563 perf tech: exam 8
Algorithm Criteria for Selection of Patients
Criteria for Selection of Patients
Separation from CPB "gradual transition from __ circulation to the __ cardiac activity with the aim of providing satisfactory oxygen through the __ and __ circulations"* Failure to wean? "difficult separation from CPB needing at least __ inotropes or vaso__ to successfully accomplish __ from CPB"
"gradual transition from extracorporeal circulation to the native cardiac activity with the aim of providing satisfactory oxygen through the pulmonary and systemic circulations"* Failure to wean? "difficult separation from CPB needing at least 2 inotropes or vasopressors to successfully accomplish separation from CPB"
Helpful Adjuncts TEE -Can identify residual intraventricular __, ventricular __, LV __, prosthetic valve __ / stenosis, hypovolemia, optimum preload and heart filling, aid in proper __ placement TEG -Aid in identifying and correcting __ problem and guiding blood __ therapy Autologous blood processing and reinfusion -Concentrates pump __ at end of the case - direct admin vs. hemobag vs. cell saver, Rapid infusion device? Post cardiotomy support available -IABP vs. __
TEE -Can identify residual intraventricular air, ventricular failure, LV distention, prosthetic valve leaks / stenosis, hypovolemia, optimum preload and heart filling, aid in proper cannula placement TEG -Aid in identifying and correcting bleeding problem and guiding blood replacement therapy Autologous blood processing and reinfusion -Concentrates pump volume at end of the case - direct admin vs. hemobag vs. cell saver, Rapid infusion device? Post cardiotomy support available -IABP vs. VADs
What I'm thinking about while doing preop workup oAnticipate failure to terminate if -oPatient is __, EF is __, fresh MI oPrep : __ leads, pull equipment (IABP pump, VAD, ECMO), pull __. Hope for the best and anticipate the worst oAnticipate excessive bleeding (sternotomy/dissection vs. case as a whole) -oRedo sternotomy or chest __, __ platelet count, on platelet __, history of __ oPrep : pull _P cannula, rapid infusor?, blood processing, banked blood available?, anticipate __ CPB initiation, prep for __ bypass, prep for quick cannulation if in chest
oAnticipate failure to terminate if -oPatient is older, EF is low, fresh MI oPrep : IABP leads, pull equipment (IABP pump, VAD, ECMO), pull disposables. Hope for the best and anticipate the worst oAnticipate excessive bleeding (sternotomy/dissection vs. case as a whole) -oRedo sternotomy or chest radiation, low platelet count, on platelet inhibitors, history of heparin oPrep : pull femoral cannula, rapid infusor?, blood processing, banked blood available?, anticipate rapid CPB initiation, prep for sucker bypass, prep for quick cannulation if in chest
Post-operative Care In ICU: Ventilatory Support __ support - M__ - Inhaled __ oxide If excessive __ chest left __ in ICU When PAs are normalized, wean __ and extubate Remove __ tubes Anticoagulation with aspirin + warfarin T__ and N__ __-flow devices: Hemopump, HeartMate II, Incor, DeBakey, Impella, Jarvik 2000 ASA only: H__ Physical therapy and nutrition Discharge home to live with their __ while awaiting transplantation or as destination therapy
In ICU: Ventilatory Support RV support - Milrinone - Inhaled nitric oxide If excessive bleeding chest left open in ICU When PAs are normalized, wean NO and extubate Remove chest tubes Anticoagulation with aspirin + warfarin Thoratec and Novacor Axial-flow devices: Hemopump, HeartMate II, Incor, DeBakey, Impella, Jarvik 2000 ASA only: Heartmate Physical therapy and nutrition Discharge home to live with their devices while awaiting transplantation or as destination therapy
♥ Ventricular assist device (VAD): - Is a mechanical pump used to help hearts that can no longer __ blood effectively due to heart __ -VAD may be used: Bridge to __ (BTT), Bridge to __ (BTR), Alternative to heart __ Ventricular Assist Devices -__ Term Support -__/Long Term Support -__ Artificial Heart
- Is a mechanical pump used to help hearts that can no longer pump blood effectively due to heart failure -VAD may be used: Bridge to transplant (BTT), Bridge to recovery (BTR), Alternative to heart transplant Ventricular Assist Devices -Short Term Support -Mid/Long Term Support -Total Artificial Heart
Ventricular Assist Devices (VADS) - __ circulatory support (MCS) devices most often are __ assist devices (VADs), which are indicated for __ to myocardial recovery, cardiac __, or as a __ assist device (__ therapy). I. Heart f II. Patient s III.Devices and device __
- Mechanical circulatory support (MCS) devices most often are ventricular assist devices (VADs), which are indicated for bridging to myocardial recovery, cardiac transplantation, or as a permanent assist device (destination therapy). I. Heart failure II. Patient selection III.Devices and device selection
Key Points -Cardiac transplantation is the __ standard treatment for patients with __-stage heart failure. Unfortunately, the __ for donor organs far outstrips the number of __ hearts. • The principal growth area for VADs in recent years has been __ therapy. The predominant device used for this indication is the A__ H__. • In New York Heart Association class __ heart failure, VADs provide better survival and quality of life than medical therapy. • A variety of __ right ventricular assist devices (__VADs) and a __ total artificial heart (TAH) are Food and Drug Administration (FDA) approved for bridging to __ or to __.
