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Pulsatility is overrated: Acute Decompensated

Heart Failure in the ICU

Carolina Dimsdale DNP, ACNP-BC, AACC

No Disclosures

I have no current affiliation or financial

arrangement with any grantor or commercial interests that might have direct interest in the

subject matter of this CE Program.

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Objectives

1. Discuss clinical manifestations of acutely

decompensated heart failure.2. Describe management strategies including

medical and surgical options for therapy.

3. Review modern indications and usage of mechanical circulatory support.

What’s Acute Heart Failure?

• Ejection Fraction

• Symptoms

• End Organ Functiono Liver function

o Kidney function

o Neurologic status

Low Cardiac Output

Hypotension

Oliguria

Classifications• Framingham Heart Study classification

• ACC AHA

• Forrester

• Killip

• NYHA Yancy et al, 2013

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Acute Heart Failure

Case Study• 59F with PMH of ICM, VT s/p ICD placement. EF known to be

35%, mild AI, moderate TR.

• Admitted to ED complaining of lethargy, swelling, nausea x 1 week. Says she has been compliant with her diuretic regime, no dietary indiscretions

• Today’s echo: EF 20%, severe RV dysfunction, severe TR

• Objectively: dyspneic, nauseous, significant JVD, extremetiesare cool but dry

She is admitted to the Cardiac ICU for medical management.

ICU AssessmentNeuro: sedation, pain management, deliriumRespiratory: ETT, FiO2 and vent requirementCardiac: MCS sounds, arrhythmias, pacing device, swanGI: enteral access, nutrition, Renal: foleys, dialysis accessHeme: bleeding, clotting, anticoagulationInfectious: antibiotics, immunosuppressionLines: central lines, dialysis, chest tubesImaging: chest x-ray, echo, ultrasound, EKG

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Cardiac Output =Heart Rate x Stroke Volume

Heart size

Fitness level

Gender

Contractility

Duration of contraction

Preload

Afterload

Autonomic Innervation

Hormones

Fitness level

Age

Medical Management

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Case StudyOur patient is being treated with Dopamine, Dobutamine, Lasix infusion. She was recently intubated for hypoxemia

r/t pulmonary edema. Epinephrine was added to support biVfunction.

Afternoon labs:

Lactate 6.2 (rising)

Creatinine 3.0

BUN 75

He soon experiences VT arrest refractory to antiarrhythmics.

VA ECMO is deployed.

Extracorporeal Membrane Oxygenation

• Indications:o refractory cardiac arrest

o refractory cardiogenic shock

• Contraindications:o Lack of neurological function

o Unrecoverable cardiac function

o Prolonged CPR without adequate tissue perfusion

Rescue, not a therapy

Gift of time

Decompression=recovery

Veno-Arterial (VA) ECMO• Cannulation Technique

o Open, surgical access (Cut down)

o Percutaneous (Seldinger)

o Surgical (open chest)

• Cannulation Strategieso Central (RA to Aorta)

o Peripheral (fem vein to descending aorta)

o Sites: Axillary, Femoral, Jugular

• Oxygenationo CO2 removal (sweep)

o Oxygenation 100% FiO2

Banfi et al., 2016

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Banfi et al, 2016

Percutaneous Femoral

Cannulation with Distal Perfusion

Catheter

Subclavian Artery Cannulation

Central Cannulation

ECMO Management• Preload dependent, afterload sensitive

• Anticoagulation: PTT goal 60-80

• Echocardiogram

• Modification of drug dosing

• Multidisciplinary

Complications

• Major bleeding (40.8%)

• Infection (30.4%)

• Stroke (6%)

• Neurologic complications (13.3%)

• Acute Kidney Injury (55.6%)

• Lower extremity ischemia (16.9%)

• End of Life Care

Cheng et al, 2014

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Case StudyOur patient’s end organ function improves on ECMO. On echo, the biventricular function is not improved.

