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2020 prodigy refresher vad
1. Stop Draggin’ My Heart
Around….
Life Sustaining Interventions in EMS and Critical Care: An Overview
2. Who am I
• Steve Cole
• 30+ years in EMS
• Work in SW Idaho
• EMS Training Captain
• Adjunct faculty at local university
• No financial disclosures
3. Questions and Objectives
• How to Ventricular Assist Devices Work?
• Describe the function of ventricular assist devices (VAD)
• How do I assess a patient with a Ventricular Assist Device?
• Describe key assessments of a patient with a VAD
• How to I care for a patient with a VAD if they are in distress?
• Discuss treatment strategies for patients with a VAD
Suffering an emergency
• What do I have to be cognizant of when transporting a patient
with a VAD?
• Discuss prehospital and intra-facility implications of
patients with a VAD
4. Definitions
• VAD: Ventricular Assist Device
• L-VAD: Left Ventricular Assist Device
• TAH: Total Artificial Heart
• Pulsatile Flow
• Continuous Flow
This Photo by Unknown Author is licensed under CC BY-NC-ND
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
• www.mylvad.com
• No age limit
7. 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. There are about 3,000 new devices implanted each year.
Nate Southerland, eastidahonews.com in 2016
10. Why a VAD?
• Temporary, bridge-to-transplant (BTT)
• About 25%
• Permanent, destination therapy (DT)
• About 50%
• Other Temporary indications
• bridge-to-candidacy/bridge-to-decision
• bridge-to-recovery
• Survival
• 80% survive > 2 years
• 30% survive > 5 years
11. 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)
12. Types of VADs
• A BiVad is not a
separate class of VAD,
but the combination
of Left and Right VADs
in the same patient.
13. The
“Drive Line”
• The device is “powered” externally, with the “drive line” entering the
body to run the “pump”
• The actual “power” is external in the “controller”.
14. Example of L-VAD system: HeartWare
System
Implanted Pump
Driveline
Battery Battery
Controller
15. Example of L-VAD system: HeartMate II
System
Implanted Pump
Battery
Battery
Controller Driveline
16. 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
18. 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
19. Critical VAD Connections
Never disconnect both power sources! Never disconnect driveline!
HeartWare HVAD HeartMate II
Power
Driveline
Power
Power
Power
Driveline
20. 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
22. 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
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. 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.
26. 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
28. VAD complications: Stroke
• 13-30% incidence depending
on VAD type.
• About ½ will be fatal
• Ischemic/Embolic more
common than hemorrhagic
29. VAD complications: infection
• Independent predictor of mortality
• Originally 41%, down to approx. 20% of
patients
• Many hospital admissions in VAD patients are
secondary to infection, not cardiac problems.
• Early detection and treatment is essential to
reduce mortality
• Assess for signs of infection (especially at the
insertion point) or sepsis
30. 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
31. 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.
32. 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
33. 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
34. 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, the highest
level of care available in your system. Consult VAD hotline.
Q: What does that mean in your local area?
36. 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
37. 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.
38.
39. TAH
• The device is
implanted in place
of the lower
portions of the
heart, taking over a
majority of its
circulatory function
40. 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
The International Consortium of Circulatory Assist Clinicians.
The basic parts of a VAD include: a small
tube that carries blood out of your heart into a
pump; another tube that carries blood from the
pump to your blood vessels, which deliver the
blood to your body; and a power source.
https://www.eastidahonews.com/2016/09/my-heart-failed-and-today-i-become-part-machine/
There are over 1700 new devices inplanted each year.
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
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
The two basic types of VADs are a left ventricular assist device (LVAD) and a right ventricular assist device (RVAD). If both types are used at the same time, they may be called a biventricular assist device (BIVAD). However, a BIVAD isn't a separate type of VAD.
The LVAD is the most common type of VAD. It helps the left ventricle pump blood to the aorta. The aorta is the main artery that carries oxygen-rich blood from your heart to your body.
RVADs usually are used only for short-term support of the right ventricle after LVAD surgery or other heart surgery. An RVAD helps the right ventricle pump blood to the pulmonary (PULL-mun-ary) artery. This is the artery that carries blood to the lungs to pick up oxygen.