-Cardiac transplantation is the gold standard treatment for patients with end-stage heart failure. Unfortunately, the demand for donor organs far outstrips the number of available hearts. • The principal growth area for VADs in recent years has been destination therapy. The predominant device used for this indication is the Abbott HeartMate II. • In New York Heart Association class IV heart failure, VADs provide better survival and quality of life than medical therapy. • A variety of nonpulsatile right ventricular assist devices (RVADs) and a pulsatile total artificial heart (TAH) are Food and Drug Administration (FDA) approved for bridging to recovery or to transplantation.
HEART FAILURE -__ Heart Study is now considered one of the longest, most important epidemiological studies in medical history. ♥ Epidemiology In the 1960s, the study demonstrated the role __ smoking plays in the development of heart disease. Those findings helped to fuel the first __ campaigns of that era. 2009-2010 Framingham Heart Study researchers contribute to discovering hundreds of new __ underlying major heart disease risk factors. body __ index, blood c__, __ smoking, blood __, and __/diabetes.
-Framingham Heart Study is now considered one of the longest, most important epidemiological studies in medical history. ♥ Epidemiology In the 1960s, the study demonstrated the role cigarette smoking plays in the development of heart disease. Those findings helped to fuel the first anti-smoking campaigns of that era. 2009-2010 Framingham Heart Study researchers contribute to discovering hundreds of new genes underlying major heart disease risk factors. body mass index, blood cholesterol, cigarette smoking, blood pressure, and glucose/diabetes.
VA D - SHORT TERM SUPPORT -Three __-flow pumps are currently being utilized in the United States as short-term support devices: CentriMag, the TandemHeart, and Impella Types of VAD Levitronix CentriMag used as __ and __ __ term (__ days) The CentriMag pump is most utilized with an __ chest implantation with __ atrial or __ inflow cannulation for the LVAD and __ aortic cannulation for outflow. The right atrium or RV can be cannulated for __ and the pulmonary artery as __ for an RVAD. Impella RecoverLD/LP 5.0 used as LVAD and RVAD __ invasive catheters __ term (__ days) __cardiac __ or single VAD Up to __ liter per minute Can be implanted __ or via cutdown through a __ Tandem heart percutaneous LVAD __ term support LVAD (__ days) Can be inserted in __ lab or in OR The inflow is placed via the right common __ vein, across the intra-__ septum into the __ atrium. The outflow is in the __ thoracic aorta via a cannula placed in the __ artery. Medos Delta stream - European __ term DP 1: __ :used in __ extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) options in the __ population. DP 2: __ pulsatile Medos VAD & HD eight ( __ to __ term) On the market since 1994 and is one of the leading systems in __. __ pump LVAD, RVAD, or BVAD Different sizes of __
-Three continuous-flow pumps are currently being utilized in the United States as short-term support devices: CentriMag, the TandemHeart, and Impella Types of VAD Levitronix CentriMag used as LVAD and RVAD Short term (14 days) The CentriMag pump is most utilized with an open chest implantation with left atrial or LV inflow cannulation for the LVAD and ascending aortic cannulation for outflow. The right atrium or RV can be cannulated for inflow and the pulmonary artery as outflow for an RVAD. Impella RecoverLD/LP 5.0 used as LVAD and RVAD Minimally invasive catheters Short term (7 days) Intracardiac BVAD or single VAD Up to 5.5 liter per minute Can be implanted percutaneously or via cutdown through a graft Tandem heart percutaneous LVAD Short term support LVAD (14 days) Can be inserted in cath lab or in OR The inflow is placed via the right common femoral vein, across the intra-atrial septum into the left atrium. The outflow is in the descending thoracic aorta via a cannula placed in the femoral artery. Medos Delta stream - European short term DP 1: Pulsatile :used in pulsatile extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) options in the pediatric population. DP 2: Non pulsatile Medos VAD & HD eight ( short to medium term) On the market since 1994 and is one of the leading systems in Europe. Pulsatile pump LVAD, RVAD, or BVAD Different sizes of ventricles
VAD -VADs can be used as an __ LVAD, an __ right ventricular assist device (RVAD), or as a __ assist device (BIVAD). These devices can be __ implanted or inserted __. Total Artificial Heart - TAHs differ from VADs in that a TAH is inserted by __ both ventricles and anastomosing the sewing __ of the TAH to the __ and __ annuli. SynCardia TAH, headquartered in Tucson, AZ, was founded in 2001 -TAH implant requires __ of both ventricles. -__ventricular -Implantable for full cardiac __ -SynCardia's products include the original __cc TAH; the newer, smaller __cc TAH, designed to fit patients of __ stature, including more __ and adolescents Jarvik-7 A AbioCor Artificial Heart due to insufficient evidence of its efficacy, AbioMed __ further development of the product.
