2019 ISU Paramedic course overview of LVAD

1. Stop Draggin’ My Heart
Around….
Life Sustaining Interventions in EMS and Critical Care: An Overview

2. Objectives
Compare and Contrast ECMO, VAD, IABP,
and TAH
Properly assess a patient with a VADs,
IABPs, or TAHs.
Discuss treatment strategies for patients
with VADs, IABPs, or TAHs.
Discuss prehospital and intra-facility
implications of patients with ECMO, VADs,
IABPs, or TAHs.

3. Definitions
• ECMO: Extracorporeal Membrane Oxygenation
• IABP: Intra-aortic balloon pump
• VAD: Ventricular Assist Device
• L-VAD: Left Ventricular Assist Device
• TAH: Total Artificial Heart
• Bridge Therapy: Temporary therapy to “bridge” to definitive therapy
• Destination Therapy: Anticipated terminal therapy. While not
“definitive”, probably the best available for the patient circumstances.

4. Why is this important?

5. VENTRICULAR ASSIST
DEVICES
(L-VAD)

6. Ventricular Assist
Devices
• A VAD is a Mechanical Circulatory Support
(MCS) device designed to restore blood
flow and improve survival, functional
status, and quality of life for those suffering
from advanced heart failure
• The device is implanted in parallel with the
heart, taking over a majority of its
circulatory function
• Multiple devices and brands in use
• Refer to the ICCAC Field Guide
• No age limit

7. There are currently over 60 LVAD patients in Idaho
Nate Southerland, eastidahonews.com in 2016

8. Ventricular Assist
Devices
• The device takes blood from a
lower chamber of the heart
and helps pump it to the body
and vital organs, just as a
healthy heart would.
• It “assists” the left
ventricular function of the
heart.

9. Types of VADs
• L-Vad – Left Ventricular Assist
Devices
• R-VAD – Right Ventricular Assist
Devices
• BiVAD- Bi-Ventriculat Assist
Devices.
• Total Artificial Hearts (discussed
later)

10. Types of VADs
• A BiVad is not a
separate class of VAD,
but the combination
of Left and Right VADs
in the same patient.

11. Ventricular Assist
Device
• Implanted in heart failure patients
• Augments the function of the
ventricles in circulating blood
• Sometimes implanted as a
temporary treatment (“bridge
therapy” , and sometimes used as a
permanent solution “destination
therapy” to very low cardiac output

12. Ventricular Assist Device (VAD)
• There are 3 common indications for implanting an LVAD:
• Bridge to Transplant
• The patient must meet criteria to be listed for a heart transplant
• The VAD is taken out at time of transplant
• Destination Therapy
• The patient does not qualify for a heart transplant but meets criteria for
Destination Therapy
• The patient lives the rest of their life with an VAD
• Bridge to Recovery
• VAD for a few days or weeks, provides temporary support
• Ex. Patient with post partum cardiomyopathy

13. Ventricular
Assist
Devices
• The device is “powered” externally, with the “drive line” entering the
body to run the “pump”
• Think of the driveline as the “PTO” of a tractor.
• The actual “power” is external in the “controller”.

14. VAD Special Considerations
• VAD patients are unique and require specialized care
• Routine assessments such as blood pressure, pulses, and pulse-
oximetry may not be unattainable
• Chest compressions are usually not indicated
• The patients carry external equipment: a controller and power
sources that operate the implanted pump though a single driveline

15. VAD Patient
Assessment
• Attempt to auscultate over the apex of the
heart for a “whirling” or “smooth,
humming” sound indicating that the VAD
is working
• A cable exits the abdominal wall that
connects the device to power and the
control unit
• SOME VAD patients also have an
implanted cardiac defibrillator and/or a
pacemaker

16. Example of L-VAD system: HeartWare
System
Implanted Pump
Driveline
Battery Battery
Controller

17. Example of L-VAD system: HeartMate II
System
Implanted Pump
Battery
Battery
Controller Driveline

18. External VAD Components
Patients have options for carrying their
external equipment to best suit their
comfort and lifestyle
Ensure that the equipment is
protected
at all times with no stress on
the driveline
Patients will have an additional
supply bag for their extra batteries and
backup Controller close at hand. This bag
should always accompany the patient on
transport

