VADs

[SilverStreak]

I took a class yesterday on cardiac support devices. I learned a lot. Pretty interesting stuff. We infrequently get VADs about 1 every other year so it's a big deal to us when we do. Does anybody work with them more frequently in a transplant center? It just blows my mind that they can be up walking around pushing the plastic ventricle that's pumping for the heart.

It seems that they would be much more challenging patients to treat for a variety of reasons. We give volume based on a set ideal range of CVP/PAD, I'd be nervous to give the amounts of volume they were talking to these guys without looking at the numbers especially if they only had a uni VAD in place. But, the way the rep explained it, it's a preload driven system, so they have to have the volume for the bladders to empty and fill to pump to systemic circulation. The clotting/anticoagulation meds/bleeding would be a difficult balance I would think also.

I was also surprised to hear the rep say that "partial support devices" ie inotropes and IABPs only boost CO by about 20%, I would have thought the IABP to be higher than that. Her point was that if you've had one failed off pump run, give it 30 minutes and try some Dob, two failed pump runs, go no longer than an hour total off pump trial (including 30 minutes above) with IABP, if that's not working, then they recommend placing a VAD. This was a new thought for me too, since if that was the guideline, we'd see a lot more VADs than what we do now. It made me wonder if some of our IABPs we see do so crappy shouldn't be considered more seriously for a VAD. She said the company is trying to switch mentality from a last ditch effort to place a VAD more to a use it early with success. What are the trends everywhere else?

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[BIS]

I took a class yesterday on cardiac support devices. I learned a lot. Pretty interesting stuff. We infrequently get VADs about 1 every other year so it's a big deal to us when we do. Does anybody work with them more frequently in a transplant center? It just blows my mind that they can be up walking around pushing the plastic ventricle that's pumping for the heart.

It seems that they would be much more challenging patients to treat for a variety of reasons. We give volume based on a set ideal range of CVP/PAD, I'd be nervous to give the amounts of volume they were talking to these guys without looking at the numbers especially if they only had a uni VAD in place. But, the way the rep explained it, it's a preload driven system, so they have to have the volume for the bladders to empty and fill to pump to systemic circulation. The clotting/anticoagulation meds/bleeding would be a difficult balance I would think also.

I was also surprised to hear the rep say that "partial support devices" ie inotropes and IABPs only boost CO by about 20%, I would have thought the IABP to be higher than that. Her point was that if you've had one failed off pump run, give it 30 minutes and try some Dob, two failed pump runs, go no longer than an hour total off pump trial (including 30 minutes above) with IABP, if that's not working, then they recommend placing a VAD. This was a new thought for me too, since if that was the guideline, we'd see a lot more VADs than what we do now. It made me wonder if some of our IABPs we see do so crappy shouldn't be considered more seriously for a VAD. She said the company is trying to switch mentality from a last ditch effort to place a VAD more to a use it early with success. What are the trends everywhere else?

You cant always listen to the reps. Remember they are trying to sell or promote the device. Of course all other devices suck and theirs is superior. At a facilty I rotate thru and worked as a RN we got 2-3 VADS a week sometimes. We did many FDA trials for some new devices as well.

As far as anticoagulation goes it really depends on the VAD and how it works. Is it axial flow such as the Heartmate II or DeBakey or is it pulsatile such as heartmate I, thoratec, novacor, abiomed ect. They are inserting many more destination therapy VADS. These folks go home and live relatively normal lives. IF they are TP candidates then when their time comes they take the VAD out and TP the heart. Those that are not candidates go home with the VAD. IF they are lucky they will recognize a malfunction before its devastating and possible get a new one. If not they die when the VAD poops out or when they throw a clot. I have cared for VAD pts that could jog further that me.
Recently the debakey vad people have shrunk the device and have implanted a few in kids for bridge to TP purposes.

Yes all devices are preload driven though afterload effects flows or C.O. as well. With axial flow VADS you will only have mean pressures. Flows are RPM's are important. They folks also tend to throw more clots or have issues with the pump clotting off. The heartmate I eventually requires little to no anticoagualtion. When the pt is getting dry depending on if the pumps are external or internal you can visualize the bladders not filling enough. They look more shriveld and squeeze weakly. They many times are bleeding and continue to bleed for a while. You are pooring in products yet the pt is on a herapin infusion. I have even cared for your ocassional pt that came back to the ICU with a VAD and IABP. Boy is that fun.

This one cat they saved with a thoratec when he arrested in holding just before his transplant. The heart had not made it from the trauma center to the TP center so they put in the BIVAD. Not sure if you are familiar with the old school thoratec but the external unit is almost as big as a freaking 3ft tall fridge. This guy walked around in Vfib for 3wks with someone pushing that big unit behind him. They had to stop monitoring his ecg b/c central ECG monitoring would call codes everyday. He eventually transplanted and did well. We even will ambulate someone with a VAD that is trached and on the portible vent dragging all kind of $hit behind.

These companies have grown and advanced the technology drastically over the past 30yrs. The reps have told me that the goal is eventually to have a small internal pump that last for 10 years or so. They hope to totally eliminate the need for heart transplants and the immunosuppression issues that goes along with it. When the VAD fails you get a new one if possible, if not you go.

 

[deleted59964]

You cant always listen to the reps. Remember they are trying to sell or promote the device. Of course all other devices suck and theirs is superior. At a facilty I rotate thru and worked as a RN we got 2-3 VADS a week sometimes. We did many FDA trials for some new devices as well.

As far as anticoagulation goes it really depends on the VAD and how it works. Is it axial flow such as the Heartmate II or DeBakey or is it pulsatile such as heartmate I, thoratec, novacor, abiomed ect. They are inserting many more destination therapy VADS. They folks go home and live relatively normal lives. IF they are TP candidates then where their time comes they take the VAD out and TP the heart. Those that are not candidates go home with the VAD. IF they are lucky they will recognize a malfunction before its devastating and possible get a new one. If not they die when the VAD poops out or when they throw a clot. I have cared for VAD pts that could jog further that me.
Recently they debakey vad people have shrunk the device and have implanted a few in kids for bridge to TP purposes.

Yes all devices are preload driven though afterload effects flows or C.O. as well. When the pt is getting dry depending on if the pumps are external or internal you can visualize the bladders not filling enough. They look more shriveld and squeeze weakly. They many times are bleeding and continue to bleed for a while. You are pooring in products yet the pt is on a herapin infusion. I have even cared for your ocassional pt that came back to the ICU with a VAD and IABP. Boy is that fun.

This one cat they saved with a thoratec when he arrested in holding just before his transplant. The heart had not made it from the trauma center to the TP center so they put in the BIVAD. Not sure if you are familiar with the old school thoratec but the external unit is almost as big as a freaking 3ft tall fridge. This guy walked around in Vfib for 3wks with someone pushing that big unit behind him. They had to stop monitoring his ecg b/c central ECG monitoring would call codes everyday. He eventually transplanted and did well. We even will ambulate someone with a VAD that is trached and on the portible vent dragging all kind of $hit behind.

it's been a while since i worked in a transplant centre (CCRN), i remember one patient referred to us in conscious VT, had an AICD that was driving the poor man insane. we disabled it with a magnet, but once every 20min or so, he would flip the axis on his VT, and lose his output. Interestingly the VT with no output was slower than the VT with output. Our treatment for the VT with no output was to remove the magnet, and let the AICD do it's thing. I "defibrillated" this guy more than 20 times one night using this method. we got a vad (thoratec) into him in the morning, bridge to transplant, got transplant some time later, then died of post op infection. i lost interest in transplants after that - think of all the people you could help with those resources.