MCSDs, VAD, Total Artificial Heart, Heart Transplantation

In which population is strengthening of proximal muscles particularly important? A. VAD B. TAH C. Heart Transplantation

C. Look at slide 96 for Activity Levels after cardiac transplantation ICU treatment focus: optimize pulmonary hygiene and breathing mechanics, improve strength and ROM in UE and chest, improve exercise tolerance of low to moderate intensity exercise IP rehab treatment focus: independence with ADLs, increased activity tolerance and endurance, development of home exercise program, patient education OP treatment focus: skeletal muscle strengthening, aerobic conditioning, independence with progressive exercise program, independence with self-monitoring, education Education topics: Technique and safety with exercises, with functional mobility, with ADLs Sternal precautions Self-monitoring using HR, RPE, RPD Aerobic exercise guidelines Signs/symptoms of activity intolerance (pallor, flushing, excessive sweating)

Pump, cannula, driveline, controller, and power source are all components of: A. Impella B. IABP C. VAD D. ECMO

C. Pump: circulates the blood; placed in the abdomen or thorax Cannula: connects pump to CV system; inflow cannula commonly at apex of L ventricle & outflow cannula at ascending aorta (or from R atria to pulmonary trunk) Driveline: connects the pump to the controller; starts inside the body & goes outside through R abdomen Controller: computer that operates the VAD Power source: can be plugged into an outlet or can use batteries Classified based on how they function mechanically: LVAD = left ventricle (most common) RVAD = right ventricle BiVAD = both ventricles TAH

A patient with a VAD suddenly has decrease in CO (as indicated on monitor). He is demonstrating hypotension, tachycardia, and arrhythmias. What is the first thing you should do? A. Contact VAD team B. Continue therapy C. Place individual in supine position with legs elevated D. Ask patient if he/she feels lightheaded

C. Suckdown is occurring due to lack of adequate blood volume --> collapsed ventricle --> pump not filling (CRITICAL SITUATION!) Syncope and change in mental status may also occur so can't ask patient how he/she feels Contact VAD team after elevating patient's legs

True or false? PT is contraindicated for patients with IABPs.

True Patients with IABPs are hemodynamically unstable and are on bedrest If MD requests therapy for uninvolved extremities, limit activity to avoid disruption of the catheter, balloon rupture, or incision site infection

True or false? PT is contraindicated for patients with an impella.

True Patients with impella are hemodynamically unstable

True or false? INR management for VADs is critical.

True Risk for bleeding events is high

True or false? Patients who have had a heart transplantation are on sternal precautions post-surgery.

True Sternal precautions: Limit push, pulling, lifting to 10 lbs for 6 weeks Do UE ROM as tolerated May use arms to steady self during transfers but need assistance is more than 10 lb restriction May need to use heart pillow for adherence No resistance on UBE or arm bike No MMT for shoulder Okay to MMT at elbow and wrist

True or false? Ventricular assist devices (VADs) can be taken home with the patient.

True Used for management of heart failure Indications: Bridge to transplantation (most common) Bridge to candidacy Destination therapy Bridge to recovery

True or false? NYHA class III and IV are indications for heart transplantation.

True Other indications: End stage heart disease with refractory response to conventional therapy Poor QOL due to severe functional limitation Congenital heart disease Cardiac tumors Inclusion criteria: Reliable social support Commitment to self care Appropriate insurance coverage Psychiatric/ psychological evaluation Look at slide 77 for exclusion criteria

True or false? Patients with VADs are often on anticoagulation medications.

True Warfarin and Aspirin Also inotropes and vasopressors, anti-arrhythmics, and diuretics

TAH relies on ___ to increase cardiac output. A. Venous return B. Hormones C. Respiratory rate D. Stroke volume

A.

Which MCSD is this: temporary device to support cardiac pump function by a catheter being threaded up from the femoral artery to the descending aorta, which inflates at the beginning of diastole to increase intra-thoracic pressure and improve blood flow to coronary arteries and deflates during systole to decrease left ventricular afterload A. IABP B. ECMO C. VAD D. TAH

A. Most frequently used MCSD Requires some heart function to be available (simply augments flow of blood through coronary arteries) Increases CO, decreases SBP, decreases HR

When should you alert the VAD team? Hint: there's at least 2 reasons

1. If patient's MAP is <70 or >90 mmHg HTN >90 mmHg = pump is less effective, increased power use, risk for return of heart failure symptoms or hemorrhagic stroke 2. 3-5 lb. weight gain in 3 days

Select all of the following indications for TAH placement: [A]. Bridge to transplantation [B]. Bridge to candidacy [C]. Bridge to recovery [D]. Destination therapy

A, D Bi-ventricular, pneumatic, pulsatile pump Both native heart ventricles and all 4 valves removed Mechanical valves between atria and TAH