-VADs can be used as an isolated LVAD, an isolated right ventricular assist device (RVAD), or as a biventricular assist device (BIVAD). These devices can be surgically implanted or inserted percutaneously. Total Artificial Heart - TAHs differ from VADs in that a TAH is inserted by resecting both ventricles and anastomosing the sewing cuffs of the TAH to the mitral and tricuspid annuli. SynCardia TAH, headquartered in Tucson, AZ, was founded in 2001 -TAH implant requires resection of both ventricles. -Biventricular -Implantable for full cardiac replacement -SynCardia's products include the original 70cc TAH; the newer, smaller 50cc TAH, designed to fit patients of smaller stature, including more women and adolescents Jarvik-7 A AbioCor Artificial Heart due to insufficient evidence of its efficacy, AbioMed abandoned further development of the product.
Vasoplegic syndrome (VPS) - hypotension -•Characterized by: —◦ Severe __tension secondary to a deficit of vascular smooth muscle cell __ —◦ Decreased __ —◦ Normal-to-__ cardiac output —◦ __ filling pressures —◦ Poor response to intravascular __ —◦ Refractory to vaso__ (don't __) •Occurs in __ - __% of adult patients •Etiology not completely understood -• CPB - massive __ response, anemia, h__ •Patient and surgical risk factors include: -◦ Preoperative EF < __% -◦ __ EuroSCORE -◦ Pre-CBP hemodynamic __ -◦ __ of CPB —◦ __% increased risk for every additional 30-minute interval •Treatment includes: -◦ Vit C? -◦ V__ -◦ N__ -◦ P__ -◦ __ blue
-•Characterized by: —◦ Severe hypotension secondary to a deficit of vascular smooth muscle cell contraction —◦ Decreased SVR —◦ Normal-to-high cardiac output —◦ Low filling pressures —◦ Poor response to intravascular volume —◦ Refractory to vasopressors (don't work) •Occurs in 5 - 20% of adult patients •Etiology not completely understood -• CPB - massive inflammatory response, anemia, hemodilution •Patient and surgical risk factors include: -◦ Preoperative EF < 35% -◦ High EuroSCORE -◦ Pre-CBP hemodynamic instability -◦ Duration of CPB —◦ 38% increased risk for every additional 30-minute interval •Treatment includes: -◦ Vit C? -◦ Vasopressin -◦ Norepinephrine -◦ Phenylephrine -◦ Methylene blue
History 1966 - Dr. Michael DeBakey, the 1st successful clinical implant of a __ for postcardiotomy cardiac failure in patient and survived for 4 days. 1978 - Dr. Denton Cooley 'The 1st successful use of MCS as a "__" to transplantation 1982 - Dr. William DeVries ,The 1st __ (TAH) on Dr. Barney Clarke,at the University of Utah [3]. The pump was a Jarvik-7 TAH . 1992 - __ BVS 5000 ,The 1st pump FDA approval in USA. 1995 - the HeartMate IP and the Novacor system, Two __ pumps were then approved for inpatient __-term 1996 - the __ VAD system approved as a __-term support system. 2001 - the approval of the Thoratec VE for __ therapy, the landmark __ (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure) trial led to the approval of it.
1966 - Dr. Michael DeBakey, the 1st successful clinical implant of a VAD for postcardiotomy cardiac failure in patient and survived for 4 days. 1978 - Dr. Denton Cooley 'The 1st successful use of MCS as a "bridge" to transplantation 1982 - Dr. William DeVries ,The 1st total artificial heart (TAH) on Dr. Barney Clarke,at the University of Utah [3]. The pump was a Jarvik-7 TAH . 1992 - Abiomed BVS 5000 ,The 1st pump FDA approval in USA. 1995 - the HeartMate IP and the Novacor system, Two implantable pumps were then approved for inpatient long-term 1996 - the Thoratec VAD system approved as a long-term support system. 2001 - the approval of the Thoratec VE for destination therapy, the landmark REMATCH (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure) trial led to the approval of it.
