AdvancedTroubleshootingVAD

CharlesT.Klodell,Jr.M.D.
AssociateProfessor
DepartmentsofSurgeryandAnesthesiology
DivisionofCardiothoracicSurgery
DirectorofCardiacMechanicalAssistDeviceProgram
ShandsHospitalattheUniversityofFlorida

1. VentricularAssistDevice(VAD)
a. WhatisaVAD?
i. AVADisamechanicalcirculatorydevicethatisusedtopartiallyorcompletely
replacethefunctionofafailingheart
ii. Goalofdevice:todirectbloodawayfromthefailingventricle(Leftand/orRight)
andprovideflowtothecirculation(Systemicand/orPulmonary)
2. WhenareVADsused?
a. BridgetoRecovery(BTR)
b. BridgetoTransplant(BTT)
i. Nonreversibleleftheartfailure
ii. Imminentriskofdeath
iii. Candidateforcardiactransplantation
c. DestinationTherapy(DT)
i. NYHAClassIIIBorIVheartfailure
ii. OMM45outoflast60days
iii. Notacandidateforcardiactransplantation
3. ThemanyclassificationsofVADs
a. AxialFlowvs.CentrifugalFlow
b. FirstGeneration
i. HeartMateXVE,PVAD,IVAD
1. Pulsatilepumpsmimicthenaturalpulsingactionoftheheart.These
pumpsarealsoknownasdisplacementpumps
c. SecondGeneration
i. HeartMateII
1. Continuousflowdeviceshavearotorcontainingpermanentmagnets
thatarecontrolledwithelectriccurrentsapplyingforceonthemagnets
whichinturnrotatetherotors
d. ThirdGeneration
i. HeartWare,DuraHeart
4. FirstGeneration
a. Displacementpumpsthatmimickedthehumanheart.
b. Fillandejectionphasessimilartoyourownheart
c. Providespulsatilepressure
d. Earlyversionshadadiaphragmthatpushedwithcompressedair
e. Mechanicalvalvesprovidedonewaybloodflow
5. FirstGenerationDownfalls
a. Difficulttodischargehomeitisdoneinsomefacilities
b. Issueswithsiteinfections
c. Bulkyequipmentevenportableequipment
6. FirstGenerationAdvancements
 a. Implantabledesign.
b. Smallerexitwound
c. Reducedinfection
d. Moremobility
e. Electronicmotorwithpusherplatedesign.
f. Moreefficient
g. Batteryandsystemcontrollerwearablebypatient
7. HeartMateXVE
8. XVEdownfalls
a. Largesizemanymenandwomenaretoosmallforsuchabigdevice
b. Difficultoperation/implant
c. Durabilitydevicewearsoutin18months
d. Percutaneousdrivelinesiteproblemforinfection
9. SecondGenerationAPulselessHeart
a. HeartMateIIonlyFDAapprovedcontinuousflowdeviceforbothdestinationtherapy
andbridgetotransplanttherapy.
b. Electricallypoweredcontinuousflowpumpwithspinningaxialimpeller
c. Valvelesspumpdesign
d. Continuousbloodflowtranslatestodampedpulsepressurenopulseonpalpation.
10. ThirdGeneration
a. Samecontinuousflowdesignassecondgeneration
b. Magneticallysuspendedrotor,nobearingsGreaterthan10yearpumplifespan?
c. Smaller,easiertoimplant
d. Lowerenergyconsumption,longerbatterylife
e. Longtermadvantagesareunknowntrialsongoing

11. HeartMateII
ClinicalOperationandPatientManagement
12. HeartMateIILVAS
SystemComponents
a. Implantabletitaniumbloodpump
b. SystemController
c. SharedComponents:
d. SystemMonitor
e. DisplayModule
f. PowerSources
g. PowerModule
h. Batteries&Clips
i. EmergencyPowerPack
j. Accessories
13. HeartMateIILVASKeyDesignFeatures
a. RelativelySimpleDesign
b. Valveless
c. Onlyonemovingpart,therotor
d. Bloodimmersedbearingsdesignedforminimizationofblooddamage
e. Allmotordriveandcontrolelectronicsareoutsideoftheimplantedbloodpump
f. Speedrange:6,000to15,000rpm
g. Flowrange:310L/min
14. InternalView/PumpBloodFlowDesign
15. Intraoperativeconcerns
a. AorticInsufficiency
b. PFO/ASD
c. Inflowcannula
d. Outflow
e. Rightheartfunctionandprotection

