ALL THE BELLS AND WHISTLES OF TROUBLING SHOOTING A

VAD!PATRICK C. CULLINAN, DO, FCCM, FACOEP, FACOI

Associate Clinical Professor, UIWSOM

Adjunct Assistant Professor, University of Texas Health Science Center,

Department of Emergency Medicine

San Antonio, Texas Methodist, Santa Rosa and Baptist Health Systems

NO DISCLOSURES!

OBJECTIVES:

•Review Types of Ventricular Assist Devices

•Discuss the physiology of VADs

•Review a systematic approach to evaluating a sick ED

patient with a VAD

FACTS AND NOTHING BUT THE FACTS

•5.7 million people treated for heart failure

•50% with the diagnosis of CHF will die in the next 5 years

•> 30 Billion/year to treat heart failure

VADS

•1st implanted left ventricular assist device was … 1966

•1st long term implant was … 1988

•1st FDA approval came in … 1994

VADS

•Bridge to transplantation

•Bridge to decision

•Bridge to recovery

•Destination therapy

VADS•Pulsatile

•HeartMate I

•Continuous

•HeartMate II

•Jarvik 2000

•HeartWare

•HeartMate III

HEARTMATE I

HEARTMATE II

JARVIK 2000

HEARTWARE

VADS

•Axial

•Centrifugal

AXIAL

CENTRIFUGAL

PRE-ARRIVAL

•Type of device

•Implantation hospital/VAD coordinator

•DNR status

PHONE A FRIEND

INITIAL ASSESSMENT•C, A, Bs …circulation/connections

•Mental status

•EKG

•US, Doppler … BP assessment

•Skin, capillary refill, signs of sepsis

•Caution with pulse ox

THINK LIKE ATLS

SECONDARY ASSESSMENT•DEVICE

•Power

•Auscultate LUQ of abdomen – “HUM”

•Connections – Just like a ventilator

•Adjusting settings?

VAD PARAMETERS•RPMs – Set

•Power – measured

•Directly proportional to flow across the pump

• Low – Low flow, high systemic BP

•High – High flow, pump thrombosis

•Flow – calculated, surrogate for cardiac output

•Pulse Index – reflects variation in ventricular

pressure

• Indirectly reflects LV contractility

COMPLICATIONS•Cardiac arrest – CPR?

•AMS

•CVA

•Hemorrhage

•Sepsis

•Dysrhythmias

COMPLICATIONS

•Cardiac arrest – CPR?

•Drugs - yes

•Compressions – maybe

AMS

•Etiology

•Standard evaluation

•Treat the underlying problem

CVA

•Ischemic

•Carotids

•Pump thrombus

•Hemorrhagic

HEMORRHAGE

•Antiplatelet drugs

•Anticoagulants - Coumadin

•AVMs with GI bleeding (20-40%)

•Acquired Von Willebrand deficiency

•FFP

•Cryoprecipitate

•DDAVP and/or vasopressin

SEPSIS

•Typical sites

•Drive line infection

•Early antibiotics

•Cover MDR and MRSA

DYSRHYTHMIA

•Stable – medication

•Unstable - cardioversion

COMPLICATIONS

•Hypovolemia…vasodilated, sepsis, diarrhea

•Bleeding…GI, trauma

•Hemolysis…Dark urine, jaundice

•Preload issue

•Clinical status, Power

PRELOAD•Right heart failure

•Pulmonary hypertension

•Arrhythmia…afib, SVT, Vtach, Vfib

•Cardiac tamponade

•Thromboembolism…PE, pump clot

- PUMP POWER?

AFTERLOAD

•Malignant hypertension

•Goal MAP 60-80

RIGHT VENTRICULAR FAILURE•Increased pulmonary resistance

•Hypoxia, hypercarbia, acidosis

•Increased CVP

•Arrhythmia – afib, vfib, vtach

•LV pump malposition – suction events

RIGHT VENTRICULAR FAILURE

•Management ?

•Cardioversion

•Inotropes

•Vasopressors

•Slowing RPMs

SUMMARY•Phone a friend – VAD coordinator

•Rapid assessment of A, B, C, Device

• EKG, ECHO, US/Doppler BP

•Trouble shoot Device

•Ancillary tests

SUMMARY•Treatment

• Cardioversion?

• Airway/Breathing

• Volume vs no volume

• Pressors vs inotropes vs antihypertensives

• RV and MAP

• Blood products?

• Antibiotics