Common Problems During and Shortly After Separation from CPB Common Problems •Sinus Bradycardia — Easy fix : temporary __ placed prior to coming off CPB •ST segment elevation / Arrythmias - Usually due to __ in the coronaries -◦ Fix by increasing __ until air comes out -Could also be due to ongoing __ / incomplete __ repair -Give __ and __ prior to taking clamp off to prevent -P__ helps -Sometimes a__ needed •Vasodilation -•Inadequate blood pressure despite an acceptable __ -•Treatment includes the use of vasopressors —◦ N__ —◦ P__ —◦ V__ •Hypertension -•Often due to __ anesthesia or __ -•Can cause _P/tearing -•Usually treated with n__ •Vasoplegic syndrome - h__ •Hemodynamic __ •Hypoxemia -•Common causes are collapsed __, broncho__, and p__ reaction -•Treatment: —◦ Visual lung __ —◦Aerosolized__ -agonist (-__) —◦ Slow p__ administration
Common Problems •Sinus Bradycardia — Easy fix : temporary pacemaker placed prior to coming off CPB •ST segment elevation / Arrythmias - Usually due to air in the coronaries -◦ Fix by increasing MAP until air comes out -Could also be due to ongoing ischemia / incomplete coronary repair -Give Mag and lidocaine prior to taking clamp off to prevent -Pacing helps -Sometimes amiodarone needed •Vasodilation -•Inadequate blood pressure despite an acceptable CI -•Treatment includes the use of vasopressors —◦ Norepinephrine —◦ Phenylephrine —◦ Vasopressin •Hypertension -•Often due to light anesthesia or inotropes -•Can cause bleeding/tearing -•Usually treated with nitroglycerin •Vasoplegic syndrome - hypotension •Hemodynamic deterioration •Hypoxemia -•Common causes are collapsed lung, bronchospasm, and protamine reaction -•Treatment: —◦ Visual lung expansion —◦Aerosolizedβ2-agonist (-erols) —◦ Slow protamine administration
Device Selection Will it be __-term or __-term heart recovery? Is it bridge to __ or __ therapy? What is the __ of the patient, and what __ device will they tolerate? Does the patient need __ or only left-sided support? ♥ DeBakey VAD, Jarvik 2000, or HeartMate II For __ patients ♥ AbioCor TAH For __ therapy __ventricular support BUT it is important to tailor the __ to the __ and not the patient to the device
Device Selection Will it be short-term or long-term heart recovery? Is it bridge to transplantation or destination therapy? What is the size of the patient, and what size device will they tolerate? Does the patient need biventricular or only left-sided support? ♥ DeBakey VAD, Jarvik 2000, or HeartMate II For smaller patients ♥ AbioCor TAH For destination therapy Biventricular support BUT it is important to tailor the device to the patient and not the patient to the device
Summary Heart failure continuous to be a problem Much has been done in the area of medical __ yet, acute/severe heart failure remains a serious complication VAD are now the new __ option and is expanding Large-scale studies are required to assess the __ of improved survival
Heart failure continuous to be a problem Much has been done in the area of medical therapy yet, acute/severe heart failure remains a serious complication VAD are now the new therapeutic option and is expanding Large-scale studies are required to assess the influence of improved survival
Deaths from Heart Failure Vary by __ Heart failure is more common in some areas of the United States than in others. Epidemiology - About __ million adults in the United States have heart failure.
Heart failure is more common in some areas of the United States than in others. Epidemiology - About 6.5 million adults in the United States have heart failure.
What are the risk factors for heart failure? Medical Conditions • Coronary artery disease (CAD) (the most __ type of heart disease) and heart __ • D • __ blood pressure • O__ • Other Conditions Related to Heart __ • __ Heart Disease Unhealthy Behaviors • Smoking __ • Eating foods high in __, cholesterol, and sodium • Not getting enough __ activity • Excessive __ intake
Medical Conditions • Coronary artery disease (CAD) (the most common type of heart disease) and heart attacks • Diabetes • High blood pressure • Obesity • Other Conditions Related to Heart Disease • Valvular Heart Disease Unhealthy Behaviors • Smoking tobacco • Eating foods high in fat, cholesterol, and sodium • Not getting enough physical activity • Excessive alcohol intake
Patient Selection ♥ Hemodynamic Parameters ♦ Cardiac index < __ L/min/m2 ♦ SBP < __ mmHg ♦PCWP> __ mmHg Patient Selection ♥ Technical Considerations for Exclusion ♦ Body surface area < __ m2 ♦ Aortic i__ ♦ __ to __ shunt ♦ Abdominal aortic __ ♦ Prosthetic __ ♦ Left ventricular t__ ♦ Severe __ ventricular failure ♥ Preoperative Risks Factors ♦RA pressure>__ mmHg ♦ PT > __ s ♦ Reoperation ♦WBC>__ ♦ Temperature > __°C ♦ Mechanically ventilated ♦ Urine output < __ cc/h ♦ Prior __ ventricular assist device
Patient Selection ♥ Hemodynamic Parameters ♦ Cardiac index < 2 L/min/m2 ♦ SBP < 80 mmHg ♦PCWP>20mmHg Patient Selection ♥ Technical Considerations for Exclusion ♦ Body surface area < 1.5 m2 ♦ Aortic insufficiency ♦ Right to left shunt ♦ Abdominal aortic aneurysm ♦ Prosthetic valves ♦ Left ventricular thrombus ♦ Severe right ventricular failure ♥ Preoperative Risks Factors ♦RApressure>16mmHg ♦ PT > 16 s ♦ Reoperation ♦WBC>15 ♦ Temperature > 38°C ♦ Mechanically ventilated ♦ Urine output < 30 cc/h ♦ Prior left ventricular assist device
