AdvancedHeartFailureStagesandCurrentTherapies

KimMaxson,RN,MSNVADCoordinator

Objec've

•  Par'cipantwillbeabletoiden'fytheprogressionofadvancedheartfailurestagesandcurrenttherapies.

HeartFailure

•  Heartfailureiswhentheheartspumpingabilityisinsufficientinmaintainingbloodflowtomeetthebody’sneeds

LeBVentricle

RightVentricle

CardiacAbnormali'es

•  Restric'veMyopathy-heartmuscleisrigidandlackflexibilitytoexpandnormally.(goodexampleisamyloidosis).

•  HypertrophicMyopathy-thickmyocardium(smallventricularcavity).

CardiacAbnormali'es

•  Congenitalheartdisease-birthdefectoftheheartand/orvessels.(ExampletetralogyofFallot)

•  DilatedMyopathy-weakenedandenlargedventricle,poormuscletone.

CardiacAbnormali'es

•  Valvularheartdisease-poorfunc'oningvalvecausingpoormovementofbloodinoroutofthechambers.

HeartFailure(HF)

•  TheleadingcauseofHFiscoronaryarterydisease,highbloodpressureanddiabetes.

•  2.4%oftheadultpopula'onareaffectedwithHF.– GreaterDesMoinespopula'onis~599,789.Thiswouldmean~14,394ofadultsintheDesMoinesareamayhaveheartfailure.

Allen,L.(2012)DecisionMakinginAdvancedHeartFailure

Systolicvs.DiastolicHF

•  Normallytheheartejects50-75%ofthebloodfromtheleBventricle.

•  DiastolicHeartFailure-LeBventricleisnotabletofillproperlyduringthediastolic(filing)phase.Lessbloodisejectedfromtheheartthanwhatshouldbe. –  HFpEF(preservedejec'onfrac'on>50%).

•  SystolicHeartFailure-LeBventricleisnotabletosqueezehardenoughtopushbloodouttotherestofthebodyduringsystole.(heartdamagefromMI,thin/narrowmusclelining).–  HFrEF(reducedejec'onfrac'on<50%).

TherapyOp'ons

•  Diet•  Exercise•  Diabetesmanagement•  Bloodpressurecontrol•  Op'onsforstructuralissues(parachute,TAVR,MitraClip,surgery)

•  Coronaryinterven'on(sten'ng,balloonangioplastyand/orcoronaryarterybypassgraB(CABG))

•  Pacemaker/resynchroniza'ontherapy/ICD•  Mechanicalcirculatorysupport/Cardiactransplant

PaBentswithAdvancedHeartFailure

•  RepeatedhospitalizaBons(greaterorequalto2withintheyear)•  ProgressivedeterioraBoninrenalfuncBon(riseinBUNandCr)•  Weightlosswithoutothercause(cardiaccachexia)•  IntolerancetoACEinhibitorsorb-blockersduetohypotensionand/or

worseningHF.•  Frequentsystolicbloodpressure<90mmHg•  PersistentdyspneawithdailyacBviBes(bathinganddressing)•  Inabilitytowalk1blockonthelevelgroundduetodyspneaorfaBgue•  FrequentICDshocks(arrhythmias)•  IncreaseescalaBonofdiureBcs(examplefurosemideequivalentto>160

mgperday).•  Progressivedeclineinserumsodium(<133)

HeartFailureClassifica'on

Optimal Timing for Advanced Therapies

Peura J et al. Circulation 2012;126:2648-2667

B189-0312

INTERMACSPROFILES4–7:AmbulatoryHeartFailure

StevensonLW,PaganiFD,YoungJB,etal.INTERMACSprofilesofadvancedheartfailure:thecurrentpicture.JHeartLungTransplant.2009;28:535-41.

INTERMACS PROFILES AND OTHER CLASSIFICATION SYSTEMS

Profile # Description NYHA Class Time to MCS therapy AHA/ACC Stage

INTERMACS 1 Crashing and burning IV Within hours D

INTERMACS 2 Progressive decline on inotropic support IV Within a few days D

INTERMACS 3 Stable but inotrope dependent IV Within a few weeks D

INTERMACS 4 Recurrent advanced heart failure; resting symptoms at home on oral

therapy Ambulatory IV Within weeks to

months D

INTERMACS 5 Exertion intolerant Ambulatory IV Variable D

INTERMACS 6 Exertion limited or walking wounded Ambulatory IV Variable C-D

INTERMACS 7 Advanced NYHA III IIIB Variable C

A depiction of the clinical course of heart failure with associated types and intensities of available therapies.

