Ventricular Assist Device Implantation

W8 Ventricular Assist Device Implantation



Robert L. Kormos



image Before Procedure



Indications



• Postcardiotomy failure (left ventricular assist device [LVAD]):
• Elevated left atrial pressure and cardiogenic shock despite inotropic support and intraaortic balloon pump (IABP)
image Left arterial pressure (LAP) >25

image Cardiac index <2 L/min/m2

image Severe left ventricular (LV) dysfunction on echocardiogram

image Intractable ventricular arrhythmias

image Ongoing myocardial ischemia despite revascularization

• Postcardiotomy failure (bilateral ventricular assist device [BiVAD]):
• Evidence of elevated central venous pressure (CVP: 9 > 18 mm Hg) despite pulmonary afterload reduction

• Evidence of severe right ventricular (RV) dysfunction on echocardiogram

• Inability to provide adequate blood flow of filling of LVAD if in place

• Bridge to cardiac transplantation:
• Failure of optimal medical therapy that raises risk of compromised life or end-organ function while awaiting cardiac transplantation:
image Cardiac index <2 L/min/m2

image Mixed venous oxygen saturation <50% on optimal medical therapy

image Ventricular arrhythmias

image Severe symptoms at rest

image Need for multiple inotropic agents

image Non-responsiveness to diuretics, with rising creatinine

image Pulmonary artery hypertension

image Cool and constricted extremities reflective of poor perfusion

image Low blood pressure, resting tachycardia, rales, and/or distended neck veins

image Laboratory evidence of prerenal azotemia or hepatic dysfunction or prolonged coagulation levels

image Requirement for supplemental oxygen

• Bridge to bridge: in conditions of cardiogenic shock where indications for cardiac transplantation are not yet met but are potentially attainable

• LVAD versus BiVAD:
image Biventricular assist devices should be considered for:
• Intractable ventricular tachycardia or fibrillation

• Cardiogenic shock requiring resuscitation with extracorporeal membrane oxygenation (ECMO)

• Cardiogenic shock with presence of multiorgan failure

• Pulmonary edema despite maximal medical therapy

• Chronic RV failure with presentation of ascites, low pulmonary artery pressure, severe hepatic or renal dysfunction, and tricuspid insufficiency

• Severe acute respiratory distress syndrome

• Giant cell myocarditis

• Large anterolateral myocardial infarction with involvement of anterior right ventricle

• RV infarction

• Destination therapy:
image Indicated for those patients who meet above criteria for bridge to transplant LVAD candidacy but are not eligible for transplantation based upon: age, obesity, renal dysfunction that will not tolerate immunosuppressive agents, other added comorbidities that suggest that transplantation risk is unacceptable

image Patients with advanced heart failure (HF) symptoms (class IIIB or IV) who are (must meet one criterion):
• On optimal medical management (OMM) for at least 45 out of 60 days and are failing; or

• In class III or IV for at least 14 days and dependent on IABP for 7 days and/or inotropes for 14 days; or

• Treated with angiotensin-converting enzyme (ACE) inhibitors or beta-blockers for at least 30 days and found to be intolerant

• VO2 max ≤14 mL/kg/min or ≤50% predicted VO2 max with AT, if not contraindicated due to IV


Contraindications



• Postcardiotomy failure:
• Sepsis

• “Stone heart” or lack of any innate cardiac function

• Age >70

• Condition where recovery is not anticipated and patient is not a candidate for cardiac transplantation

• Bridge to transplantation:
• Patient not a candidate for cardiac transplantation

• Sepsis

• End-organ damage not likely to recover
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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Ventricular Assist Device Implantation

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