Pulmonary Edema •Pre-existing or new-onset heart __ -◦ Exacerbated by additional __ administration during CPB —◦ Hemoconcentration and __ on CBP may minimize this complication •TRALI and ARDS •Prolong CBP times -◦ > __ hours Pulmonary Edema: Treatment •D__ •Inhaled __ Oxide and E__ •ECMO
Pulmonary Edema •Pre-existing or new-onset heart failure -◦ Exacerbated by additional fluid administration during CPB —◦ Hemoconcentration and diuresis on CBP may minimize this complication •TRALI and ARDS •Prolong CBP times -◦ > 4 hours Pulmonary Edema: Treatment •Diuresis •Inhaled Nitric Oxide and Epoprostenol •ECMO
VA D - MID/LONG TERM SUPPORT The two most used __-flow LVADs are the Thoratec HM II LVAD and the Heartware HVAD. The HM II was FDA approved as a bridge to __ in 2008 and received FDA approval for use as __ therapy in January 2010. Types of VAD Mid To Long Term Thoratec VAD - FDA approved as a bridge to __ in 2008 and received FDA approval for use as __ therapy in January 2010 P__ system Uni or BVAD __ pump Flow (__ LPM) Novacor left-ventricular assist system (LVAS) is an implantable, __ powered device that is presently approved both in Europe and in the United States for temporary use as a bridge to cardiac __ Implantable __ term About the __ of human heart __ pump Berlin heart is a heart pump that maintains blood flow in __ and __ children with __ heart failure. Implantable used in approximately __ children worldwide and is the only device of its kind available for babies and children with __ heart failure. __ flow
The two most used continuous-flow LVADs are the Thoratec HM II LVAD and the Heartware HVAD. The HM II was FDA approved as a bridge to transplantation in 2008 and received FDA approval for use as destination therapy in January 2010. Types of VAD Mid To Long Term Thoratec VAD - FDA approved as a bridge to transplantation in 2008 and received FDA approval for use as destination therapy in January 2010 Paracorporeal system Uni or BVAD Pulsatile pump Flow (7 LPM) Novacor left-ventricular assist system (LVAS) is an implantable, electrically powered device that is presently approved both in Europe and in the United States for temporary use as a bridge to cardiac transplantation Implantable long term About the size of human heart Pulsatile pump Berlin heart is a heart pump that maintains blood flow in babies and small children with serious heart failure. Implantable used in approximately 1,000 children worldwide and is the only device of its kind available for babies and children with severe heart failure. Pulsatile flow
Types of VAD ♥ Long Term VentrAssistTM LVAD it has a __-generation, implantable, __ blood pump with hydrodynamic suspension __ size Outstanding b__ Assists the __ heart which is not removed for patients who potentially require __-term __ support Heart mate IP • __ pump • Flow __ LPM Heart mate II LVAS • Axial flow (__ LPM) • __ ascending aorta DeBakey axial-flow ventricular assist device (VAD) Development of it began in 1988, after a visit with __ engineers MicroMed-Debakey/Noon VAD Small: 451 implants (155 of those in the U.S.), including 19 pediatric 95 grams 1.2 inches in diameter 3 inches long Flow __ titanium; the revolutions per minute (rpm) ranged from __ to __, with flow rates up to __ L/min. Jarvik 2000 - is a __ electrically powered __ axial-flow left ventricular assist device (LVAD) that has been developed and refined over the last __ years. Pump positioned inside the _P with the outflow graft extended to the __ aorta
VentrAssistTM LVAD it has a third-generation, implantable, centrifugal blood pump with hydrodynamic suspension Small size Outstanding biocompatibility Assists the natural heart which is not removed for patients who potentially require long-term circulatory support Heart mate IP • Pulsatile pump • Flow 11 LPM Heart mate II LVAS • Axial flow (10 LPM) • Apex ascending aorta DeBakey axial-flow ventricular assist device (VAD) Development of it began in 1988, after a visit with NASA engineers MicroMed-Debakey/Noon VAD Small: 451 implants (155 of those in the U.S.), including 19 pediatric 95 grams 1.2 inches in diameter 3 inches long Flow non-pulsatile titanium; the revolutions per minute (rpm) ranged from 7,500 to 12,500, with flow rates up to 10 L/min. Jarvik 2000 - is a valveless electrically powered non- pulsatile axial-flow left ventricular assist device (LVAD) that has been developed and refined over the last 25 years. Pump positioned inside the ventricle with the outflow graft extended to the descending aorta
Heart Failure ♥ Ventricular Assist Devices VAD -__ circulatory support (MCS) devices most often are __ assist devices (VADs), which are indicated for bridging to myocardial __, cardiac __, or as a __ assist device (__ therapy).
Ventricular Assist Devices VAD -Mechanical circulatory support (MCS) devices most often are ventricular assist devices (VADs), which are indicated for bridging to myocardial recovery, cardiac transplantation, or as a permanent assist device (destination therapy).
WRMVP: Wide receiver most valuable player (__ tool) Warm: What is the bladder and blood __? Rhythm: Are they in __ or do you need to pace? Is the __ adequate? Monitors On: Turn em back __ if you turned them __ for bypass. Turn back __ the alarms. Ventilation: Turn __ the ventilator Perfusion: What is the pump __?