Allen L A et al. Circulation. 2012;125:1928-1952

Copyright © American Heart Association, Inc. All rights reserved.

TriggersTriggersbelowhelpthehealthcareproviderevaluatethepa'entsdeclineinheartfunc'onthereforepromptcollabora'onwithheartfailurecardiologist.•  Hospitaliza'onforheartfailure•  FirstICDshock•  UpgradetoCRT-Ddevicewithnoimprovementinheartfailuresymptoms

•  Developmentofcardiorenalsyndrome•  WithdrawalofACE

Timing•  Heartfailureisaprogressivedisease.Theartofcaringforadvanceheartfailurepa'entsishelpingthemmakedecisionsonnextbesttreatmentop'onsandeduca'ngthemonselfcareandsymptommanagement.

•  Fiveyearsurvival,50%.•  Best'metotalkaboutop'onsisintheambulatoryselng.

•  Hospitaladmissionshouldbea'metoreviewandpossiblyupdatecareop'onsratherthanintroduceadvancedtherapycaredecisionop'ons.

•  Advancedtherapiesisaboutimprovingqualityoflife.

Lesny,P.etal.(2013).JournalofHeartandLungTransplant

AdvancedHeartFailureTeam

•  Physicians/ARNP•  HeartFailureCaseManagers•  VADCoordinator•  VADSocialWorker•  Pallia'veCareCoordinator•  TransplantpartnersatUIHC

WhatdoesaVADdo?•  TheVADassiststheheartby

helpingpumpmorebloodtotherestofthebody,fromtheleBventricleuptotheaorta.

•  VentricularAssistDevicecanbecalledothernames:–  LVAS(LeBVentricularAssistSystem)–  MCS(MechanicalCirculatory

Support)•  HeartMateIIistheonlylong

termmechanicalassistdeviceapprovedbytheFDA(pa'entliveswiththedeviceathome).

Thoratec©

PictureaboveistheVADpumpapachedtotheheart(internally).

Power

Battery

Heart Pump (inside body)

Driveline, exits the body here

Power Cord

Battery

Power Cord

Pocket Controller

Thoratec©

20

FDAApproval

•  BridgetoTransplant–  Non-reversibleleBheartfailure–  Imminentriskofdeath–  Candidateforcardiactransplanta'on

•  Des'na'onTherapy–  Notacandidatefortransplant–  Allothertreatmentop'onshavebeenexhausted.–  GoalistoimprovequalityoflifeanddecreaseHFsymptoms.

CriteriaforDesBnaBonTherapy

End-Stageheartfailure(NewYorkHearAssocia'onClassIV)whoarenotcandidatesforhearttransplanta'on,andmeetallofthefollowingcondi'ons:• Havefailedtorespondtoop'malmedicalmanagement(IncludingBeta-blockersandACEInhibitors)foratleast45ofthelast60days,orhavebeenballoonpump-dependentfor7days,orIVinotrope-dependentfor14days;and

• HavealeBventricularejec'onfrac'on(LVEF)<25%;and• Havedemonstratedfunc'onallimita'onwithapeakoxygenconsump'onof<14ml/kg/minunlessballoonpumporinotropedependentorphysically

unabletoperformthetest(cardiopulmonarytreadmill-CPX).

Evalua'onPhaseTesBngforcardiactransplantandLVAD•  Labs•  LeBheartcath(angiogram)toevalcoronaries•  Rightheartcath-toevaluateincreasedfillingpressures/backupoffluidon

therightside.•  CTofchestifprevioussternotomy•  CPX-Cardiopulmonaryexercisestresstest-VO2lessthan14•  Echocardiogram-BubblestudyneededifmaygetLVAD•  6minwalktest•  Ultrasounds-Caro'dandAbdominal•  ABI-toruleoutPVD•  Colonoscopy•  Mammogram,Pap,prostateeval(persex)•  Pallia'veRN(evaluatesPOA/Will,5wishesandcopingwithdiseaseprocess)•  SocialWorker(evaluatessocialsupportathomeandinsurancecoverage)

HeartMateII

RegistryInformaBontodate(fromThoratec)•  Pa'entsimplanted:20,000+worldwide•  100+pa'entsonsupportforover5years,withmul'plepa'entsover8years

•  Longestsupportedpa'entonasingledevice(8+years)

•  Agerange:10-91years

Optimal orientation of the LVAD cannulas

Pa'entEquipment

•  Pa'entmusthavebackupequipmentwiththematall'mes!

