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CV Perf Tech III > VADs- Exam 2 > Flashcards

VADs- Exam 2 Flashcards

1
Q

History: VAD 1930s - Carrell and Lindbergh and Demikhov

A

Experimented with mechanical support in animal models

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2
Q

History: 1953- Gibbon

A

1st use of CPB

Inability to wean fuelest interested in prolonged mechanical suport in order to promote myocardial recovery

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3
Q

History: 1963- Spencer, et. al

A

Reported using a roller pump to support a patient to recovery
Roller pumps aren’t good VADS

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4
Q

What are the limitations of roller pumps as VADs?

A

Tethering, Blood trauma, Adjust pump speeds due to changes in heart pressures

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5
Q

History: 1966- DeBakey

A

1st successful clinical application of a true VAD
Pneumatically driven diaphragm pump
Paracorporeal

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6
Q

Describe the paracorporeal setup of DeBakey in 1966?

A

LA to Axillary ARtery

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7
Q

Describe DeBakey’s patient and the use of the VAD

A

37 y/o patient who could not be weaned from CPB s/p AVR/ MVR
Supported for 10 days
Weaned and Discharged

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8
Q

History: 1960’s Klaus, et al.

A

Introduced the concept of atrial counter pulsation

Rapid systolic unloading of the ventricle with diastolic augmentation

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9
Q

What did 1960’s Klaus development lead to?

A

Development of the balloon pump which was developed in 1963 and applied clinically in 1967

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10
Q

When was the total artificial heart used in dog model? How long was it supported?

A

1958

90 minutes

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11
Q

1962: TAH Reported survival for how long?

A

Up to 24 hours

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12
Q

1969: Cooley TAH

A

1st used a TAH to temporarily support a patient to transplant
47 y/o man failure to wean from CPB s/p LV Aneurysm repair
TAH had only been tested for up to 12 hours in animal model
Implanted the “Liotta Heart” which was a pneumatic device
Supported the patient for 64 hours

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13
Q

History: TAH: Research continued into the ________.

A

1980’s

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14
Q

Who were the first investigators in the world to implant a permanent TAH on 12/2/1982.

A

University of Utah

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15
Q

Describe the first patient to receive a permanent TAH (University of Utah)

A

Jarvik 7 TAH performed by Dr. William DeVries
Implanted into Dr. Barney Clark, 61 y/o dentist with end stage idiopathic dilated cardiomyopathy
Died of complications from aspiration pneumonia, renal failure, colitis with septicemia
Was supported for 112 days

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16
Q

When 5 patients received permanent TAH under FDA trial, what was the longest survival?

A

620 days

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17
Q

1985: Where was the first planned TAH implant as a Bridge to Transplant?

A

Copeland at the University of Arizona

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18
Q

BTT

A

bridge to transplant

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19
Q

TAH: Device implanted in __________ had issues with the manufacturer so the FDA withdrew the FDA exemption for implantation. Describe the device.

A

Tuscon; Syncardia, Cardiowest

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20
Q

Who revived the Syncardia, Cardiowest model?

A

Drs. Olsen and Copeland (Tuscon, AZ)

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21
Q

Syncardia was modified and renamed what?

A

Cardiowest C70

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22
Q

Cardiowest 70 received FDA approval as a BTT in _______.

A

2004

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23
Q

____________ provided a stimulus for the development of VADs for support until transplant.

A

Transplantation

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24
Q

1978- Norman (VAD as a BTT)

A

Device used for 5 days of support
Intracorporeal pneumatic device
patient died of multi-organ system failure s/p transplant

