1 / 16

Who Should Not Receive a VAD: Pragmatism and Futility in Patient Selection

Who Should Not Receive a VAD: Pragmatism and Futility in Patient Selection. INTERMACS 9 th Annual Meeting MCSD: Evolution, Expansion, and Evaluation May 15-16, 2015. Disclosures: None. Joseph G. Rogers, MD Professor of Medicine Duke University.

mildredclark
Download Presentation

Who Should Not Receive a VAD: Pragmatism and Futility in Patient Selection

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Who Should Not Receive a VAD: Pragmatism and Futility in Patient Selection INTERMACS 9th Annual Meeting MCSD: Evolution, Expansion, and Evaluation May 15-16, 2015 Disclosures: None Joseph G. Rogers, MD Professor of Medicine Duke University

  2. Contraindications to VAD Therapy: Clinical Trial Definitions • Mechanical aortic valve without plan to replace or close • Thrombocytopenia • Other condition that limits survival to < 24 months • Uncontrolled, systemic infection • Recent stroke or cerebrovascular disease that increases risk for intra-operative CVA • Contraindication to systemic anticoagulation or antiplatelet therapy • Significant right heart failure • Psychosocial instability (ongoing substance abuse, lack of care giving plan, non-compliance)

  3. Who is (or is not) a VAD Candidate?Duke Criteria • Sick but not too sick • Not too old • Not too much right heart failure • Not too much renal dysfunction • Not too malnourished • Not too septic • Not supported on mechanical ventilation for too long • Not too crazy

  4. The Impact of Illness Severity on MCS Outcomes J Heart Lung Transplant 2008;27:1065-72 Anticipated Survival without VAD X J Heart Lung Transplant 2011;30:155-23 J Heart Lung Transplant 2013;32:141-56 J Heart Lung Transplant 2014;33:555-64

  5. How Old is Too Old? J Am Coll Cardiol 2013;61:313-21 J Am Coll Cardiol 2011;57:2487–95

  6. Issues of Nutrition (Low) Markers of Poor Nutrition • BMI < 20 kg/m2 • Pre-albumin < 15 mg/dl • Transferrin > 250 mg/dl • Total Cholesterol < 130 mg/dl • Lymphocyte Count < 100 Strategies • PO supplements • Enteral nutrition • TPN (last resort) J Heart Lung Transplant 2010: (4 Suppl):S1-39.

  7. Chronic Biscuit Poisoning Obesity not a contraindication • Devices may provide adequate support • Has not impacted outcomes • May be contraindication for transplant • Patients not losing weight on VAD support J Heart Lung Transplant 2010: (4 Suppl):S1-39.

  8. I shall not attempt to further define the kinds of material I understand to be embraced within the short-hand description of hard-core pornography and perhaps I should never succeed in intelligibly doing so. But I know it when I see it… Uh…. I think that fella is too frail for a VAD. Joseph Rogers, MD Potter Stewart , Associate Supreme Court Justice

  9. The Importance of Frailty in LVAD Patient Selection Circ Heart Fail 2012;5:286-93

  10. Decision-Making in Advanced Heart Failure VT Right heart failure Infection risk Urgency Malignancy Infection risk Renal insufficiency Older Age DT VAD ECTx

  11. The Importance of RV Function in MCS • Pre-implant diagnosis is challenging • Definition • Need for inotropic support > 14 days • Need for RVAD • Limits device function by reducing pre-load • Associated with end-organ dysfunction and prolonged LOS • Important cause of post-implant morbidity and mortality • MSOF • New description of “late” RV failure, etiology unknown J ThoracCardiovascSurg 2010;139:1316-24

  12. Predictors of Post-LVAD RV Failure Clinical • Pre-implant mechanical ventilation • Pre-implant renal or hepatic dysfunction • Need for vasopressors Hemodynamic • High RA, low PA • CVP:PCWP pressure > 0.63 • RVSWI < 300 mmHgxml/m2 Echocardiographic • RV size and function • Tricuspid insufficiency • TAPSE • RV Strain

  13. Hepatic Function & Coagulopathy • Determine etiology of hepatic dysfunction • LFT’s • Serologies • Liver biopsy to r/o cirrhosis • If labs are normal the liver disease may be well compensated • The minimum screen for coagulation abnormalities should include: • PT/INR, PTT • Platelet count • Platelet aggregation studies • HIT assay (Heparin induced thrombocytopenia, platelet antibody) Clinical Management of Continuous-flow LVADs JHLT 2010: 1-39.

  14. The Impact of LVAD on Ventricular Arrhythmias • 100 consecutive VAD patients • Mean age=51 yrs, 63% ischemic J Am Coll Cardiol 2005;45:1428-34

  15. Neurologic, Psychosocial, and Psychiatric Considerations • Assess candidates’ ability to: • Care for equipment • Exercise • Comply • Consider history of psychiatric disorders, drug abuse • Psychosocial support team • Address advanced directives Clinical Management of Continuous-flow LVADs JHLT 2010: 1-39.

  16. Who Should not be Treated with a VAD • It is often not evidence-based or entirely clear. • Be mindful of • The aged and frail • The under- and over-nourished • Those with VT • Those with right heart failure • Those with primary coagulopathy and liver disease • The crazy people whose mothers don’t love them

More Related