LVAD Summary : Matthew Belford, M.D. 

Feb 21st, 2007

 

Heart Failure Data

nEstimated 4.7 million Americans ; 550,000 new cases annually

nAnnual cost estimates range from 10 billion to 40 billion

nAggregate 5 year survival ~50% ; Advanced disease mortality may approach 50% @1yr

nThe median survival after HF diagnosis is 1.7 years for men and 3.2 years for women

n2005: 1,842 heart and heart–lung, transplants were performed for U.S. adults in 2005 (UNOS data)

nWaiting list for heart transplant is roughly 3500-4000

nCurrently, the 1-year survival following heart transplant exceeds 86%

 

Optimal Medical Therapy

•ACE/ARB, BB, Diuretics, Digoxin, Spironolactone, ICD

 

What is a VAD – from Washington Manual of Surgery

nThe physiologic effect of a VAD is decompression of the left or right ventricle (or both) and restoration of cardiac output, resulting in decreased myocardial oxygen consumption. The goal is either to permit recovery of myocardium that is not irreversibly injured (e.g., “stunned” myocardium) or to support the circulation in patients with a failing heart until a heart transplantation is possible.

 

Issues with LVAD’s: the bad

nClot, Infection, Neurologic complications, Pump failures, Damage to cells, Surgical issues (Thorax vs thoracic and abdominal)

 

 

Contraindications ; Absolute/Relative

•Irreversible Neurologic injury

•Irreversible end organ failure ; ESRD, CRF >2.5 or CrCl<25mL/min, Hepatic dysfunction (Bili >2.5, ALT/AST>2x ULN)

•Sepsis

•Small patient size

•Age >65                                             

•pHTN

•Recent PE

•Malignancy

•Severe PVD

•Mental illness

•Psychosocial instability                       

•Substance abuse

•Morbid obesity

 

 

Causes of cardiogenic shock

Acute myocardial infarction

Pump failure

Large infarction, generally involving 40 percent of the left ventricle

Smaller infarction with preexisting left ventricular dysfunction or a prior infarction

Infarction extension or expansion

Reinfarction

Mechanical complications

Acute mitral regurgitation caused by rupture of a papillary muscle or chordae tendinae or severe papillary muscle dysfunction

Ventricular septal defect caused by rupture of the interventricular septum

Left ventricular free wall rupture

Pericardial tamponade due to rupture of the left ventricular free wall or hemorrhagic pericardial effusion

Right ventricular infarction

Other conditions

End-stage cardiomyopathy

Myocarditis

Septic shock with severe myocardial depression

Left ventricular outflow tract obstruction

Aortic stenosis

Hypertrophic obstructive cardiomyopathy

Obstruction to left ventricular filling

Mitral stenosis

Left atrial myxoma

Acute mitral regurgitation (chordal rupture)

Acute aortic insufficiency

Myocardial contusion

Prolonged cardiopulmonary bypass