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PTE Masters + A Practical Approach to Transesophageal Echocardiography > 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
Q

What are the ICU concerns for LVAD placement?

A
  1. Hypoxia –> Look for PFO
  2. CVA –> Look for PFO or thrombus
  3. HD instability
    - Hypovolemia
    - Tamponade
    - RV Failure
    - Infection (sepsis)
    - Device Failure
26
Q

What are the indications for IABP?

A
  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
Q

What are the contraindications for IABP?

A
  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
Q

What are the complications for IABP?

A
  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
Q

Where do you want the IABP placed?

A

1cm distal to the left subclavian artery

30
Q

What is the complication of IABP placed:

  1. Too proximally?
  2. Too distally?
A

Too proximal = Occlude arch vessels

Too distal = Not enough coronary perfusion during diastole

31
Q

Read the image question

A

Rotor and or bearing thrombosis with pump obstruction

32
Q

Whata is the differential when you have an LVAD low flow alarm?

A

LVAD suction event

Hypovolemia

RV failure

Tamponade

Malignant Hypertension

Inflow thrombus or outflow graft kinking/obstruction

Arrythmias

33
Q

Whata is the differential when you have an LVAD high flow (High Power) alarm?

AKA “Power Spike”

A

Sepsis with vasodilation

Medication with vasodilation effect

Rotor/Bearaing thrombosis with pump malfunction (Mechanical obstruction)

Significant AR

34
Q

What is the QLVAD when:

AV doesnt open and No AI

A

QLVAD = QRVOT

35
Q

What is the QLVAD when:

AV opens and No AI

A

QLVAD = QRVOT - QLVOT

36
Q

What is the QLVAD when:

AV doesn’t open and AI present

A

QLVAD = QAI + QRVOT

37
Q

What type of valve should be used if you are replacing the aortic valve due to AI in setting of LVAD placement?

A
  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
Q

What is Barlow’s Disease?

A

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
Q

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?

A

Inflow cannula misalignment resulting from inflow obstruction

40
Q

Why does AI worsen after LVAD placement?

A

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
Q

How does LVAD affect RV preload?

A

Increases RV preload, may contribute to RV failure

42
Q

How can the LVAD worsen RV function in terms of the septum?

A

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
Q

What is the abnormal value for RV function:

TAPSE

A

<16 - 17 mm

44
Q

What is the abnormal value for RV function:

Fractional Area Change

A

<35%

45
Q

What view are you assessing Fractional Area change of the RV?

A

4 chamber view

46
Q

What is the abnormal value for RV function:

RVEF?

A

<45%

47
Q

RVEF is best measured via what modality?

A

Cardiac MRI

48
Q

What is the abnormal value for RV function:

dp/dt

A

< 400 mmHg / sec

49
Q

What is the abnormal value for RV function:

RV free wall 2d Strain

A

More positive than -20

50
Q

What is the abnormal value for RV function:

RV Isovolumetric acceleration

A

<2.2 m/s2

51
Q

What is the abnormal value for RV function:

Tissue Doppler peak lateral tricuspid annulus systolic velocity (s’)

A

Tissue Doppler peak lateral tricuspid annulus systolic velocity (s’) of:

<10 cm/sec

52
Q

What is the abnormal value for RV function:

Myocardial Performance Index by tissue doppler

A

> 0.55

53
Q

What is the abnormal value for RV function:

Myocardial Performance Index by pulse wave doppler

A

> 0.4

54
Q

What are the 4 major contraindications to an impella device?

A
  1. Severe AS
  2. Severe AI
  3. Severe aortic atheromatous disease
  4. Presence of interatrial septal defects
55
Q

How should the interventricular septum change during LVAD placaement?

A

Maintain neutral position and check your velocities of the inflow cannula

56
Q

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?

A
  1. Decrease LVAD pump speed
  2. Give some volume

Classic Suction Event, Septum is being sucked up into the cannula

Decreasing LVAD flow

57
Q

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

A

Moderate AI

Gradient is higher so you need to repair the valve or sew it shut

PTE Masters + A Practical Approach to Transesophageal Echocardiography (55 decks)

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