Warm: What is the bladder and blood temp? Rhythm: Are they in NSR or do you need to pace? Is the rate adequate? Monitors On: Turn em back on if you turned them off for bypass. Turn back on the alarms. Ventilation: Turn on the ventilator Perfusion: What is the pump flow?
Inotropic Drug Therapy •Calcium chloride ◦ Low Ca due to __, banked blood -◦ Bad - __tension, coagulopathy, myocardial __ ◦ Normalized -◦ Positive __ effect in presence of hyper__ or hypo__ -◦ May help normalize __ pressure due to __ post CPB ◦ Should normalize __ calcium levels before coming off CPB (__ - __mg); __mg per unit banked blood ◦ May help with protamine associated __ ◦Hypercalcemia can lead to myocardial __, cardiac __, and p__ -◦ Ca admin should be avoided while heart is __ —◦ Cause elevated __ Ca2+ levels in ischemic cells = __ heart, reperfusion __ -◦ Role of Ca in reperfusion injury - post CPB __? —◦ Calcium __
•Calcium chloride ◦ Low Ca due to hemodilution, banked blood -◦ Bad - hypotension, coagulopathy, myocardial depression ◦ Normalized -◦ Positive inotropic effect in presence of hyperkalemia or hypocalcemia -◦ May help normalize arterial pressure due to vasoplegia post CPB ◦ Should normalize ionized calcium levels before coming off CPB (500 - 1000mg); 200mg per unit banked blood ◦ May help with protamine associated hypotension ◦Hypercalcemia can lead to myocardial injury, cardiac arrhythmias, and pancreatitis -◦ Ca admin should be avoided while heart is ischemic —◦ Cause elevated intracellular Ca2+ levels in ischemic cells = stone heart, reperfusion injury -◦ Role of Ca in reperfusion injury - post CPB stunning? —◦ Calcium paradox
Inotropic Therapy for Left Ventricular Failure •Calcium c__ •E •N •D •D •I •M
•Calcium chloride •Epinephrine •Norepinephrine •Dopamine •Dobutamine •Isoproterenol •Milrinone
Hemodynamic Deterioration: Causes •Cardiac __ •Graft or valve __ •__ embolus in coronary arteries •Reaction to medications -◦ P__ •Closure of the p__ •Closure of the sternum -◦ T__ effect •Ischemia -◦ Graft k__, c__, embolization —◦ May require surgical __ •Coronary __ •New cardiac abnormality —◦ assess with __ •Surgical or technical problems —◦ __/tears
•Cardiac arrhythmias •Graft or valve malfunction •Air embolus in coronary arteries •Reaction to medications -◦ Protamine •Closure of the pericardium •Closure of the sternum -◦ Tamponade effect •Ischemia -◦ Graft kinking, clotting, embolization —◦ May require surgical revision •Coronary vasospasm •New cardiac abnormality —◦ assess with TEE •Surgical or technical problems —◦ Bleeding/tears
Inotropic Drug Therapy •Dobutamine ◦Useful when further vaso__ is undesirable ◦ __, __, receptor agonist with minimal __-receptor activity
•Dobutamine ◦Useful when further vasoconstriction is undesirable ◦ β1, β2, receptor agonist with minimal α-receptor activity
Inotropic Drug Therapy •Epinephrine and Norepinephrine ◦ Useful when ventricular __ is accompanied by peripheral vaso__ ◦ Potent __-receptor agonist
•Epinephrine and Norepinephrine ◦ Useful when ventricular dysfunction is accompanied by peripheral vasodilation ◦ Potent α-receptor agonist
MCS Therapy •If ventricular function remains inadequate despite appropriate __ therapy -◦ Add __ support —◦ IABP -—◦__ insertion —-◦__ only for post op use —◦ LVAD —◦ ECMO
•If ventricular function remains inadequate despite appropriate inotropic therapy -◦ Add mechanical support —◦ IABP -—◦Prophylactic insertion —-◦Leads only for post op use —◦ LVAD —◦ ECMO
Left Ventricular Failure •Inadequate cardiac __ performance ◦ Despite appropriate r__, r__, __load, __load •Commonly caused by: ◦ Ischemia or __ injury (incomplete re-vascularization) -◦ Helped by —◦ N__ administration —◦ Maximize __ blood flow and improve __ relaxation ◦ Pre-existing cardiac __ (prophylactic __) -◦ May need additional __ support Left Ventricular Failure: Causes •Ischemia (__ failure) - regional ◦ C__ graft ◦ __ in graft ◦ K__ graft ◦ Inadequate __ blood flow -◦ Low __ pressure ◦ E__ in graft ◦ C__ spasm •Valve failure (__ vs. __) -• SAM or LVOT obstruction
•Inadequate cardiac pump performance ◦ Despite appropriate rate, rhythm, preload, afterload •Commonly caused by: ◦ Ischemia or reperfusion injury (incomplete re-vascularization) -◦ Helped by —◦ Nitroglycerin administration —◦ Maximize coronary blood flow and improve diastolic relaxation ◦ Pre-existing cardiac dysfunction (prophylactic inotropes) -◦ May need additional pharmacologic support Left Ventricular Failure: Causes •Ischemia (graft failure) - regional ◦ Clotted graft ◦ Air in graft ◦ Kinked graft ◦ Inadequate coronary blood flow -◦ Low diastolic pressure ◦ Emboli in graft ◦ Coronary spasm •Valve failure (aortic vs. mitral) -• SAM or LVOT obstruction
