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BCC > LVAD/RVAD/Heart Transplant > Flashcards

LVAD/RVAD/Heart Transplant Flashcards

1
Q

What were the first generation LVADs?

A

HeartMate1, Thoratec PVAD, and Novacor N100; they were pulsatile

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2
Q

What is the difference between centrifugal and axial flow LVADs?

A

Axial flow = blood enters one end of a rotor and is driven along the axia of the rotor to the outflow (higher shear stress and hemolysis); Centrifugal flow = blood enters at the central axis and is driven outward to the outflow pump (less shear stress)

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3
Q

Which LVAD works via axial flow?

A

HeartMate II

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4
Q

What are the 6 components of an LVAD?

A

Inflow cannula + pump + outflow cannula + percutaneous driveline + power supply + controller

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5
Q

What are absolute contraindications for an LVAD?

A

Unrepaired VSD/PFO/ASD + acute endocarditis + aortic dissection + AI >/= moderate + mechanical AV (increased risk of thrombus)

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6
Q

What considerations should you have with your anesthetics in a minimally invasive LVAD implantation?

A

Peripheral CPB + ventilation required while on CPB + one lung ventilation at times + TEE

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7
Q

What are pre-implantation red flag findings on TEE?

A

LV and interventricular septum findings (small LV size, thrombus, aneurysm, or VSD) + RV (dilation or decreased function) + LAA thrombus + PFO/ASD + valvular abnormalities (prosthetic valves, >mild AI, mod/sev MS, mod/sev TR, > mild TS, > mild PS, mod/sev PR) + acute aortic pathology + mobile mass lesion

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8
Q

What are post-implantation red flag findings on TEE?

A

Septal shifts + size of LV (large or small) + RV dysfunction + > mild AI + mod/sev TR + turbulent outflow

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9
Q

What is the pulse index?

A

A unitless value that averages the number of LV contractions (flow pulses) over a 15 sec interval

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10
Q

What are you concerned about if you see an alarm for high flow? Low flow?

A

High flow = vasodilatory state (i.e. sepsis -> consider vasopressor); Low flow = suction event (i.e. hypovolemia)

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11
Q

What are you concerned about if you see an alarm for high power? Low power?

A

High power = pump thrombosis (tx = anticoagulation or pump exchange); Low power = Pump failure/ disconnection

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12
Q

What are you concerned about if you see an alarm for low pulse index?

A

Suction event

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13
Q

How much can an Impella RP flow?

A

Up to 5L/min of axial flow

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14
Q

Where does an Impella RP sit?

A

Usually starts at the femoral vein; the silver ball outlet should be 2-4cm from the pulmonic valve while the inlet should be at the level of the IVC

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15
Q

What is the ProtekDuo?

A

Dual-lumen cannula where inflow sits in SVC/RA junction and the second lumen (outflow) sits in the PA; usually accessed via the RIJ and can give 4-5 L/min of centrifugal flow; you can also ambulate unlike the Impella RP

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16
Q

What is the Spectrum Medical Dual Lumen Cannula?

A

Similar to the ProtekDuo except it has two drainage sites (one in the RA and another in the RV); the outflow outlet remains distal to the PA

17
Q

What is the CentriMag RVAD?

A

Surgically implanted RVAD with the inflow cannula in the RA (via SVC or IVC) and the outflow cannula in the PA; centrifugal pump that can provide up to 7 L/min

18
Q

Can you add an oxygenator to an Impella RP?

A

No

19
Q

What makes a patient a Status 1 transplant candidate?

A

ECMO (up to 7 days) + VAD + mechanical circulatory support with ventricular arrhythmias

20
Q

What are contraindications for orthotopic heart transplantation?

A

Sever systemic illness + pulmonary HTN (PVR > 3 Wood units) + psychosocial criteria + acute or recent malignancy + multisystem disease with organ dysfunction + severe symptomatic cerebrovascular disease

21
Q

What is the biatrial technique for OHT?

A

The posterior wall of the RA with connections to the IVC/SVC remain attached; will see two p waves

22
Q

What is the bicaval technique for OHT?

A

The RA is explanted without the IVC/SVC connections so you need to reconnect the IVC/SVC as well as the LA and the great vessels

23
Q

What is the total OHT technique?

A

The entire heart is explanted leaving behind two LA cuffs (pulmonary veins); need to make SVC/IVC, great vessels, and two LA cuff anastamoses

24
Q

How is ex-vivo heart perfusion (EVHP) done?

A

The ends of the IVC and SVC are ligated and the donor aorta and PA are cannulated; maintenance solution is infused

25
Q

What is the goal total ischemic time for OHT?

A

<300 minutes (but ideally <240 minutes)

26
Q

What is primary graft dysfunction?

A

Diagnosed within 24 hours of transplant; can be left (PGD-LV) or right (PGD-RV); increased 30-day and 1-year mortality

27
Q

What is secondary graft dysfunction?

A

Hyperacute rejection with known pulmonary HTN or surgical complication

28
Q

What are donor specific risk factors for primary graft dysfunction?

A

Age, female, cause of death, trauama, cardiac dysfunction, inotropic support

29
Q

What are recipient specific risk factors for primary graft dysfunction?

A

Age, elevated PVR, Inotropic support, congenital heart disease, preop amio use, redo sternotomy, allosensitization

30
Q

What are procedural specific risk factors for primary graft dysfunction?

A

Ischemic time, donor-recipient sex and weight mismatch, increased transfusions, cardioplegic solution, experience of team, redo heart transplant

31
Q

How does brain stem death in the donor affect the potential for primary graft dysfunction?

A

Increased ICP -> adrenergic response -> Pulm/systemic HTN -> increased afterload and O2 demand; Loss of spinal cord SNS -> decreased preload/afterload -> severe vasodilation -> myocardial NE release -> increased O2 demand

32
Q

What is the major indicator for what level of primary graft dysfunction we have after lung transplantation?

A

The PaO2/FiO2 ratio; if <200, grade 3

33
Q

What is the most common valvular dysfunction after OHT?

A

Tricuspid regurgitation (possibly from pulmonary HTN, annular dilation from RV dilation, alteration of RA morphology due to surgery, or papillary dysfunction)

34
Q

Why is the bicaval technique for OHT better than the biatrial technique?

A

The bicaval technique reduces the incidence of late RA dilation, need for temporary pacing, SVT arrhythmias, and TR

BCC (29 decks)

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