clinical criteria for LVAD
- NYHA Class III to IV or refractory heart failure
- Left ventricular ejection fraction <25%
- Peak VO2 <14
- Severe HF despite optimal medical therapy
- Inability to tolerate medical therapy
- Requiring inotropic support
- Does not respond to Biventricular pacing
- 1 or more HF related admission in past 6 months
- Recurrent symptomatic ventricular arrhythmias requiring defibrillation.
- Progressive cardio-renal syndrome and hyponatremia
- Ineligible for cardiac transplantation
inappropriate VAD candidates
- Irreversible major end-organ failure
- Uncertain neurologic status
- Severe hemodynamic instability
- Complex Comorbid Condition (i.e.
cancer) - Physical or visual impairment
- Cognitive or mental impairment
- Unable to Tolerate
- Anticoagulation/Bleeding Disorder
- Sepsis/active infection
- Severe right heart failure
- Unresolved psychosocial issues (noncompliance, poor support)
also cant get a VAD if you got
severe:
▫ Peripheral Vascular Disease
▫ Chronic Obstructive Pulmonary Disease
▫ Renal Failure
▫ Diabetes
▫ Malnutrition
▫ Obesity
what really is a VAD anyway
A ventricular assist device (VAD) is an
implantable device designed to partially replace
the function of the failing heart, providing
mechanical circulatory support to restore the
circulation of blood flow to the body
what does a VAD do
▫ Decreases preload
▫ Decreases cardiac workload
▫ Increases systemic circulation & tissue perfusion
▫ Decreases neurohormonal response
all VADs have these 4 parts:
▫ An inflow cannula which takes blood from the ventricle to the pump
▫ A pump
▫ An outflow cannula that takes the pumped blood to the ascending aorta
▫ A power source for the pump
what should MAP be for patients with VAD
65-85 mmHg
what is ECMO
ECMO is a life support machine used in patients with a severe and life-threatening illness that stopped their heart and/or lungs from working properly (ex. cardiogenic shock, infection)
what are the goals of ECMO
▫ Improve tissue oxygenation
▫ CO2 clearance
▫ Cardiac Output
▫ ECMO may also be used to support patients with heart or lung disease while waiting for a transplant
ECMO indications
- Cardiac Index <2.2L/min/m2 or Sv02<60%, on two inotropes
- Rising lactate, worsening metabolic acidosis
- Hypotension with escalating doses of pressors/inotropes
- Acute hypoxic or hypercarbic respiratory failure on mechanical ventilation
ECMO Contraindications
- Acute intracranial hemorrhage
- CPR duration- witnessed vs. not witnessed
- Contraindication to anticoagulation
- Advanced cancer
- End- stage liver disease
- End- stage kidney disease
- Age
- Psychosocial
Ambulation in ECMO patients
- Requires mobility order from CV surgery at ACMC
- Pt must be off sedation, alert, and follows commands
- Hemodynamic stability
- No bleeding at cannulation site
- Perfusionist present for mobilization of patient
- Team effort for successful mobilization
- Please refer to hospital specific mobility protocols
total artificial heart eliminates
▫ Failing ventricles
▫ Malfunctioning heart valves
▫ Arrhythmias and other electrical complications
▫ Donor heart rejection
i did not include any of the VAD types in here bc i dont care and am not sure that it matters
goal of PT post LVAD
- To provide the highest quality of life to patients with end stage heart failure through exercise and rehabilitation.
- To provide readiness for discharge from the hospital.
- To minimize duration of VAD support in bridge to transplant patients while optimizing their surgical outcomes.
- To improve muscle mass and tone, maximize strength, flexibility, and exercise capacity, improve myocardial oxygen consumption and improve cardiovascular aerobic conditioning
post op VAD complications
- Hypovolemia
- Right Heart failure and
Pulmonary hypertension - Cardiac tamponade
- Bleeding
- Arrhythmia
- Infection
- Stroke
- Hemolysis
- Thromboembolism
- Neurologic dysfunction
- Psycho-social issues
inpatient issues post-VAD
▫ Surgical wound healing and care
▫ Maintenance of skin integrity
▫ Pulmonary hygiene and lung function
▫ Range of motion
▫ Cardiovascular endurance
▫ Muscle force production
▫ Education of patient and family
patient monitoring during therapy
- Heart rate – continuous via telemetry
- Blood pressure – pre, mid and post-exercise
- Sp02 – pre, mid and post exercise
- LVAD rate and flow pre/post if on power
module - Signs and symptoms – continuous
- Rate of perceived exertion (Borg scale) – with
each mode of exercise
normal parameters post VAD
⚫ LVAD flows 4.0L/min – 8.0 L/min
⚫ Pulse Index (PI) 4.0-7.0 – Heartmate II only
⚫ Exception: low PI in Heartmate 3 is typical, contact VAD coordinator with concerns
⚫ MAP 65- 85 mmHg
⚫ SpO2 90%-100%
⚫ RR 12-20 bpm
⚫ HR 60-120 bpm
⚫ Resting Borg Scale RPE of 6
⚫ Resting Dyspnea Index of 0
what does LVAD cause an increase of?
diastolic pressure and flow
what happens when the pump speed of a heartmate II is increased
- diastolic pressure increases
- systolic pressure is equal
- pulse pressure (systolic-diastolic) decreases
6MWT
▫ Initiate during pre-VAD work-up as pt conditions allows
▫ Rest for 5 minutes prior to walk. Check resting BP, SpO2, HR, RPE, and Dyspnea.
▫ Begin walking on a level surface. Check vitals 3 minutes and 6 minutes. During recovery phase check vitals 5 minutes post test.
▫ Repeat when medically appropriate after VAD implantation and every month thereafter to measure gains
precautions/contraindications for exercise
- Chest pain, fatigue, dizziness
- Subjective intolerance using Borg Scale of perceived exertion (>13 on scale of 6-20)
- MAP> 120 mmHg or <60 mmHg
- Pump flows and/or PI of <3.0 LPM - defer therapy
▫ If pump flow and/or PI = 2.5-3.0 LPM and not symptomatic use clinical judgment - Heart rate >150 bpm
- Oxygen Saturation < 85%
- Hazard or Advisory Alarms
ideal treatment progression - POD #1
▫ Start BUE/BLE PROM
▫ Address pressure relief and repositioning issues