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25
Early 1980's- what happened with transplantation?
Transplanation became a widely applied therapy
26
What percent of patients died on the list in the early 1980's?
30%; became an incentive to develop devices that could be used for patients with acute cardiac decompensation while awaiting transplantation
27
1980: NIH sent out request for proposals to develop what?
"Implantable, integrated, electrically powered left heart assist system" that could be used on a long term basis and allow extensive patient mobility
28
9/1984 - Standford University: Oyer and Colleagues implanted what?
Novacor LVAD
29
Novacor LVAD
1st successful transplant s/p BTT with LVAD | Follow by Hill and colleagues who implanted a Pearce- Donachey pneumatic LVAD
30
1992- Frazier and colleagues
1st to report successful BTT with Thoratec Heartmate IP VAD (implantable, pneumatic) restored near normal hemodynamics
31
Pneumatic
containing or operative by air or gas under pressure
32
What are some limitations of Thoratec Heartmate IP VAD?
devices dependent on large consoles for power and controller function patients confined to hospital until transplantation despite being fully ambulatory
33
1990- Kormos at University of Pittsburg
developed a program to transfer VAD patients to a monitored outpatient setting until transplantation
34
1991-Frazier at Texas Heart Institute
First to use an untethered vented electric LVAD for long term support 33 y/o patient Battery operated Heartmate VE 500 days of support Patient died of embolic cerebral vascular accident
35
1994: _________ LVAD was the first FDA approved implantable device for BTT.
Heartmate
36
What are some biological barriers to VAD design?
Blood versus foreign surface Moving parts changes to patient's anticoagulation and immune system over time in response to the mechanical pump Pharmacologic modifications (heparin, coumadin, asa)
37
VADS: Blood vs. Foreign Surface
blood contact surface cannot harm the patient | minimum generation of blood clots
38
VADS: changes to patient's anticoagulation over time
coagulopathy immediately after implantation because of bypass; period of hypercoagulability, returning to baseline
39
What are some indications for VAD?
Bridge to Transplant | Destination Therapy
40
Bridge to Transplant
Worsening hemodynamics despite high level of IV inotropic support and/or vasodilator therapy or refractor arrhythmias
41
Destination Therapy
patients who are not transplant candidates | have an EF less than 25% and NYHA Class IV symptoms despite optimal Therapy
42
What are the contraindications for VADs?
``` High surgical risk Recent/evolving stroke Neurological deficits impairing ability to manage device Coexisting terminal condition Abdominal aortic aneurysm (greater than 5cm) active infection fixed pulmonary htn severe pulmonary dysfunction multisystem organ failure inability to tolerate anticoagulation HIT psychiatric illness lack of social support prengancy ```
43
Devices need to be configured for their eventual application. Describe configuration types.
Shorter term vs. partial assist vs. long term support vs total support. Different uses and device requirements impact design
44
What can impact the design of the VAD?
different uses and device requirements
45
VADs: Anatomically compatible
used over large variations in body mass, chest size/shape, abdominal girth, etc.
46
What else is important regarding the design of a VAD?
structurally stable in a corrosive saline environment operate continuously w/o regular maintenance for yrs cannot fail under increased stress conditions reduce power requirements to save battery life must be efficient-reduce heat waste
47
What are the two different types of VAD pumps?
``` Positive displacement (usually pneumatic) Rotary ```
48
Comparison of pumps: Flow and Pressure
Positive displacement: change volume in the chamber | Rotary: Rotating Impellar
49
Comparison of Pumps: Source of Energy
Positive Displacement: Air pressure/electricity | Rotary: Electricity
50
Comparison of Pumps: Size
Rotary is smaller with a smaller cannula
51
Comparison of Pumps: Prime Volume
Positive Displacement: Large prime volume | Rotary: Smaller prime vol
52
Comparison of Pumps: Flow Ranges
both plagued with thrombosis with decreased flow and hemolysis with increased flow
53
Comparison of Pumps: Afterload
positive displacement: unaffected by changes in afterload | rotary: flow drops with increased svr
54
Comparison of Pumps: preload
Positive displacement: passive filling, output follows venous return Rotary: flow increases with increased VR, but no active suction applied
55
How do positive displacement pumps propel fluid?
Changing the internal volume of a pumping chamber; compression of a sac/membrane, etc.
56
What type of flow do positive displacement pumps provide?
Pulsatile flow
57
What do positive displacement pumps require to produce forward flow?
1 way valves
58
What is the flow in positive displacement pumps?
5-10 L/min
59
