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PTE Masters Ravi > VAD (Ventricular Assist Devices) > Flashcards

VAD (Ventricular Assist Devices) Flashcards

1
Q

What are the 3 indications for LVAD?

A
  1. Bridge to Transplantation
  2. Temporary Support (Improve neurohumoral process and remodeling)
  3. Destination Therapy
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2
Q

What is the one year survival with end stage heart failure for:

Medical Therapy?

LVAD Therapy?

Cardiac Transplantation?

A

Medical Therapy = ~20%

LVAD Therapy = 50%

Cardiac Transplantation = 88%

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3
Q

What are the 4 segments of the TEE Exam that need to occur when evaluating LVAD?

A
  1. Pre-bypass
  2. Weaning from Bypass
  3. Post Bypass
  4. Post Operative (ICU)
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4
Q

What are the Pre-bypass concerns for LVAD?

A
  1. Aortic Valve Function (Assess for AI)
  2. Intracardiac Shunts (Interatrial Septal Defects)
  3. Intracardiac Thrombus (LAA and in chambers)
  4. RV Function (FAC and TAPSE)
  5. Aortic Atherosclerosis (Epiaortic Exam
  6. Mitral Valve Exam (Rule out stenosis)
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5
Q

What are your options if you have aortic insufficiency and the patient needs an LVAD?

A
  1. Sew valve shut
  2. Bioprosthetic Valve
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6
Q

What would happen if you had an intraatrial communication during LVAD placement?

A
  1. Possible Paradoxical Emboli
  2. Right to Left shunt to create hypoxia

Rule out PFO and ASD

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7
Q

What degree of TR is recommended to be surgically addressed when placing LVAD?

A

If moderate –> Repair/Replace

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8
Q

When you wean from bypass, what are the aspects of the LVAD you need to evaluate?

A
  1. Evaluate LVAD inflow cannula
  2. Adequate Flow (Appropriate LV Volume)
  3. Aortic Valve Function (Ensure no re-entry circuit)
  4. Intracardiac Shunts (Interatrial Septal Defects)
  5. De-airing (Anterior located coronary artery)
  6. RV Function (Milrinone, Epi, Nitric Oxide, Epoprostenol)
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9
Q

What is the treatment if you have the LVAD inflow cannula sucked against the septum?

A
  1. Increase Preload
  2. Increase Afterload
  3. Decrease flows of Axial Devices (Decrease flow through device)

These will decrease septal obstruction

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10
Q

What is the diameter of pulsatile LVAD inflow cannulas?

A

16 mm

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11
Q

What is the stroke volume of pulsatile LVAD inflow cannulas?

A

65 mL

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12
Q

What is the peak velocity of pulsatile LVAD inflow cannulas?

A

<230 cm/sec

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13
Q

What is the peak velocity of pulsatile LVAD inflow cannulas is consistent with obstruction?

A

(>230 cm/sec = Obstruction)

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14
Q

When you have a non-pulsatile LVAD, What is the Peak velocity you should obtain when weaning from bypass?

A

<200 cm/sec

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15
Q

When you have a pulsatile LVAD, What is the Peak velocity you should obtain when weaning from bypass?

A

<230 cm/sec

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16
Q

What are the 4 most common inflow cannula sites?

A
  1. LV Apex
  2. Trans-Aortic
  3. Trans-Atrial Septum
  4. LA
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17
Q

What is the most common inflow cannula site?

A

LV Apex

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18
Q

What is the major complication with LV inflow cannula placement in the LV apex?

A

Obstruction with inflow cannula sucking down on septum

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19
Q

What is the complication that can occur with inflow cannula sites in the trans-aortic position?

A

Possible SAM

Ensure the Aortic Valve isn’t being sucked into the device

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20
Q

What is the Tandem Heart inflow cannula site?

A

Through Femoral vein and crosses atrial septum into LA

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21
Q

Where is the outflow cannula of the LVAD placed most commonly?

A

Ascending Aorta

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22
Q

Where is the outflow cannula in the Tandem Heart?

A

Femoral Artery (Percutaneously)

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23
Q

Where is the outflow cannula placed with the Jarvik 2000?

A

Descending Aorta via right thoracotomy

24
Q

What are the post bypass concerns for LVAD placement?

A
  1. RV function
  2. Unobstructed Inflow Cannula
    - Vpeak <230 cm/sec
  3. Volume Status
  4. Intact Septum

5.