Predictors - Intraop •Incomplete re-vascularization ◦ __ vessels ◦ Vessel __ - •Valve replacement with __ valve or sub-__ valve repair •Valve replacement combined with CABG = __ risk •Ventricular distension BAD -• VF while __ -• AI with __ CPS = __ ventricle Increased bypass time and cross clamp time = more __ to separate from CPB •Incomplete myocardial __ during cross-clamping ◦ ECG not __ ◦ Warm myocardium -◦ Mispositioned cardioplegia __ -◦ __ hypertrophy -◦ __ grade coronary artery disease -◦ Washout of cardioplegia (non-coronary __ flow) or improperly placed __ -◦ Poor LV __ (LV __) ◦ Labs -◦ Increasing __ may indicate continuing myocardial __
•Incomplete re-vascularization ◦ Small vessels ◦ Vessel spasm - •Valve replacement with small valve or sub-optimal valve repair •Valve replacement combined with CABG = increased risk •Ventricular distension BAD -• VF while warm -• AI with antegrade CPS = distended ventricle Increased bypass time and cross clamp time = more difficult to separate from CPB •Incomplete myocardial preservation during cross-clamping ◦ ECG not asystolic ◦ Warm myocardium -◦ Mispositioned cardioplegia cannula -◦ LV hypertrophy -◦ High grade coronary artery disease -◦ Washout of cardioplegia (non-coronary collateral flow) or improperly placed XCL -◦ Poor LV venting (LV distension) ◦ Labs -◦ Increasing lactate may indicate continuing myocardial ischemia
Use of Inotropes: Controversial Issue •Increase myocardial oxygen __ relative to __ -◦ Especially after cardiac surgery with __ cardiac arrest •Delay use until heart has a chance to recover from __ immediately after cross-clamp removal
•Increase myocardial oxygen consumption relative to supply -◦ Especially after cardiac surgery with ischemic cardiac arrest •Delay use until heart has a chance to recover from ischemia immediately after cross-clamp removal
Therapeutic Goals: Treatment of RV Dysfunction •Increase ventricular __ •Decrease __ (__) •Maintain adequate preload (__) but don't __ -•Don't __ coming off pump •Maintain adequate systemic __ pressure -◦Provide adequate __ perfusion pressure
•Increase ventricular contractility •Decrease afterload (PAP) •Maintain adequate preload (CVP) but don't distend -•Don't overfill coming off pump •Maintain adequate systemic arterial pressure -◦Provide adequate coronary perfusion pressure
Treatment: RV Failure •Inhaled pulmonary vaso__ •__ with vasodilator effects •Vaso__ as needed to maintain coronary perfusion •IABP •RVAD •Inhaled __ oxide •Inhaled prostacyclin analogs -◦ E__ -◦ Iloprost - PG__ analog = potent vaso__ -◦ Helps with pulmonary __ •Selective for __ circulation •Provide effective pulmonary vaso__ •Dobutamine and Isoproterenol ◦ Infused into right __ ◦ Increases RV __ without increasing __ •Milrinone ◦ Increases RV __ ◦ __ pulmonary vascular resistance •Vasopressin ◦ __ systemic pressures without increasing __ •If ventricular function remains inadequate despite appropriate inotropic therapy and pulmonary vasodilation ◦ Add __ support —◦ IABP —◦ RVAD —◦ ECMO
•Inhaled pulmonary vasodilators •Inotropes with vasodilator effects •Vasoconstrictors as needed to maintain coronary perfusion •IABP •RVAD •Inhaled nitric oxide •Inhaled prostacyclin analogs -◦ Epoprostenol -◦ Iloprost - PGI2 analog = potent vasodilator -◦ Helps with pulmonary hypertension •Selective for pulmonary circulation •Provide effective pulmonary vasodilation •Dobutamine and Isoproterenol ◦ Infused into right atrium ◦ Increases RV contractility without increasing PAP •Milrinone ◦ Increases RV contractility ◦ Reduces pulmonary vascular resistance •Vasopressin ◦ Increases systemic pressures without increasing PVR •If ventricular function remains inadequate despite appropriate inotropic therapy and pulmonary vasodilation ◦ Add mechanical support —◦ IABP —◦ RVAD —◦ ECMO
Separation from CPB: Difficult Situations •__ Ventricular Failure •__ Ventricular Failure •Pulmonary __
•Left Ventricular Failure •Right Ventricular Failure •Pulmonary Edema
Inotropic Drug Therapy •Milrinone ◦ __ (PDE) inhibitor, __ intracellular cyclic __ levels ◦ Positive __ effect ◦ Inotropic activity is synergistic with __-agonist agents ◦ Often used with e__ or n__ ◦ Causes vaso__ -◦ Use vaso__ or p__ to counteract effect