16. PumpPower
a. Measuredinwatts
b. Relatedtopumpspeedandflow
c. Undernormalpatientconditions,powershouldremainwithinacertainrangefora
specifiedspeed
d. SpeedPower
e. Notebaselinepowerforlaterdiagnosticuse
17. FlowEstimatorDesign
a. Flowmeasurementdoesnotuseasensororflowprobe
b. Derivedfrommotorpowerandspeedprovidinganestimateofpumpflow
c. PowerFlow
d. PowerFlow
e. Foragivenspeed,pumpflowislinearlyrelatedtopower(overalimitedrange)
18. PumpFlowPrinciples
a. Pumpflowisafunctionof:
b. Thespeedoftherotor
1. SpeedFlow
2. SpeedFlow
c. Thedifferenceinpressureacrossthepump
i. PressuregradientFlow
1. PressuregradientFlow
19. PressureFlowCurves
20. PumpFlowWaveform
21. FlowEstimatorGreenZone
22. PulsatilityIndex
a. ThePulsatilityIndex(PI)isameasurementofflowpulsethroughthepump
b. ItisdeterminedbythedegreeofnativeLVcontractilityandpumpspeed
c. PumpspeeddeterminestheamountofLVunloading
d. AsspeedincreasesthePIgoesdown
e. AsspeeddecreasesthePIgoesup
f. PIisadimensionlessvaluewhere:
g. PI=[(powermaxpowermin)/poweraverage]x10
23. PulsatilityIndex
a. PIrelatestoamountofunloadingprovidedbythepump&thereforetheamountof
nativeheartfunction
b. ThelowerthePIthegreatertheamountofsupport/unloadingbeingprovidedbythe
pump
c. ThehigherthePIthelesstheamountofsupport/unloadingbeingprovidedbythe
pump(morenativeheartfunction)
d. PIwillnaturallyvarybypatient
 e. NotethebaselinePIforlaterdiagnosticuse
24. PIEvents
a. TheHM2incorporatesasuctiondetectionalgorithmtohelpreducetheriskof
unwantedevents.
b. Thesystemmonitorssuddenchangesinpumpflowpulsalitiy(aPIevent)
c. IfaPIeventisdetected,thepumpspeedisautomaticallyreducedtotheautospeedlow
limitsetting)toavoidsuction.
d. Immediatelyfollowinganeventtheoperatingspeeddisplayedonthemonitorwillbe
lowerthanthesetspeedandthenslowlyreturntothesetspeed.
25. PI/SuctionEvent
a. Management
b. Volumestatus
i. Correctbleeding
c. TreatRVfailure,arrhythmias
i. Adjustfixedspeedsetting
d. Repositioninflowconduit
26. Alarmsandtroubleshooting
a. Advisory,HazardandBatteryAlarms
i. AdvisoryAlarms
1. PowerLeadDisconnected
2. SCBatteryModuleLow
3. ReplaceSystemController
4. LowSpeedOperation
5. Lowvoltage
ii. HazardAlarms
1. Lowvoltage
2. PERCUTANEOUSLEADDISCONNECTED
3. LOWFLOW
4. LOSSOFPOWER
27. CausesofLowFlow:
a. Decreasedpreload(rightheartfailure,tamponade,hypovolemia,bleeding,etc)
b. Obstructionofpumpinfloworoutflow
c. Systemichypertension
d. Pumpofforpercleaddisconnected
i. Action:
1. Assesspatient
2. ECHOtoassessRV,LVfunction,inletcannulaobstruction
3. Ifpersist,seekadditionalhelpimmediately
28. Patientmanagement
a. Defibrillation/Cardioversion
i. Externaldefibrillationorcardioversion
1. Donotstopthepump
ii. Internaldefibrillationorcardioversion
1. Disconnectthepercutaneousleadfromthecontroller
a. Considerclampingtheoutflowgrafttopreventretrogradeflow
b. UniqueTreatmentIssuespulseandB/P
i. Closesurveillanceforchangesinafterload(SVR)orpreload(filling)isrequired
ii. Understablephysiologicconditions:
 1. AutomatedB/Pmaynotbeaccurate
2. ManualB/Precommended
3. InvasiveB/Pwhenindicatedwhenflowispulseless
iii. Whenindoubt,ECHO
1. HelpsdecideonLVvolume
2. RVfunction
3. AppropriateSpeed
4. Aorticvalveopening
5. Tamponade
6. Mixedvenousoxygensaturation

29. HeartWareHVAD Guidelines
a. Recommendedspeed:24003200RPM
b. FlowTrough>2L/min
c. FlowPulsatility2to4L/min
d. Expectedpowerrange:37watts
e. Sethighpoweralarmat2wattsaboveaveragepower
f. Setlowflowalarmat2L/minbelowaverageflow
30. PostOperativeManagement
a. Fluidsaregiventomaintainpumpflowindexatgreaterthan2.0L/min/m2withcentral
venouspressureandleftatrialpressurelessthan20mmHg
b. Vasopressorsand/orvasodilatorscanbeusedasrequiredtoadjustvasculartone
c. Patientsmayrequireinotropicassistanceofrightventricularfunction
d. ControlhypertensionmaintainMAP<90mmHg
31. Arrhythmias/EmergencyProcedures
a. OKtodefibrillateHeartWareSystempatients
b. Antiarrythmicdrugs,pacemakers,andICDsarecompatiblewiththeHeartWareSystem
c. InstituteappropriateACLSprotocols
i. Ifchestcompressionshavebeenadministered,confirmfunctionandpositioning
ofHVADpump

References:

AdvancedPracticeGuidelinesForHeartMateDestinationTherapy.Vol1.Pleasanton,CA:Thoratec
Corporation;2004

AdvancedPracticeGuidelinesForHeartMateDestinationTherapy.Vol2.Pleasanton,CA:Thoratec
Corporation;2004

MarioCDeng,YoshifumiNaka.MechanicalCirculatorySupportTherapyInAdvancedHeartFailure.
ImperialCollegePress.Chapter3.2007

PatientManagementGuidelinesFortheHeartMateIILVAS.Vol1.Pleasanton,CA:ThoratecCorporation;
2007

HeartMateIILVASOperatingManual2010.Pleasanton,CA:ThoratecCorporation;2010

HeartMateIILVASPatientHandbook2010.Pleasanton,CA:ThoratecCorporation;2010

HeartWareLVASOperatingManual.MiamiLakes,FL:HeartWareInc.;2011

HeartWareLVADPatientHandbook2010.MiamiLakes,FL:HeartWareInc.;2011

Slaughter,MS,Pagani,FD,Rogers,JG,etal.ClinicalManagementofConitnuousflowleftventricular
assistdevicesinadvancedheartfailure.JHeartLungTransplant2010;29:S1S39