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Dr. Morgan Snavely - LVADs
- 2. WHAT IS IT? • Left Ventricular Assist Device – “LVAD” • A mechanical pump used to provide adequate cardiac output when heart failure is resistant to medical treatment
- 3. Indications • Bridge to recovery • Bridge to heart transplant • Bridge to candidacy • Destination therapy if not eligible for cardiac transplantation
- 4. Components • PUMP • DRIVELINE • PERIPHERALS • Controller • Batteries • Line power • Carry bag
- 5. LVAD Basics • 1 : Preload dependent • 2: ECG independent • 3 : After load sensitive • 4 : Anticoagulated • 5 : Prone to infection/ bleeding/ stroke/ malfunction
- 6. BP Management • Afterload/BP management • Patients may have reduced or no pulse pressure • MAP is key parameter (assess with manual cuff) • Typical target 65-90 mmHG • Hypertension • Reduced flow!
- 8. LVAD flow: Speed & Pressure dependent Speed of Rotor SPEED FLOW SPEED FLOW Pressure across pump Pressure FLOW Pressure FLOW
- 9. Arrhythmias • VT Problem in LVAD? • YES, due to decreased filling of ventricle • VT Problem in BiVAD? • NO, both ventricles are supported
- 11. Approach to the LVAD patient… LISTEN, LOOK, FEEL LISTEN: hum versus no hum LOOK: at ALL the connections FEEL: for a hot control box
- 12. Specific LVAD questions.. • Do you have a pulse with your device? • Do you have a hand pump of any kind? • Where is your emergency back up bag located? • Where is your home power source located? Do you have a portable power plug? • How do I contact your LVAD coordinator? • Do you have a binder of information about your device?
- 13. Remember when it comes to LVAD patients… • Peripheral pulses may not be palpable!!! • Assess the patient for signs of good circulation to determine if perfusion is adequate • Standard measures to obtain blood pressure and pulse oximetry may produce unreliable and inaccurate readings. • Pump flow is dependent on preload and afterload! • Some VADs do not have valves, so retrograde flow back into the left ventricle can occur if the pump stops • Patients are at risk of bleeding due to anticoagulation and antiplatelet therapy
- 14. Additional transport considerations.. • Keep straps loose and NOT over the device gear • Be CAREFUL with scissors!
- 15. EMS Approach to LVAD patient • Make every effort to contact the patients primary caretaker • Treat non-LVAD associated conditions in accordance with OC EMS system protocol • IF patient meets trauma or stroke alert criteria transfer to appropriate receiving facility • IF STEMI criteria transfer to PCI capable LVAD center • Contact the patients LVAD coordinator • IF any condition suspected to be LVAD related transfer to LVAD center of patient request • BE sure to transport all available LVAD device components
- 16. MyLVAD.com
- 18. Basic Life Support • Establish patent airway • 100% supplemental Oxygen • Check blood glucose if any AMS, weakness, hx of DM • Assist patient in replacing device batteries or cables
- 19. Advanced Life Support • Full ALS assessment and treatment • Monitor capnography • Administer boluses of 0.9% NaCl at 250cc if signs of hypoperfusion • Evaluate unresponsive patients carefully for reversible causes prior to initiation of CPR • Chest compressions may cause irreversible damage to device • Expedite transport and treat other conditions as per appropriate protocols
- 21. A Demanding and Growing Future • Less organ donors- longer transplant list wait times • VAD technology – continues to improve, with smaller enhanced and less complicated devices • Growing patient population- LVADS have been proving their success
- 22. Questions..?
Editor's Notes
- -first implanted in 1960 -public more aware after Dick Cheney former VP required an LVAD
- 1- temporizing measure to optimize ventricular function while awaiting native ventricular function to return (e.g. unable to wean off bypass, transient cardiomyopathy, post cardiotomy shock) **Medicare stopped using these recently** 2- 3-decision — temporizing measure until a decision can be made on one of the above (may smoke, drugs, poor social support, place VAD and see if become candidate) 4-such as age, kidney disease or lung disease, BMI **for Destination therapy- must have <2 yrs life expectancy, Class IV HF, failed to respond to maximal medical therapy
- 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.
- 1- require Left ventricular filling for VAD to work 2- not timed to QRS ( like a balloon pump would be)
- -in continuous flow- really no SBP -MAP >90 causes increaswed pressure through VAD Increases thrombosis risk, decreases tissure perfusion -uses same drugs, hydralazine, ACEi, Ca Channel blockers
- MAP = SBP + 2(DBP) / 3
- - Treating arrhythmia is still important, though, because ultimately the VAD is a preload-dependent device. - If the native heart is not able to deliver adequate blood flow to the VAD, the patient's circulation will suffer
- Heartmate 2- workhorse pump across the world Most patients have tag located on their controller around their waist indicating what type of device it is, what institution put it in, and a number to call.
- FEEL- HIGH RPM and LOW flow with a HOT box suspect pump thrombosis- have med control or LVAD coordinator on phone
- Can see a history profile
- -should sound like a hummm -in cases of continuous flow devices First, the paramedic should check whether the LVAD is working (by auscultation, for a continuous or a pulsatile noise depending on the LVAD device). If the system is not working, it should be confirmed that the system controller cable is con- nected to the LVAD, both batteries are properly in- serted into the battery clips, and the system controller power cables are connected to a power base. If the con- dition persists, power should be disconnected and ei- ther hand pumping started or a restart of the LVAD attempted by reconnecting the power cable to the con- troller. As soon as possible, the help of a specialist should be sought.
- CPR could potential dislodge cannulas in heart and cause exsanguination
- As a higher percentage of permanent support and longer time on the LVAD will increase the risk for out-of-hospital emergencies, leading to more EMS calls, EMS will be faced with LVAD patients in life- threatening situations where fast and correct handling would improve outcome.