•  AllVADpa'entshaveaprimarycaregiverwhoisfullytrainedtotroubleshoottheequipment.

•  Bagwillcontainemergencycallnumberandalarmtroubleshoo'ngguide.

Typicalcarrycaseholdingextraequipment.

BloodPressureMonitoring•  Lesspulsa'lityofna'vepressureduetocon'nuous-flownatureoftheHeartMateII

•  Bloodpressuremeasurement– DopplerultrasoundonceA-lineremoved– Automa'ccuffsareinaccurate

•  Targe'ngMAPwithagoalof:– Mean≈70-90mmHg

•  Hypertension–  Effectsonpumpsupport

•  Maydecreaseforwardflow•  Decreaseinpumpflowandpower

–  Inan'-coagulatedpa'ents,mayincreaseriskofhemorrhagicstroke

Titra'ngAn'coagula'on•  WarfarindoseforINRtargetof2.0±0.5•  Aspirin81to325mg/day•  Considerincreasingan'coagula'onduringlowflowstates

–  LVADFlow<3.0L/minute

•  Gastrointes'nalbleeding–  vonWillebranddisease–  Reducedpulsa'lity

•  TypicallyhighINR’swillnotrequirereversalagent,pa'entmaybeadmipedformonitoringwhiletrendingdown.

Emergencies•  Intheoccurrencethatthepa'entbecomesunresponsive,DO

NOTperformchestcompressionsasthismaydislodgethedevice.

•  Allothermeasurestoresuscitatethepa'ent(medica'onsandairway)shouldbeperformed(checkcodestatus).

•  Mostpa'entshaveapacer/ICD.IfshockadvisedandcurrentICDisnotshockingthepa'ent,externaldefibrilla'oncanbeperformedwithoutdisconnec'ngtheVAD.

•  Ifthedevicehasanyalarms,seekaVADcompetentorVADtrainedpersonrightaway.

•  Aheartfailurephysicianisoncall24/7.AllpumprelatedemergenciesshouldbedirectedtoVADcoordinatoroncall.Theyaredirectedtocall515-633-3770,IHCheartfailureline.

Risks

•  Bleeding–  Duetononpulsi'lity,pa'ents

areatriskforAVM’s–  GIbleedingismostcommon

•  Stroke–  Pa'entsmustbean'-

coagulated.–  TypicalINRgoalis2.0-3.0

•  Powerdisconnect–  Neverdisconnectboth

sourcesofpoweratthesame'me(i.e.bothbaperies).

•  InfecBon–  Mustmaintainsterile

dressingtodrivelinesite–  Assessforinfec'on

•  SucBonevents–  Wheninflowcannulacontacts

ventricularwallcancauseectopicbeats.

–  Evaluatepa'entfordehydra'onorarrhythmias

SuccessStory•  July2007acutepulmonaryedemaPTCA/stentstoRCAandOM1andramus.Afew

hourslatercodedandrequiredastenttotheRCAagain.•  June2012seenbyDr.Frazier,beganverbalizingdepressiveconversaBons.NYHAIII.•  September21,2012JerrywasreferredtoDr.WickemeyerforanadvancedHFconsult•  May3,2013LVADimplantedbyDr.PrabhakarwithDr.BatesattheUniversityof

Iowa.•  May21,2013Mercyacuterehabfor2weeks•  June7,2013firstvisittotheIHCadvancedheartfailureclinicwithnewLVAD.•  July25,2013firstroadtriptoKansasCity.

SupportGroup

VADsupportgroupbringsotherVADpaBentsandtheircaregiversfromthe

communitytogethertotalkaboutlivinglifewithanLVAD.

Pa'entSurvival

*NYHA functional class was determined by an independent clinician at the time points shown. Improvements were statistically significant in both trials (p<0.001).Rogers JG, Aaronson KD, Boyle AJ et al, JACC, 2010;55:1826-34.

Six Month Follow-up for BTT Patients

Two Year Follow-up for DT Patients

Func'onalCapacityaBerHMIILVAD

Reference•  Allen,L.(2012)DecisionMakinginAdvancedHeartFailure:AScien'ficStatement

FromtheAmericanHeartAssocia'on.Circula'on.•  Lesney,P.(2013)Long-TermSurvivalandPrognos'cMarkersin1000Pa'entswith

AdvancedHeartFailure.ASingle-CenterAnalysis.JournalofHeartandLungTransplanta'on.Vol32,Issue4.