A patient with a VAD recently had a change in his anticoagulation and antiplatelet medications. He reports to you that he is experiencing hematuria, the battery life for his VAD is not lasting as long, and there's a grinding sound coming from the VAD. What complication are you suspecting? A. Thrombus B. Hemolysis of RBCs C. Right heart failure D. Infection

A. Patient's Hbg/HCT levels will also be decreased due to the thrombus 20% risk of thrombus formation in pump or ventricle 45% risk of TIA or CVA

Name three therapy considerations for patients with VADs (there's more than 10). Note: rehab focus is to restore functional mobility for home and community, increase activity tolerance, education, home exercise program, safe discharge home with progression to outpatient cardiac rehabilitation

Be familiar with, know how to interpret and manage all alarms Make sure to check battery power Organize environment due to short cannulas and drivelines. Drivelines and cannulas need to be secure Do not position stomach (prone) to avoid driveline occlusion Limit sidelying due to driveline and pump positioning Make sure patient always has back up VAD with him/her Be cautious about obstructions to blood flow (mostly occur during supine to sit, sitting with poor posture, sit to stand transfers i.e. increased trunk flexion) Be cautious about increased hip flexion as that may be painful due to positioning of internal VAD components (stairs, NuStep, seated bicycle) Monitor cardiac index (2.6-4.2 L/min/m^2) and LVAD flow (>3 L/min) during activity Use RPE (goal is fairly light to somewhat hard level (11-14) and RPD (not to exceed moderate i.e. <5) Monitor signs/symptoms that indicate activity intolerance: dyspnea, dizziness, lightheadedness, angina, claudication, fatigue, weakness, pain, cyanosis, pallor, orthostasis 6MWT recommended Education on VAD management: alarms, record parameters daily, system check, power module system check, battery charge, driveline inspection, weekly dressing change, shower, switch power from cables to batteries, daily weight Look at Exercise progression slide (slide 45) for more detail on specific interventions

Which MCSD is this: percutaneously inserted ventricular assist device (inserted through femoral artery) meant for short term support (up to 6 days); pulls blood from L ventricle and expels blood into aorta to reduce ventricular workload/support cardiac pump function A. IABP B. TAH C. Impella D. ECMO

C. Used for patients with severe heart failure, cardiogenic shock, and high-risk heart PCI interventions Other purposes: improve blood flow to myocardium, decreased afterload, decreased myocardial oxygen demands

Which MCSD is this: life support machine for when mechanical ventilation alone is inadequate to support life AKA cardiopulmonary bypass A. TAH B. Impella C. IABP D. ECMO

D. Pumps blood from body to an artificial lung (oxygenator) and then returns blood back with a pump with the same force as the heart VA-ECMO bypasses heart and lungs VV-ECMO is more for patients with lung failure

Why is warm-up important for those with heart transplantation?

Denervated heart = no autonomic regulation Need warm-up to circulate catecholamines which will increase HR (over time, denervation supersensitivity develops) Since HR does not initially increase with onset of exercise, SV increases to increase CO (Frank-Sterling mechanism)

True or false? Nonpulsatile VADs are typically seen in the hospital.

False Pulsatile VADs are typically seen in the hospital. Bigger in size, less durable, more complications. Diastolic phase = when pump fills with blood Systolic phase = when pump ejects blood into circulation Therapy considerations: Internal device --> thoracolumbar flexion could obstruct cannula (e.g. sit-to-stands) External device --> monitor cannula and pump position to not disrupt healing and prevent thrombosis formation Heavy Need abdominal binder or anchoring system to support cannula and driveline

Name three therapy considerations for patients with TAH (there's more than 10).

Do not position on left side or stomach (prone) to avoid driveline occlusion Need to wear abdominal binder to prevent pulling driveline Need to ensure driveline exit site does not get distubed Poor thoracic posture while seated may stress drivelines exiting body and compromise TAH function TAH console is large so may need extra assistance to manage lines and equipment Be familiar with, know how to interpret and manage all alarms Make sure to check batter power (lasts 24 hours) Monitor R and L ventricular fill volumes (should be 50-60 mL, with 65 mL the upper limit for activity); will be shown on external device Blood pressure (goal <20 mmHg decrease in SBP during activity); SBP <80 mmHg is lower limit for activity Heart rate (set by device at 100-130 bpm) Use RPE (goal is fairly light to somewhat hard (11-14) and RPE (not to exceed moderate i.e. <5) Monitor for signs/symptoms of activity intolerance: lightheadedness, dizziness, fatigue, SOB, pain 6MWT recommended

True or false? It's possible to achieve peak HR with exercise in those with heart transplantation.

False Achieves 70-80% of normal

True or false? Cardiac reinnervation is impossible after heart transplantation.