19. External VAD Components

20. Power Management
• Patients are responsible for managing their
power
• They have 6-8 batteries in rotation and a
home charger
• Batteries generally last 8 – 14 hours per pair
• Exchanged one at a time, so one
• power source is always connected
• to the Controller
• Patients only need to be on A/C power when
sleeping

21. Critical VAD Connections
Never disconnect both power sources! Never disconnect driveline!
HeartWare HVAD HeartMate II
Power
Driveline
Power
Power
PowerDriveline

22. The Controller
For HeartMate 2 and 3
press MENU button
to access parameters
ALARM SILENCE
Alarms have symbol
and message on screen
Yellow (beeps)
Pump is ON
Red (steady tone)
Pump may be OFF

23. Assessments
• MOST L-VADS are a continuous flow device. This means:
• Whirling sound in chest.
• No Pulse: A palpable pulse is variable and clinically insignificant in VAD patients
• Pulse Oximetry: Pleth will be unreliable. SPO2 may still be useful though.
• Look for physical s/s of ↓ oxygenation
• No systolic or diastolic blood pressure
• NIBP may be able to get a MAP
• Doppler B/P = MAP
• Rely on other prefusion signs
• EKG is typically unaffected (may be AF, , Stable VT, or even VF!!! or other
underlying condition)
• Rely on total assessment.
• Assess for bleeding issues. Patients are at high risk for bleeding complications
due to blood thinner use
• Trauma
• Falls
• GI bleed

24. Assessments: LOOK AT THE CONTROLLER
What is the flow rate???
What are the RPMs?
Alarms have symbol
and message on screen
Yellow (beeps)
Pump is ON
Red (steady tone)
Pump may be OFF

25. Auscultate over apex

26. Caution with clothing removal
• Use caution when cutting and removing
clothes, to avoid damaging the device
• VAD patients should always have a sterile
dressing covering the driveline exit site in the
lower abdomen.
• The dressing should not get wet.

27. VAD complications: infection
• Many hospital admissions in VAD patients
are secondary to infection, not cardiac
problems.
• Assess for signs of infection (especially at
the insertion point) or sepsis

28. Assessing Pump Flow
• Flow (L/min)
• Average adult Cardiac Output at rest is ~ 5
L/min
• Body size / blood volume effects pump
flow potential
• The Flow parameter is an estimate
• Flow will mainly fluctuate with changes in
activity, body position, and blood volume
• Hyper / hypovolemia
• Other physiologic conditions can also effect
flow:
• Right Heart Function
• Rhythm disturbances
• Hypo / hypertension
• Valvular function
• Pulmonary hypertension
• Thrombosis

29. Assessing for signs of Hypovolemia
Normal Flow Range 4 – 6 L/min
Asymptomatic
Sub-optimal Flow 2.5 – 3.5 L/min
Asymptomatic → Symptomatic
May be dizzy, lightheaded, fatigued, change in LOC
Low Flow < 2.5 L/min
Asymptomatic → Symptomatic
May be dizzy, lightheaded, fatigued, change in LOC

30. Treatment
• ***CALL THE VAD HOTLINE ***
• Verify the pump is “on”
• Treat as important as a “pulse check”.
• Involve Caregivers. They have had extended training in the patient’s
particular VAD.
• V.O.M.I.T. as indicated
• Hypovolemia is a common complication
• Fluid Resuscitation is a common intervention.
• Vasopressors for patients refractory to fluid challenges.

31. LVAD Patient Management
PRELOAD
Volume
Blood Pressure
CVP / PVR
Right Heart Function
Valvular Function
Rhythm
AFTERLOAD
SVR
MAP 65-85
ANTICOAGULATION
Coumadin
ASA
INR 2-3
PUMP SPEED
Set RPM to
BLOOD IN = BLOOD OUT

32. Treatment – ACLS?
• ***CALL THE VAD HOTLINE ***
• Airway management and respiratory support considerations unchanged
• OK to defibrillate or SCV per ACLS, but consult VAD Hotline first if the patient is
stable
• Avoid placing the pads directly over the device (consider anterior-posterior pad placement)
• Do Not Administer vasodilatory meds without consulting the VAD hotline.
• i.e. Nitroglycerine
• Persistent arrhythmias are treated after contacting the VAD coordinator
• Antiarrhythmics doses unchanged by LVAD, but may be changed by other underlying
conditions.
• CPR is usually last resort.
• LISTEN for “whirling sound” first. If present, no CPR unless ordered by VAD-Control Center

33. Transportation and Destination Decisions
• ***CALL THE VAD HOTLINE ***
• Always transport “go-Bag” with the patient.
• If possible, take an experienced care giver too.
• These patients have multiple co-morbidities and high risk clinical concerns
• Heart Failure
• Stroke
• LVAD related issues
• High risk of infection
• Coagulopathic issues
• These patients should be transported to either the VAD center, or in Idaho,
the highest level of care available (major medical centers). Consult VAD
hotline.
Q: What does that mean in your local area?

