Facts. STRONG Risk Factors for HF* LVAD, BiVAD, RVAD, HVAD 10/21/ million adults in the US have heart failure.

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1 10/21/18 1

2 Facts 5.8 million adults in the US have heart failure. About ½ of those who have HF have a 5 year life expectancy. STRONG Risk Factors for HF* Coronary Heart Disease/MI/Afib COPD Renal Failure High Blood Pressure* Diabetes Sleep Apnea 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment. LVAD, BiVAD, RVAD, HVAD LEFT ventricular Assist Device Bi-Ventricular Assist Device RIGHT Ventricular Assist Device HeartWare Ventricular Assist Device Basically the device shuttles blood from one or both ventricles of the heart to the next part of circulation. 2

3 10/21/18 What does a VAD patient look like? 3

4 10/21/18 SOME patients are completely dependent on their VAD and cannot survive without it. SOME patients can do okay with the VAD turned off. Brands of VADs HeartMate Series HeartWare HVAD Thoratech PVAD/IVAD Freedom Driver Jarvik 2000 Duraheart VentrAssist 4

5 Heartmate II and HeartWare HVAD The only two brands of VAD on the market FDA approved for Bridge to Destination AND Bridge to Transplant* Non-pulsatile flow system HeartMate 3* WAS FDA approved for Bridge to Transplant in

6 1 st step in candidacy for VADs How has the last year of the pt s life been (quality)? How many hospitalizations have they had in the last year? Acute Cardiogenic Shock Candidacy 1. LVEF less than 25% 2. Volume/Oxygen consumption max < 14 mg/kg/min* 3. NOT a candidate for transplant 4. One or more of the following: Class 3 Heart Failure with Stage C* at least 45 of the previous 60 days Dependence on IV inotropes for at least 14 days Dependence on IABP for at least 7 days. 5. CANNOT have irreversible renal failure, lung or liver dysfunction or active infections 6

7 Transplant Contraindications Age Coexisting systemic illness Irreversible pulmonary vascular disease Acute Pulmonary Emboli Severe PVD, irreversible renal or liver failure Diabetes with end-organ disease Severe obesity, severe osteoporosis Active Infection, Psychosocial instability, Unresolved Addiction 7

8 Bridges There are different plans of care when talking to a VAD patient Depending on their current health, their compliance and the aggressiveness of their healthcare team. Bridges Bridge to Transplant Just like it sounds Medical management isn t working Meets criteria for transplant Bridge to Destination NOT a candidate for transplant Offers a higher quality of life until the end Bridge to Recovery Endocarditis, Myocarditis Bridges Bridge to Decision Bridge to Candidacy 8

9 Common Symptoms to call Controller Alarms Shortness of Breath Hypotension* Anemia Chest Pain N/V GI Bleed Altered Mental Status Assessment You will NOT hear heart sounds. You will NOT (most likely) feel a pulse You won t be able to take a manual BP Pulse Oximetry isn t reliable. Look at skin color, temp and cap refill Assess Level of Consciousness MAP should always be at least 65 mmhg Heart Sounds A constant whirring is normal. You can chart, Unable to assess heart sounds due to LVAD sounds. Be alarmed if you hear ice in a blender sounds 9

10 Questions to ask yourself Is the patient problem VAD related? Is the patient problem CARDIAC related? STEMI s go to PCI capable centers CVA s go to Stroke Centers Trauma patients go to Trauma Centers If this is a VAD related call Call the VAD Coordinator and VAD center Check the binder and color of the tag on the system which tell what type of device it is Assess for lights, and audible or visual alarms on controller box. 10

11 Device Settings Yellow or Red lights or beeps indicate something wrong Check Batteries, change if necessary ONE AT A TIME. Check connections to make sure everything is connected and locked. Make sure the driveline isn t kinked Bits and Pieces Pump Driveline Peripherals Controller Batteries Line Power Carry Bag/harness Controller 11

12 mylvad.com 12

13 10/21/18 4 Ps of Controller Settings Pump Flow: 4-6 L/minute Pump Speed : rpm Pulse Index (PI): 3-7 Power: 4-7 W 13

14 Treatment Low Flow alarms? MAP less than 65 mmhg? Altered LOC? Poor skin color, temp and cap refill? Lay them flat and raise their legs Give a 250 ml fluid bolus Points to Remember VADS are pre-load dependent (NO NTG) Doesn t require cardiac electrical to pump Pt s are very anticoagulated Sensitive to after-load 14

15 Arrhythmias Ventricular Arrhythmias occur in up to 59% of LVAD recipients* ACLS protocols V-Tach V-Tach COULD potentially be a problem In LVADS: there is a decrease in filling of the ventricle so you will see a decrease in perfusion ( low MAP, altered LOC) In BiVADS: not a problem because both ventricles are being supported. Don t Leave Home Without It Before transporting an LVAD patient Bring the extra batteries Don t forget the charger Binder with paperwork Does this brand of VAD have a hand pump? 15

16 Power Sources Controller can be powered through direct power or batteries If a patient is going to be in one place, it is advised they plug in so they won t be using battery power Batteries can keep a VAD going for up to 18 hours before needing to change. Charging at night Heartmate 2 (older generation) 30 minutes of power is in the WALL UNIT Heartmate 2 (new generation) has 15 minutes of battery power in the CONTROLLER HVAD Heartware recommends patients plug one cable into wall unit and 2 nd cable onto a fully charged battery. 16

17 VAD Coordinator The person to call with questions about anything VAD related Doesn t necessarily have to be their patient They may/may not be familiar with EMS capabilities Lifestyle Care of driveline and dressings Care of Equipment Pro-actively charge batteries Cannot swim No Strong magnetic fields No contact sports Driving or operating heavy machinery Careful travel planning (airport security, charging batteries) 17

18 Prior to Discharge Make contact with the electric company Make contact with the local ER Make contact with the local EMS system Emergency Power Outage Electric Company is supposed to restore power 1 st Home generators EMS station Emergency Department Fire station Police Station Walmart/Target 18

19 VAD Life Expectancy Patients are told that it takes 6 months to feel full effects of VAD 2001 LVAD patients 52% at 1 year 2013 LVAD patients >90% at 1 year References University of Kansas Medical Center: Drs Andrew Sauer, Medical Director and Travis Abicht, Surgical Director April 20, 2017 Partyka, C, Taylor, B Emergency Medicine Australasia April; 26 (2); Review Article: Ventricular Assist Devices in the Emergency Department Mid-Atlantic Regional Pre-Hospital Mechanical Circulatory Support Task Force 2009 Field Guide 2017 Mechanical Circulatory Support Organization EMS Guide Ventricular Assist Devices American Heart Association Circulation Journal September