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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
Q

Early 1980’s- what happened with transplantation?

A

Transplanation became a widely applied therapy

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26
Q

What percent of patients died on the list in the early 1980’s?

A

30%; became an incentive to develop devices that could be used for patients with acute cardiac decompensation while awaiting transplantation

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27
Q

1980: NIH sent out request for proposals to develop what?

A

“Implantable, integrated, electrically powered left heart assist system” that could be used on a long term basis and allow extensive patient mobility

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28
Q

9/1984 - Standford University: Oyer and Colleagues implanted what?

A

Novacor LVAD

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29
Q

Novacor LVAD

A

1st successful transplant s/p BTT with LVAD

Follow by Hill and colleagues who implanted a Pearce- Donachey pneumatic LVAD

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30
Q

1992- Frazier and colleagues

A

1st to report successful BTT with Thoratec Heartmate IP VAD
(implantable, pneumatic)
restored near normal hemodynamics

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31
Q

Pneumatic

A

containing or operative by air or gas under pressure

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32
Q

What are some limitations of Thoratec Heartmate IP VAD?

A

devices dependent on large consoles for power and controller function
patients confined to hospital until transplantation despite being fully ambulatory

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33
Q

1990- Kormos at University of Pittsburg

A

developed a program to transfer VAD patients to a monitored outpatient setting until transplantation

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34
Q

1991-Frazier at Texas Heart Institute

A

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

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35
Q

1994: _________ LVAD was the first FDA approved implantable device for BTT.

A

Heartmate

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36
Q

What are some biological barriers to VAD design?

A

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)

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37
Q

VADS: Blood vs. Foreign Surface

A

blood contact surface cannot harm the patient

minimum generation of blood clots

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38
Q

VADS: changes to patient’s anticoagulation over time

A

coagulopathy immediately after implantation because of bypass; period of hypercoagulability, returning to baseline

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39
Q

What are some indications for VAD?

A

Bridge to Transplant

Destination Therapy

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40
Q

Bridge to Transplant

A

Worsening hemodynamics despite high level of IV inotropic support and/or vasodilator therapy or refractor arrhythmias

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41
Q

Destination Therapy

A

patients who are not transplant candidates

have an EF less than 25% and NYHA Class IV symptoms despite optimal Therapy

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42
Q

What are the contraindications for VADs?

A 
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
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43
Q

Devices need to be configured for their eventual application. Describe configuration types.

A

Shorter term vs. partial assist vs. long term support vs total support. Different uses and device requirements impact design

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44
Q

What can impact the design of the VAD?

A

different uses and device requirements

45
Q

VADs: Anatomically compatible

A

used over large variations in body mass, chest size/shape, abdominal girth, etc.

46
Q

What else is important regarding the design of a VAD?

A

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
Q

What are the two different types of VAD pumps?

A 
Positive displacement (usually pneumatic)
Rotary
48
Q

Comparison of pumps: Flow and Pressure

A

Positive displacement: change volume in the chamber

Rotary: Rotating Impellar

49
Q

Comparison of Pumps: Source of Energy

A

Positive Displacement: Air pressure/electricity

Rotary: Electricity

50
Q

Comparison of Pumps: Size

A

Rotary is smaller with a smaller cannula

51
Q

Comparison of Pumps: Prime Volume

A

Positive Displacement: Large prime volume

Rotary: Smaller prime vol

52
Q

Comparison of Pumps: Flow Ranges

A

both plagued with thrombosis with decreased flow and hemolysis with increased flow

53
Q

Comparison of Pumps: Afterload

A

positive displacement: unaffected by changes in afterload

rotary: flow drops with increased svr

54
Q

Comparison of Pumps: preload

A

Positive displacement: passive filling, output follows venous return
Rotary: flow increases with increased VR, but no active suction applied

55
Q

How do positive displacement pumps propel fluid?

A

Changing the internal volume of a pumping chamber; compression of a sac/membrane, etc.

56
Q

What type of flow do positive displacement pumps provide?

A

Pulsatile flow

57
Q

What do positive displacement pumps require to produce forward flow?

A

1 way valves

58
Q

What is the flow in positive displacement pumps?

A

5-10 L/min

59
Q

Mean BP in positive displacement pumps

A

100-150 mmHg

60
Q

Rate in positive displacement pumps

A

<120 bpm

61
Q

Mean filling pressure in positive displacement pumps

A

20 mmHg

62
Q

Thoratec PVAD/IVAD has been FDA approved as a BTT since when?

A

1995

63
Q

Thoratec PVAD/IVAD provides support for what?

A

right, left, or both ventricles

64
Q

BiVAD: ____% of LVADs will need an RVAD

A

10

65
Q

_________ is common after transplant failure, postpartum cardiomyopathy, acute MI, myocardities.

A

BiVAD

66
Q

BiVad is used least with what conditions?