25
What are the ICU concerns for LVAD placement?
1. **Hypoxia** --\> Look for PFO 2. **CVA** --\> Look for PFO or thrombus 3. HD instability - Hypovolemia - Tamponade - RV Failure - Infection (sepsis) - Device Failure
26
What are the **indications** for IABP?
1. **LV Systolic Failure** 2. **Post Bypass HD Collapse** 3. **Unstable Angina** 4. Pre-op for **high risk patients** (Left main disease, Critical AS etc)
27
What are the **contraindications** for IABP?
1. **Significant AI** (Worsen the AI when balloon inflates when AV valve is closed) 2. **Aortic Dissection** (Increase shear stress by inflating and deflating) 3. **Prosthetic Graft in Descending Aorta** 4. Severe **Aortoiliac** Disease 5. **Aorto-Pulmonary** Shunt (BT-Shunt)
28
What are the **complications** for IABP?
1. Aortic **Dissection** & Arterial **Perforation** 2. Limb **Ischemia** 3. **Thrombocytopenia** 4. **Thromboembolic** Complications 5. **Balloon Rupture with Helium Embolus** 6. Hematoma 7. Pseudoaneurysm 8. AV Fistula 9. Infection 10. Bleeding
29
Where do you want the IABP placed?
1cm distal to the left subclavian artery
30
What is the complication of IABP placed: 1. Too proximally? 2. Too distally?
**Too proximal** = Occlude arch vessels **Too distal** = Not enough coronary perfusion during diastole
31
Read the image question
**Rotor** and or **bearing** ***_thrombosis with pump obstruction_***
32
Whata is the **differential** when you have an **LVAD low flow** alarm?
LVAD suction event Hypovolemia RV failure Tamponade Malignant Hypertension Inflow thrombus or outflow graft kinking/obstruction Arrythmias
33
Whata is the differential when you have an **LVAD high flow (High Power)** alarm? AKA "Power Spike"
Sepsis with vasodilation Medication with vasodilation effect Rotor/Bearaing thrombosis with pump malfunction (Mechanical obstruction) Significant AR
34
What is the QLVAD when: **AV doesnt open** and **No AI**
QLVAD = QRVOT
35
What is the QLVAD when: **AV opens** and **No AI**
QLVAD = QRVOT - QLVOT
36
What is the QLVAD when: **AV doesn't open** and **AI present**
QLVAD = QAI + QRVOT
37
What type of valve should be used if you are *_replacing_* the aortic valve due to AI in setting of LVAD placement?
1. **Bioprosthetic** (NOT mechanical) - *_Not enough antegrade flow*_ across the valve, so you i_*ncrease risk of thrombosis_* despite being anticoagulated - Used to sew valve closed but don't do that much anymore
38
What is Barlow's Disease?
Barlow’s disease is characterized by **pronounced annular dilatation, bileaflet prolapse and/or billowing, hooding, and the presence of thick, spongy leaflets** due to *_excessive myxomatous tissue proliferation with or without calcification_*
39
54M with LV failure had a heartmate III LVAD placed. Post-Bypass prior to protamine, pump flow is low and there is turbulent color flow doppler across the inflow cannula and a peak velocity on CWD of 1.5 m/sec. What is the diagnosis?
**Inflow cannula misalignment** resulting from inflow obstruction
40
Why does AI worsen after LVAD placement?
LV diastolic pressures (LVEDP) are lower which unloads the LV and decreases LV pressures during diastole - Pressure in the **aorta** is now **higher** - Pressure in the **LV** is now **lower** - You therefore have a gradient across the aortic valve that is larger (Mean aortic pressure that pushes that valve closed is now higher) - Valve is also closed for **longer period of time** (Greater than pre-VAD placement)
41
How does LVAD affect RV preload?
**Increases** RV preload, may contribute to RV failure
42
How can the LVAD worsen RV function in terms of the septum?
LVADs decrease LV pressure and cause leftward shifting of the IV septum (Ventricular interdependence) and this results in worse RV function and TR after VAD placement
43
What is the **abnormal** value for RV function: TAPSE
\<16 - 17 mm
44
What is the **abnormal** value for RV function: ## Footnote **Fractional Area Change**
\<35%
45
What view are you assessing Fractional Area change of the RV?
4 chamber view
46
What is the **abnormal** value for RV function: ## Footnote **RVEF?**
\<45%
47
RVEF is best measured via what modality?
Cardiac MRI
48
What is the **abnormal** value for RV function: dp/dt
\< 400 mmHg / sec
49
What is the **abnormal** value for RV function: RV free wall 2d Strain
More positive than -20
50
What is the **abnormal** value for RV function: ## Footnote **RV Isovolumetric acceleration**
\<2.2 m/s2
51
What is the **abnormal** value for RV function: ## Footnote **Tissue Doppler peak lateral tricuspid annulus systolic velocity (s')**
Tissue Doppler peak lateral tricuspid annulus systolic velocity (s') of: ## Footnote **\<10 cm/sec**
52
What is the **abnormal** value for RV function: ## Footnote **Myocardial Performance Index by tissue doppler**
\> 0.55
53
What is the **abnormal** value for RV function: ## Footnote **Myocardial Performance Index by *_pulse wave_* doppler**
\> 0.4
54
What are the 4 major contraindications to an impella device?
1. Severe AS 2. Severe AI 3. Severe aortic atheromatous disease 4. Presence of interatrial septal defects
55
How should the interventricular septum change during LVAD placaement?
**Maintain neutral position** and check your velocities of the inflow cannula
56
Post bypass LVAD you have: Worsening TR, Elevated RAP, Decompressed LV cavity, Leftward IV septum deviation and low flow on the VAD. What is your next step?
1. Decrease LVAD pump speed 2. Give some volume **Classic Suction Event, Septum is being sucked up into the cannula** **Decreasing LVAD flow**
57
Which is the following is most concerning during pre-bypass for an LVAD? A. Moderate AI B. Severe MR C. Mildly stenotic bioprosthetic MV D. Mild to moderate pulmonary insufficiency E. RV TR jet with a peak velocity \> 2.8 m/sec
**Moderate AI** Gradient is higher so you need to repair the valve or sew it shut

PTE Masters Ravi (45 decks)

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