Both an LVAD and RVAD (sometimes called a BIVAD) are used if both ventricles don't work well enough to meet the needs of the body. Another treatment option for this condition is a total artificial heart.
What is the power source?
The power source is either batteries or AC power. The power source is connected to a control
unit that monitors the VAD’s functions. The batteries are carried in a case usually located in a
holster in a vest wrapped around the patients shoulders.
What does the control unit or controller do?
The control unit gives warnings, or alarms, if the power is low or if it senses that the device
isn’t working right. It is a computer.
Auscultate below the apex the device sits below the diaphragm.
By auscultating over the apex, providers will be listening over the device itself.
67 yo patient went into cardiac arrest after he accidentally cut his LVAD wires. ED physician reconnected with hemostats and restored flow.
Because they have a blood pump, VAD patients may be stable in V-Tach or V-Fib
VAD flows may be affected
Persistent arrhythmias are treated after contacting the VAD coordinator
Many VAD patients have an ICD / Pacemaker
If patient’s ICD delivers a shock, notify VAD Coordinator
Okay to defibrillate & cardiovert VAD patients per ACLS protocol
Okay to administer anti-arrhythmic medications per ACLS protocol
All VAD patients are on anticoagulation medications
They are at high risk for embolic or hemorrhagic stroke.
Level of consciousness may deteriorate rapidly
Because patients are already anti-coagulated, they do not follow routine stroke protocol
Bleeding is the most common complication and cause of readmission after VAD implantation.23 Of these, gastrointestinal bleeding (GIB) is the most common, occurring in 15% to 30% of patients across all device-types, especially among older patients with previous history.24,39,40 Various mechanisms, such as low-pulsatility, shear-stress leading to acquired von Willebrand deficiency, angiodysplasia (arteriovenous malformation) and anticoagulation have been proposed, with endoscopic or laboratory correlations.
As the mechanism of infection is direct, excellent hygiene is imperative in addition to preoperative antibiotic therapy and avoidance of hematomas, which can be a nidus for infection. Early recognition and aggressive treatment are essential in preventing rapid dissemination of pathogen, which may ultimately require device exchange.
https://well.blogs.nytimes.com/2011/02/14/a-plastic-heart-that-beat-for-three-days/?_r=0“Nearly 42 years ago, the world’s first artificial heart was implanted in a history-making operation at St. Luke’s Hospital in Houston.
The patient, 47-year-old Haskell Karp, was dying of heart failure and awaiting a heart transplant. The artificial device, implanted April 4, 1969, kept him alive for three days until a human heart was available for transplant. Sadly, he lived less than two days after the human heart was implanted. The procedure also led to one of the longest-running feuds in medical history.
“ https://www.nytimes.com/2007/11/27/health/27docs.html?scp=1&sq=denton%20cooley&st=cse
Total Artificial Heart is the only device that provides immediate, safe blood flow of up to 9.5 L/min through both ventricles to help vital organs recover faster. Once stable, Total Artificial Heart patients in the hospital are listed UNOS Status 1A and moved to the top of the transplant list. Compared to all heart devices, the SynCardia TAH has the highest rate of successful bridge-to-transplant.
The two basic types of VADs are a left ventricular assist device (LVAD) and a right ventricular assist device (RVAD). If both types are used at the same time, they may be called a biventricular assist device (BIVAD). However, a BIVAD isn't a separate type of VAD.
The LVAD is the most common type of VAD. It helps the left ventricle pump blood to the aorta. The aorta is the main artery that carries oxygen-rich blood from your heart to your body.
RVADs usually are used only for short-term support of the right ventricle after LVAD surgery or other heart surgery. An RVAD helps the right ventricle pump blood to the pulmonary (PULL-mun-ary) artery. This is the artery that carries blood to the lungs to pick up oxygen.
Both an LVAD and RVAD (sometimes called a BIVAD) are used if both ventricles don't work well enough to meet the needs of the body. Another treatment option for this condition is a total artificial heart.
https://healthblog.uofmhealth.org/heart-health/living-for-years-without-a-heart-now-possible Stan Larkin, pictured above, a 25-year-old with a rare form of cardiomyopathy who lived for 555 days — outside of the hospital — using a Total Artificial Heart before receiving a heart transplant at UMHS in May. “He’s absolutely thriving now.”