A

idiotpathic CM and ischemic CM

67
Q

According to the Thoratec Registry, ____% received BiVad support with hybrid RVAD and LVAD or Thoratec BiVAD.

A

25%

68
Q

BiVAD has increased ____% since 2000.

A

18%

69
Q

What are some preop risk factors for right heart failure?

A

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
Q

Indicators of BiVAD: Higher prep lab values

A

Bilibrubin

Creatinine (normalize within 2-3 weeks after implant of VAD)

71
Q

Greater transfusion requirements increases ___________ and promotes the development of ________.

A

PVR; right heart failure

72
Q

What is common for BiVAD patients? What is it related to?

A

Post-op bleeding; related to severity of hepatic failure

73
Q

What is the stroke volume pump chamber?

A

65 mL

74
Q

What is the pump chamber in the Thoratec PVAD/IVAD made of?

A

Thoralon polyurethane

75
Q

How many mechanical valves does the Thoratec PVAD/IVAD use?

A

2 mechanical valves

76
Q

What alternates in a thoratec PVAD and IVAD?

A

positive and negative air pressure by console/ portable driver

77
Q

How many beats per minute does the thoratec pvad/ivad?

A

40-110 bpm

78
Q

What is the flow in the thoratec pvad/ivad?

A

1.3- 7.2 L/min

79
Q

Where is the thoratec pvad/ivad placed?

A

anterior abdominal wall with cannulas crossing into the chest wall to connect the VAD to the heart and great vessels

80
Q

External location of Thoratec PVAD/IVAD is suitable for use in smaller patients. What BSA?

A

> 0.73 m2

81
Q

DDC

A

Dual Drive Console

82
Q

TCII approved what year.

A

2003

83
Q

Thoratec PVAD/IVAD ideally uses what type of cannulation?

A

Bicaval

84
Q

Thoratec Pump considerations

A

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
Q

Describe Anticoagulation for Thoratec.

A

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
Q

Can a PVAD be used in pediatrics?

A

yes.

87
Q

When is an IVAD used?

A

When longer term support is anticipated

88
Q

When was IVAD approved?

A

Approved in 2004 by the FDA as a BTT or BTR

89
Q

IVAD BSA requirement ; Why?

A

> 1.3 m2 b/c of intracorporeal position

90
Q

How is IVAD different from PVAD?

A

Polished titanium body- makes it implantable
reduced weight (339 gms vs 417 gms)
Narrower percutaneous leads
9mm vs. 20mm

91
Q

Heartmate XVE placed in how many patients worldwide?

A

5000 patients

92
Q

What type of anticoagulation is needed with the Heartmate XVE?

A

None, except an antiplatelet agent

93
Q

What limits thrombogenesis in the Heartmate XVE?

A

Texture inner surface promotes pseudointimal layer

94
Q

What’s a con of the Heartmate XVE?

A

Immunologically active; limits transplant candidacy due to increase in immunologic reactivity

95
Q

What type of pump does the Heartmate XVe use?

A

Positive displacement pump

96
Q

What is the Heartmate XVE made out of?

A

Made of titanium with a polyurethane diaphragm and a pusher plate actuator (which is responsible for producing mechanical energy)

97
Q

How is the Heartmate XVE powered?

A

Pneumatically (emergency) or electrically

98
Q

What do you cannulate in the Heartmate XVE? What type of valve?

A 
LV apex (apical cannula) (dacron conduit with 25 mm porcine valve)
and descending aorta (dacron conduit outflow graft with porcine valve)
99
Q

How heavy is the driver console in the Heartmate XVE?

A

9kg driver console

100
Q

How is the Heartmate XVE powered?

A 
2 batteries (4-7 hours of use)
External controller
101
Q

What is the stroke volume in the Heartmate XVE?

A

83 mL

102
Q

What types of modes does the Heartmate XVE use?

A

Fixed and Auto

103
Q

Heartmate XVE: Auto Mode

A

SV maintained at 97 % full

Flow 4-10 L/min

104
Q

Heartmate XVE: Fixed Mode

A

SV depends on filling

Rate is adjusted manually to keep stroke volume between 70-80mL

105
Q

When do the bearings wear out in the Heartmate XVE?

A

18-24 months; requires replacement

106
Q

Heartmate XVE: What percent survival transplant/recovery?

A

65%

107
Q

Heartmate XVE: If they survive the first month, they have what percent chance of a successful outcome?

A

85%

108
Q

How is the Micromed -Debakey VAD anticoagulated?

A

Coumadin

109
Q

Heartmate II: Flow is an estimate that is not accurate when flow is less than what?

A

3 L/min

CV Perf Tech III (16 decks)

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