The Heart Failure team deems her a candidate for durable LVAD.

She is taken to the OR for ECMO decannulation and VAD implantation.

Role of Echocardiography in the ICU

� volume status

� valvular abnormalities

� wall motion abnormalities

� rule out tamponade

� aids in weaning MCS/inotrope

image/video

Ventricular Assist Device

Temporaryo Bridge to recovery

o Bridge to durable device

Durableo Bridge to Transplant

o Destination

LEFT VENTRICLE

AORTA

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Aortic Valve Options

• Oversew

• Replace with bioprosthesis

Management Challenges

• Preload dependent

• Afterload sensitive

• Right ventricular support

• Optimize speed

• Preventing Thrombosis

• ICD settings

image

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Echocardiographic evidence of LVAD Suction Event

Griffin & Katz, 2014

LVAD Complications

BleedingStroke

ThrombosisHemolysis

Pump failureDriveline infection

RV Dysfunction

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Intraaortic Balloon Pump

1. Increases coronary perfusion2. Decreases afterload3. Augments cardiac output4. Modest increase in CI

ACSCardiogenic shock

Periop High Risk CABGBridge to transplant

IABP- SHOCK II Trial30 Day Mortality

Femoral Approach Subclavian Approach

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Total Artificial Heart (TAH)

Bridge to Survival

> 9 lpmTang, 2014

Copeland et al, 2004

Survival to Transplant

79%

Interagency Registry for Mechanically Assisted Circulatory Support

• > 15,000 patients from 158 hospitals

• patient survival

• adverse events

• cause of death over time

With current continuous-flow devices, survival at 1 and 2 years is 80% and 70% respectively

Kirklin, et al, 2015

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Heart Transplant• Indications

o End stage heart failure – ischemic heart disease and cardiomyopathy

o Congenital heart disease

• Absolute contraindicationso Recent malignancy

o Active infection

o Systemic disease which will affect life expectancy

o Significant pulmonary vascular resistance

3%

3%

35%

49%

3%

3%

3%1%

CHD

HCM

ICM

NICM

RCM

Retransplant

VCM

Other

2%2%

42%

46%2%

3%

4%0%

2016JHLT. 2016 Oct; 35(10): 1149-1205

Adult Heart TransplantsDiagnosis

0

10

20

30

40

50

60

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

% o

f P

atie

nts

Year of Transplant

* LVAD, RVAD, TAH, ECMO

Adult Heart Transplants

% of Patients Bridged with Mechanical Circulatory Support*

2016JHLT. 2016 Oct; 35(10): 1149-1205

(Transplants: January 2000 – December 2014)

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2016JHLT. 2016 Oct; 35(10): 1149-1205

� Recipient age� Donor age

� Recipient creatinine� Ischemia time� Donor height� Recipient BSA

� Transplant center volume� Recipient total bilirubin

Risk Factors for 1 year Mortality

0

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Su

rviv

al (

%)

Years

1982-1991 (N=21,391)

1992-2001 (N=39,913)

2002-2008 (N=24,485)

2009-6/2014 (N=20,577)

Adult Heart TransplantsKaplan-Meier Survival by Era

2016JHLT. 2016 Oct; 35(10): 1149-1205

Median survival (years):1982-1991=8.5; 1992-2001=10.4; 2002-2008=11.9; 2009-6/2014=NA

All pair-wise comparisons were significant at p < 0.05.

(Transplants: January 1982 – June 2014)

New: Portable, warm perfusion and

monitoring system

Old: Cold Storage Heart

Preservation

� Increase transplantation

volume� Improve patient

outcomes� Reduce cost of

patient care

Transmedics.com

“Heart in a Box”

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Acute Heart Failure Prevention

• Same Day Access Clinics (SDAC)

• Implantable wireless hemodynamic monitoring� CHAMPION and IN-TIME trials

• Implantable intrathoracic impedence monitoring

ACC Expert Consensus Decision Pathways Task Force, 2017