Dr Priya Nair is a senior intensive care specialist at Sydney's St Vincent's Hospital and an expert in managing patients with cardiac assist devices. In this talk she takes us through the key issues encountered when on managing patients with left ventricular assist devices. As LVADs are becoming more widespread, this inside know-how is invaluable to all of us. They physiology and technology involved with these devices is pretty amazing.
This is the second of two talks at the recent Sydney Intensive Network Meeting. The first talk was by Cardiologist Chris Hayward here.
9. TOE assessment
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PFO/septal abnormalities
Aortic Incompetence- may be under-estimated
Mitral Stenosis
LV Thrombus
Ascending Aorta
?TV annuloplasty
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Chumnanvej S et al, Echocardiography for VAD implantation
Anesth Analg 2007;105(583-601)
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Scalia GM et al, Clinical utility of echocardiography in the management of
implantable ventricular assist devices. J Am Soc Echocardiogr 2000;13
31. Response to RV & LV to experimental changes in afterload
MacNee et al, AJRCCM 1994
32. • Lower sarcomere Ca++ concentrations with
reduced maximal shortening
• Less Ca++ sensitivity during inotropic
stimulation
• Compromises rapidly leading to hepatic
dysfunction & coagulopathy
• Increases peri-op mortality from 10-15% to
38-43%
33. • Peri-op- TX-A2, TNF-α, Interleukin & catechol
release during CPB, blood products,
inadequate cardioprotection, vasoconstrictors
can trigger RVF
• LVAD adds to this
– shifts inter-ventricular septum to left,
– distorts TV lead to TR
– improved CO & sudden increase in venous return
46. Take home messages
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Pre-op haemodynamic optimisation
Meticulous care of the RV
Avoid over-pumping
Serial echocardiography is vital
Cautious anticoagulation
VADs are preload dependent & afterload
sensitive
• Mortality and persistent heart failure
determined by inefficient unloading of left side
and persistent RV dysfunction
47. At discharge
• Comprehensive education of patient & NOK
• Easy contact with VAD coordinator & hospital
team
• Spare controller & battery packs
• Strict BP control
48. Emergency Department
presentations
• EMS guide January 2012, Mechanical Circulatory Support
Organisation
• www.jems.com
• emcrit.org/wee/left-ventricular-assist-devices-lvads
• heartware.org
• mylvad.com
56. 3) JUDICIOUS FLUID CHALLENGE
• Check pump flows and response.
<65mmHg- Adrenaline/Noradrenaline/Vasopressin
>65mmHg- Dobutamine/Milrinone
• Early arterial line with ultrasound guidance
• Care with CVC if RVAD in place