VAD

Ventricular assist device

1. Ventricular Assist Device (VAD) Dr. KAZI ALAM NOWAZ MD FINAL PART STUDENT CARDIOLOGY NHFH & RI

2. Ventricular Assist Device (VAD ) Long-Term LVAD Implanted surgically with the intention of support for months to years Short-Term LVAD Utilized for urgent/ emergent support over the course of days to weeks A mechanical circulatory device used to partially or completely replace the function of either the left ventricle (LVAD); the right ventricle (RVAD); or both ventricles ( BiVAD )

3. Indication of Short-Term LVAD Acute MI with shock Postcardiac surgery inability to wean CPB Viral myocarditis High-risk PCI High-risk ventricular arrhythmia ablation High-risk catheter valve procedure Post–heart transplant graft dysfunction

4. Contraindications Ongoing systemic infection Irreversible end-organ dysfunction Recent stroke Inability to take anticoagulation or antiplatelet therapy A mechanical aortic valve without plans for replacement or exclusion from the circulation A life expectancy related to another disease process of < 2 years Presence of incorrectable shunt

5. Variations of Short-Term VADs Impella 2.5 and 5.0 Tandem Heart CentriMag ECMO (V-A)

6. TandemHeart pVAD Used for LV support; not appropriate in RV failure Cannulas are inserted percutaneously through the femoral vein and advanced across the intraatrial septum into the left atrium The pump withdraws oxygenated blood from the left atrium and returns it to the femoral arteries via arterial cannulas Provides up to 5L/min of flow Can be used for up to 14 days

7. CentriMag Can be used for LV and/or RV support Cannula are typically inserted via a midline sternotomy Capable of delivering flows up to 9.9 L/min Can be used for up to 30 days

8. ECMO (VA) Used for patients with a combination of acute cardiac and respiratory failure A cannula takes deoxygenated blood from a central vein or the right atrium, pumps it past the oxygenator, and then returns the oxygenated blood, under pressure, to the arterial side of the circulation Can be used for days to weeks

9. Impella 2.5 and 5.0 Utilized for LV support only; not appropriate to use with RV failure Impella 2.5 can be inserted through the femoral artery during a standard catheterization procedure; provides up to 2.5 L of flow Impella 5.0 inserted via femoral or axillary artery cut down; provides up to 5L of flow The catheter is advanced through the ascending aorta into the left ventricle Pulls blood from an inlet near the tip of the catheter and expels blood into the ascending aorta FDA approved for support of days to week

10. When Should VAD Discussion Begin ?

11. Destination Therapy vs. Bridge to Transplantation Long-term placement Destination Therapy (DT) Not a heart transplant candidate Patients with >2 months of severe symptoms despite OMM LVEF <25% ≥3 HF hospitalizations in previous 12 months Dependence on i.v. inotropic therapy Progressive end-organ dysfunction Absence of severe right ventricular dysfunction Life expectancy < 2 years Bridge to Transplantation (BTT) Patient is approved and currently listed for transplant NYHA IV Failed maximized medical therapy

12. Adult FDA Approved Durable LVADs Bridge to Transplantation (BTT) HeartMate II HeartMate III HeartWare Destination Therapy (DT ) HeartMate II HeartMate III

13. Durable LVAD

14. SynCardia Total Artificial Heart–Temporary (TAH-t) It was approved by the FDA for BTT in 2007 in patients with severe biventricular heart failure Falling left & right ventricles and four native heart valves are removed Left & right atria, aorta & pulmonary artery remain Four quick connects sewn to that four structures TAH-t then inserted & attached via four connects

15. Management Considerations MEASURING BLOOD PRESSURE ANTICOAGULATION AND ANTIPLATELET THERAPIES HYPERTENSION MANAGEMENT SETTING DEVICE SPEED IMAGING HEMODYNAMICS

16. Potential Device Complications Inflow cannula (poor position, obstruction) Pump/rotor dysfunction (thrombus) Battery dysfunction Outflow graft (kink , leak) Drive line infection / fracture Controller malfunction

17. Long-Term Complications NEUROLOGIC EVENTS AORTIC INSUFFICIENCY TRICUSPID REGURGITATION RIGHT VENTRICULAR FAILURE VENTRICULAR ARRHYTHMIAS SYSTEMIC BLEEDING THROMBOSIS MUCOSAL BLEEDING INFECTION

18. Summary VAD’s are an excellent option for patients with both acute & decompensated chronic heart failure VAD’s require a multidisciplinary care team for complex decision making, delivery of therapy & ongoing patient care VAD’s, when utilized appropriately, can have outstanding results VAD’s continue to evolve, with game changing miniaturization & technological advances

19. THANKS TO ALL