False Does occur in some young individuals

True or false? In a denervated heart (i.e. due to heart transplantation), normal heart rate is still 60-100 bpm.

False Elevated as high as 90-110 bpm to achieve normal CO.

True or false? Heart and lungs can survive outside the body for only 7-8 hours.

False Only 4-6 hours

True or false? End stage heart disease NYHA Classes I-IV are indications for MCSDs.

False Only NYHA Classes III or IV Other indications: Unstable angina with cardiogenic shock EF <25% CO <2 L/min Reversible organ dysfunction- liver, kidneys, and bowel Ability to restore physical function

True or false? Pulse is more reliable than MAP for patients with VADs. It should be used in therapy sessions to monitor activity tolerance.

False Pulse is weak, irregular, non-palpable in patients with VADs. MAP is important to monitor in individuals with VADs (variable early post VAD implantation but stabilizes with time) Describes average BP Normal is 70-110 mmHg MAP goal for individuals with VADs is 70-90 mmHg <60 mmHg and coronary arteries and organs are not receiving appropriate perfusion MAP = (SBP + 2(DBP))/3

True or false? Sternal precautions end at 10 weeks.

False Until surgeon lifts the restrictions

True or false? Heart rate is an accurate measure to monitor activity tolerance in someone who has had heart transplantation.

False Use RPE scale with goal of exercising at fairly light to somewhat hard (11-14)

True or false? ECMOs have a high risk of causing hemolysis of RBCs.

False VADs do because the RBCs are damaged when going through pump --> hemolysis Can cause: low Hbg, HCT, decreased activity tolerance, epistaxis, hematuria

True or false? Nonpulsatile VADs have no effect on vital signs.

False Weak, irregular, non-palpable pulse Hypotension Inaccurate pulse oximetry

(Orthotopic) or (heterotopic) heart transplantation is also known as "piggyback" transplantation because the original heart is left in place and the donor heart is connected to right side of chest. Advantage is the new heart acts as assistive device if complications occur with original heart.

Heterotopic

(Orthotopic) or (heterotopic) heart transplantation is more common.

Orthotopic Left atrium left in chest cavity, new heart trimmed and sewn to fit remaining parts of old heart.

What is the gold standard for treating end stage heart failure?

Transplantation! Due to scarcity of available organs, alternative means for providing cardiac support are required. Mechanical circulatory support devices (MCSDs) have the potential to treatment patients with end stage heart failure. MCSDs include: Intra-aortic balloon pump (IABP) Impella Extracorporeal membrane oxygenation (ECMO) Ventricular assist devices (VADs) Total artificial heart (TAH)

True or false? Batteries in a VAD should last 14 hours.

True

True or false? Patients who have had a heart transplantation will be on medication regimen for the rest of their life to prevent rejection.

True

True or false? Nonpulsatile VADs have no true diastolic or systolic phase.

True Blood is moved with an axial flow or centrifugal force (blood continuously moved from left ventricle to aorta). Pump is always internal. Frequently have weak, irregular, or non-palpable pulse Hypotension, PVCs, and V-tach common Blood pressure obtained using Doppler with an estimated MAP Pulse oximetry frequently inaccurate due to no pulse Compared to pulsatile VAD, quiet and cannot be heard outside the body. Has fewer moving parts. More durable and reliable. More flexible drivelines which reduces risk of infection.

True or false? Hypotension in patients with VAD is a medical emergency.

True Cardinal sign for cardiac tamponade

True or false? In a patient with heart transplantation, SBP and DBP may be higher at rest.

True DBP elevated because of stiffness of left ventricle Blood pressure should be monitored closely. Be cautious about HTN because it may lead to ischemia with total loss of perfusion. Strategies to avoid hypertension: exercise in seated rather than supine position, avoid long periods of isometric exercise

True or false? A patient who has had heart transplantation may not have angina.

True Due to denervation Pay attention to signs of myocardial ischemia: Chest, neck, or jaw pain Increased HR Dyspnea on exertion Nausea and vomiting Sweating Fatigue

True or false? Patients who have had surgery to get a VAD typically have sternal precautions post-surgery.

True Most typical surgical approach is median sternotomy with use of cardiopulmonary bypass machine Sternal precautions: Limit push, pulling, lifting to 10 lbs for 6 weeks Do UE ROM as tolerated May use arms to steady self during transfers but need assistance is more than 10 lb restriction May need to use heart pillow for adherence No resistance on UBE or arm bike No MMT for shoulder Okay to MMT at elbow and wrist

True or false? Patients with TAH can't be monitored by telemetry.

True No longer have a native heart rate or rhythm (therefore, does not require intotropic or antiarrhythmic agents)

True or false? PT is contraindicated for a patient on ECMO.

True Patients on ECMO are medically complex and hemodynamically unstable and are generally on bedrest Dislodgement of any cannulas can be life-threatening