34. Total Artificial Hearts
(TAH)
Liotta-Cooley Artificial Heart https://well.blogs.nytimes.com/2011/02/14/a-
plastic-heart-that-beat-for-three-days/?_r=0

35. Total Artificial Heart
• Surgically implanted, externally powered
• Technically a “BiVAD”.
• The lower ventricles are surgically
removed
• Takes up less space in the chest than a
VAD.

36. Bridge Therapy
• Bridge Therapy offers a
62% chance of 2 year
survival
• Medical Therapy Less
than 26% survival for 1
year
• 10% 2 year survival
https://healthblog.uofmhealth.org/heart-health/living-for-
years-without-a-heart-now-possible

38. TAH
• The device is
implanted in place
of the lower
portions of the
heart, taking over a
majority of its
circulatory function

40. VAD versus TAH
Ventricular Assist Device
• Usually Pulseless
• Whirling assessed by auscultation
• EKG has underlying rhythm
• No NTG (*preload dependent)
• Cardioversion/Defibrillation OK
• CPR OK
• Mean Arterial Pressure only.
• MAP 70-85 mm Hg
• Often have an ICD/Pacemaker
Total Artificial Heart
• Pulsatile
• Externally perceptible
• EKG asytolic or minimally active
• NTG for SBP > 140 mm Hg
• No cardioversion/defibrillation
• No CPR
• Normal BP
• No ICD/Pacemaker

41. Assessments
• MOST TAHs are a pulsatile flow device. This means:
• You should hear two sounds if properly.
• Pulse Oximetry: Pleth will be present. SPO2 useful.
• Look for physical s/s of ↓ oxygenation
• Blood Pressure: Since there is a pulsatile waveform , there is a blood
pressure.
• The majority of the heart has been removed. Therefore the EKG is
typically asystole or minimally active.
• Assess for bleeding issues. Patients are at high risk for bleeding
complications due to blood thinner use
• Trauma
• Falls
• GI bleed

42. Treatment
• ***CALL THE TAH HOTLINE ***
• Check for a pulse.
• Verify the pump is “on”
• Treat as important as a “pulse check”.
• Involve Caregivers. They have had extended training in the patient’s
particular VAD.
• V.O.M.I.T. as indicated
• Hypovolemia is a common complication
• Fluid Resuscitation is a common intervention.
• Vasopressors for patients refractory to fluid challenges.

43. Treatment – ACLS?
• ***CALL THE TAH HOTLINE ***
• Airway management and respiratory support considerations
unchanged
• No Defibrillation (nothing left to defibrillate)
• Do Not Administer vasodilatory meds without consulting the TAH
hotline.
• i.e. Nitroglycerine
• No antiarrhythmics required
• No CPR (not enough heart left to compress)

44. Transportation and Destination Decisions
• ***CALL THE VAD HOTLINE ***
• Always transport “go-Bag” with the patient.
• If possible, take an experienced care giver too.
• These patients have multiple co-morbidities and high risk clinical concerns
• Heart Failure
• Stroke
• LVAD related issues
• High risk of infection
• Coagulopathic issues
• These patients should be transported to either the VAD center, or in Idaho,
the highest level of care available (major medical centers). Consult TAH
hotline.
Q: What does that mean in your local area?

45. Intra-Aortic Balloon Pumps
(IABP)

46. Intra-Aortic
Balloon Pumps
• An intra-aortic balloon pump
(IABP) is a type of therapeutic
device. It helps heart function. It is
often used as a bridge
intervention to more definitive
therapy.
• The IABP consists of a thin, flexible
tube called a catheter. Attached to
the tip of the catheter is a long
balloon. This is inserted into the
aorta.