•Milrinone ◦ Phosphodiesterase (PDE) inhibitor, raises intracellular cyclic AMP levels ◦ Positive Inotropic effect ◦ Inotropic activity is synergistic with β-agonist agents ◦ Often used with epinephrine or norepinephrine ◦ Causes vasodilation -◦ Use vasopressin or phenylephrine to counteract effect
Causes of Right Ventricular Failure •Pre-op RV __ •Pulmonary hypertension ◦ Chronic __ valve disease ◦ __-__ shunts ◦ Pulmonary __ ◦ Acute __ regurgitation •Inadequate __ protection •RV ischemia or __ •Reperfusion injury - __ •Volume overload - __ •Inadequate o__ and •Intra-coronary __ or __ ventilation
•Pre-op RV failure •Pulmonary hypertension ◦ Chronic mitral valve disease ◦ L-R shunts ◦ Pulmonary embolism ◦ Acute mitral regurgitation •Inadequate cardioplegic protection •RV ischemia or infarct •Reperfusion injury - stunning •Volume overload - distention •Inadequate oxygenation and •Intra-coronaryairormicroemboli ventilation
Predictors: Failure to Wean: Pre-op •Pre-operative EF < __%, diabetes, preop renal __, recent MI •Reoperation (previous __ surgery), __ operation •Severe __, recent or previous __ •Pre-existing __ or __ ventricular failure by pre-op __ •Left __ or __ vessel disease •Female patients undergoing CABG ◦ Tendency for incomplete re-__ due to __ more diseased coronary arteries •Advanced age - Elderly patients >__ •Ongoing __ or evolving __ in pre-CBP period
•Pre-operative EF < 20%, diabetes, preop renal insufficiency, recent MI •Reoperation (previous cardiac surgery), emergent operation •Severe angina, recent or previous MI •Pre-existing left or right ventricular failure by pre-op TEE •Left main or Triple vessel disease •Female patients undergoing CABG ◦ Tendency for incomplete re-vascularization due to smaller more diseased coronary arteries •Advanced age - Elderly patients >70 •Ongoing ischemia or evolving infarct in pre-CBP period
Diagnosis of Right Ventricular Failure •Use TEE to assess for: ◦ RV __ ◦ Moderate to severe __ regurgitation ◦ Volume and pressure __ •Increased __ and/or __ pressures •Decreased __ pressure •__ cardiac output
•Use TEE to assess for: ◦ RV enlargement ◦ Moderate to severe tricuspid regurgitation ◦ Volume and pressure overload •Increased PA and/or CVP pressures •Decreased arterial pressure •Decreased cardiac output
Complications ♥Bleeding __% and __% - H__ dysfunction - Anticoagulation - Coagulopathy caused by __-__ interaction - Extensive surgical __ - Prolonged cardiopulmonary bypass __ Reexploration for __ is common Death due to bleeding __% to __% ♥ Infection __% to __% of patients Infection sites: - D__ - B__ ♥ Thromboembolism __% to __% HeartMate lowest rate __% Requires only __ All other pumps require __/antiplatelet agents Thrombus formation can occur due to __ flow in any one of the conduits or devices ♥ Mechanical Failure Rate is declining to <__% Usually does not led to __ In many cases time or reserve is available to __ the device or the controller ♥ Multiorgan Failure Due to -Preoperative __-organ dysfunction -Co__ conditions -Post-op __, bleeding Mortality, __% to __%
♥Bleeding 20% and 50% - Hepatic dysfunction - Anticoagulation - Coagulopathy caused by human-device interaction - Extensivesurgicaldissection - Prolonged cardiopulmonary bypass time Reexplorationforbleedingiscommon Death due to bleeding 0% to 15% ♥ Infection 11% to 26% of patients Infection sites: - Driveline - Blood ♥ Thromboembolism 7% to 47% HeartMate lowest rate 7.4% Requires only aspirin All other pumps require warfarin/antiplatelet agents Thrombus formation can occur due to turbulent flow in any one of the conduits or devices ♥ Mechanical Failure Rate is declining to <10% Usually does not led to death In many cases time or reserve is available to replace the device or the controller ♥ Multiorgan Failure Due to -Preoperative end-organ dysfunction -Comorbid conditions -Post-op sepsis, bleeding Mortality, 11% to 29%
First try this! ✓Make sure you are warm - core temperature >__C ✓Lab data should be in __ ranges -✓PO2>__, Hct >__, no metabolic / electrolyte __ ✓Normal sinus rhythm (ideally no _P dysrhythmias) ✓Surgery complete? ✓Patient being __? ✓Vasoactive agents and inotrope __ for weaning?
✓Make sure you are warm - core temperature >36C ✓Lab data should be in normal ranges -✓PO2>100, Hct >25, no metabolic / electrolyte disturbances ✓Normal sinus rhythm (ideally no atrial dysrhythmias) ✓Surgery complete? ✓Patient being ventilated? ✓Vasoactive agents and inotrope optimized for weaning?