runs of NSVT noted NSVT /ming correlates with symptoms
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69 Case 7 Unexplained VT 72 yo man: DM, MDS Severe CAD/LVSD CABG Post CABG Day 7: failing arrest; HM II Complicated post- op course VT recurrent: refractory to meds Recurrent ICD shocks Echo suggests inflow cannula malposi/on
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71 Intra- cardiac Shunts At baseline masked by leu to right shun/ng with elevated LVEDP/LAP Right to leu shun/ng auer LV decompression with VAD Risk for Paradoxical emboli
72 Case 8 LVAD and Intra- cardiac Shunts 42 yo M s/p HM II LVAD presents with slurred speech Recent DVT INR 1.6 Normal LDH
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75 Conclusions Chest xray: overall device posi/oning visualiza/on Serial evalua/on for temporal shiuing cannula posi/on Echocardiography plays an important role in pre- LVAD implanta/on and post- LVAD management Evolving use for predic/ng post- LVAD RV failure Echo speed studies and ramp protocols useful tools to evaluate and op/mize LVAD func/on Outcomes data and further studies are necessary Echocardiography and CT are pivotal diagnos/c tools in LVAD trouble- shoo/ng
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