47. Indications for IABP
Indications
• Cardiogenic Shock
• Pre-shock syndrome
• Threatening extension of MI
• Unstable angina
• Intractable ventricular dysrhythmias
• Septic Shock
• Cardiac Contusion
• Prophylactic support
• Bridging device to other mechanical
assist
• Support during transport
Contraindications
• Absolute
• Aortic Valve insufficiency
• Dissecting aortic aneurysm
• Relative
• End-stage cardiomyopathies
• Severe atherosclerosis
• End stage terminal disease
• Abdominal aortic aneurysm
• Blood dyscrasias
• Thrombocytopenia

48. The Cardiac Cycle (Remember this?)
• The ventricles propel blood throughout
the pulmonary and systemic circulation
as a result of ventricular contraction.
• Fluid (blood) always flows from high
pressure to low.
• The cardiac cycle is divided into systole
(ventricular contraction) and diastole
(ventricular relaxation and filling)
http://www.nhf.org.nz/images/how_your_heart_works.gif

49. Preload vs. Afterload (Remember this too?)
• Preload refers to the amount of stretch on the ventricular
myocardium prior to contraction. Starling’s law described how
an increase of volume in the ventricle at the end of diastole
resulted in an increase in the volume of blood pumped out.
• Preload is often referred to as “filling pressure”.
• Afterload is the resistance to ventricular ejection which takes
several forms:
• The mass of blood that must be moved, measured by the hematocrit
• The higher the mass, the more inertia that must be generated.
• Aortic end diastolic pressure (AEDP).
• If the AEDP is 80 mm/hg, then the left ventricle must generate 81 mm/hg
in order to open the aortic valve and generate blood flow.
• Arteriole resistance

50. IABP- How it works
• The IABP is attached to a controller. The controller has a mechanism
for inflating and deflating the balloon in synchronization with the
heart.
• Inflation during diastole
• Deflation during systole
• Catheter
• 30-cm polyurethane balloon on distal end
• Balloons sized according to height
• Placed in aorta distal to left of subclavian artery . Position is critical
• Inserted in femoral artery
• During operation, rapidly inflated and deflated with 35–40 ml of helium
• Inflated to about 85-90% of diameter of aorta to avoid damage to vessels.

52. Inflation is timed off of multiple paramters
https://www.teleflex.com/usa/product-
areas/interventional/cardiac-assist/ac3-optimus-iabp/

54. Improves
Blood Flow to
Coronary
Arteries

55. https://www.youtube.com/watch?v=mADxD7
C8jBw

56. IABP in
cardiac
arrest?

57. Buys time
to surgery
or ECMO

58. Extracorporeal Membrane
Oxygenation
(ECMO)
http://www.lsuhscshreveport.edu/departments/ClinicalDepart
ments/CriticalCareMedicine/eclsecmo

59. Extracorporeal
Membrane Oxygenation
(ECMO)
• ECMO is a form of cardio-pulmonary bypass.
• It is a life support system that temporarily replaces
the function of the heart and the lungs.
• This is a life-saving measure often used in the ER or
OR, ICU, or in other specialized settings to assist
patients who have no blood pressure and failing
after a large heart attack.

60. Extracorporeal Membrane
Oxygenation
(ECMO)
• Started in the ORs and CVICUs in the 70’s.
• Now done in larger ER/EDs, ICUs, NICUs, and even in the pre-hospital
setting.
• Done in all age ranges
• ECMO is just one form of Cardio-pulmonary bypass
• Significant in that ECMO can be done via larger central
vasculature, but does not have to be placed in the aorta or
vena cava.

61. Types of ECMO
Veno-Arterial
• Requires cannulation of an artery
and a venin
• Used in cases where cardiac
support is needed.
• Post-ROSC
• Severe Hypothermia (can re-warm
too)
• Toxic exposures
• Even during cardiac arrest
Veno-Venous
• Requires cannulation of two veins
• Predominantly for cases of
Respiratory failure where
cardiovascular support is not
crucial
• ARDS, Drowning, etc

64. ECMO in the near
future
• Transportation of refractory cardiac arrest patients to ECMO
Centers
• Out of hospital physicians placing ECMO
• ECMO in the ED for sepsis, OD, cardiogenic shock, and who
knows what else…
• Partial support (partial ECMO) V-V systems similar to dialysis
machines with bicaval catheters.

67. Wrapping up…