Mean BP in positive displacement pumps
100-150 mmHg
60
Rate in positive displacement pumps
<120 bpm
61
Mean filling pressure in positive displacement pumps
20 mmHg
62
Thoratec PVAD/IVAD has been FDA approved as a BTT since when?
1995
63
Thoratec PVAD/IVAD provides support for what?
right, left, or both ventricles
64
BiVAD: ____% of LVADs will need an RVAD
10
65
_________ is common after transplant failure, postpartum cardiomyopathy, acute MI, myocardities.
BiVAD
66
BiVad is used least with what conditions?
idiotpathic CM and ischemic CM
67
According to the Thoratec Registry, ____% received BiVad support with hybrid RVAD and LVAD or Thoratec BiVAD.
25%
68
BiVAD has increased ____% since 2000.
18%
69
What are some preop risk factors for right heart failure?
Hemodynamics- low CI with inc RA pressure not necessarily an idicator of Right heart failure; may improve when LV is unloaded with LVAD Ability of RV to generate pressure low pulse pressure with high CVP- indicator of BiVAd
70
Indicators of BiVAD: Higher prep lab values
Bilibrubin | Creatinine (normalize within 2-3 weeks after implant of VAD)
71
Greater transfusion requirements increases ___________ and promotes the development of ________.
PVR; right heart failure
72
What is common for BiVAD patients? What is it related to?
Post-op bleeding; related to severity of hepatic failure
73
What is the stroke volume pump chamber?
65 mL
74
What is the pump chamber in the Thoratec PVAD/IVAD made of?
Thoralon polyurethane
75
How many mechanical valves does the Thoratec PVAD/IVAD use?
2 mechanical valves
76
What alternates in a thoratec PVAD and IVAD?
positive and negative air pressure by console/ portable driver
77
How many beats per minute does the thoratec pvad/ivad?
40-110 bpm
78
What is the flow in the thoratec pvad/ivad?
1.3- 7.2 L/min
79
Where is the thoratec pvad/ivad placed?
anterior abdominal wall with cannulas crossing into the chest wall to connect the VAD to the heart and great vessels
80
External location of Thoratec PVAD/IVAD is suitable for use in smaller patients. What BSA?
> 0.73 m2
81
DDC
Dual Drive Console
82
TCII approved what year.
2003
83
Thoratec PVAD/IVAD ideally uses what type of cannulation?
Bicaval
84
Thoratec Pump considerations
Normothermic w/o cardioplegia or XC LV vented De-aired via LV apex cannula before conntecting to the VAD Ultrafiltrate to keep hematocrit greater than 30% (in case clotting factors are needed to assist coagulation)
85
Describe Anticoagulation for Thoratec.
Chronic Warfarin Anticoagulation INR= 2.5- 3.5 Starts with heparin- PTT 1.5x baseline until GI function is stable and show low bleeding risk (10-14 days) Switch to warfarin and ASA
86
Can a PVAD be used in pediatrics?
yes.
87
When is an IVAD used?
When longer term support is anticipated
88
When was IVAD approved?
Approved in 2004 by the FDA as a BTT or BTR
89
IVAD BSA requirement ; Why?
>1.3 m2 b/c of intracorporeal position
90
How is IVAD different from PVAD?
Polished titanium body- makes it implantable reduced weight (339 gms vs 417 gms) Narrower percutaneous leads 9mm vs. 20mm
91
Heartmate XVE placed in how many patients worldwide?
5000 patients
92
What type of anticoagulation is needed with the Heartmate XVE?
None, except an antiplatelet agent
93
What limits thrombogenesis in the Heartmate XVE?
Texture inner surface promotes pseudointimal layer
94
What's a con of the Heartmate XVE?
Immunologically active; limits transplant candidacy due to increase in immunologic reactivity
95
What type of pump does the Heartmate XVe use?
Positive displacement pump
96
What is the Heartmate XVE made out of?
Made of titanium with a polyurethane diaphragm and a pusher plate actuator (which is responsible for producing mechanical energy)
97
How is the Heartmate XVE powered?
Pneumatically (emergency) or electrically
98
What do you cannulate in the Heartmate XVE? What type of valve?
``` LV apex (apical cannula) (dacron conduit with 25 mm porcine valve) and descending aorta (dacron conduit outflow graft with porcine valve) ```
99
How heavy is the driver console in the Heartmate XVE?
9kg driver console
100
How is the Heartmate XVE powered?
``` 2 batteries (4-7 hours of use) External controller ```
101
What is the stroke volume in the Heartmate XVE?
83 mL
102
What types of modes does the Heartmate XVE use?
Fixed and Auto
103
Heartmate XVE: Auto Mode
SV maintained at 97 % full | Flow 4-10 L/min
104
Heartmate XVE: Fixed Mode
SV depends on filling | Rate is adjusted manually to keep stroke volume between 70-80mL
105
When do the bearings wear out in the Heartmate XVE?
18-24 months; requires replacement
106
Heartmate XVE: What percent survival transplant/recovery?
65%
107
Heartmate XVE: If they survive the first month, they have what percent chance of a successful outcome?
85%
108
How is the Micromed -Debakey VAD anticoagulated?
Coumadin
109
Heartmate II: Flow is an estimate that is not accurate when flow is less than what?
3 L/min

CV Perf Tech III (16 decks)

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