LVAD

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Today, we're going to learn about LVAD!
Certain patients with CHF (NYHA III-IV) may qualify for a device called “LVAD” or Left Ventricular Assist Device”.  We had a presentation by Dr. Paul Saunders to tell us more about it as we have several LVAD patients here.  If you ever have an LVAD patient come to the ED, be sure to call 718-283-5CHF (Maimo Specific)
This is either a bridge to a heart transplant or in patients who are not candidates for transplant, a destination therapy.  People have lived for 10 years on this therapy.
It’s a pump that circulates the blood from the left ventricle to the aortic outflow tract with a rotor.  It has a battery that lasts for 10 hours and otherwise is plugged into the wall.
 
Because it’s a rotor and not really a pump in the traditional sense, you may not feel a pulse; this is normal.  For some patients you may feel a pulse as their heart still contracts strongly enough.
So…how do you get a blood pressure on someone who seems to have no pulse and just a whirring machine pumping their blood.
 
Get the Doppler and the Manual BP Cuff- the automated ones won’t work for this.
Inflate the cuff and hold the doppler to the brachial artery.  When you hear the doppler, that is your MAP.  This MAP may be 5-10mmHg higher than the one you would obtain with an arterial line (ideal).
TARGET MAP IS 70-90mmHg.
Depending on what the patient is there for, you can also get labs including coagulation factors.  ALWAYS get an EKG (should be normal) and ALWAYS call the LVAD team.
Usual Presentations:
  • GI Bleed- actually get small bowel AVMs
  • Epistaxis
  • Fluid Overload
  • CVA, intracranial hemorrhage
  • Driveline infections
  • Hypovolemia
  • Arrhythmias
  • Cardiac arrest
If the patient is in cardiac arrest, you can still give ACLS medications.  However, at our institution we do not do CPR (There’s controversy over this, see the link at the end).  Whatever happens, DO NOT DISCONNECT THE PUMP.
If the patient is in V-fib, they may be still complete alert and appear to be fine or just tired.  It is okay to defillibrate the patient in conjunction with the LVAD team.
Of note, INR goals are usually 2.0-2.5 unless they have a propensity for bleeding.
  • Complications
    • Stroke- patient may have a thrombo-emobolism or alternatively a hemorrhagic stroke as they must be anti-coagulated, usually on Coumadin and aspirin.
    • Pump thrombosis
    • Epistaxis
    • Driveline infections
    • Other bleeding e.g. GI Bleed 2/2 anticoagulation
  • Acquired Von-Willebrand Disease
A final note- if the patient comes in with the pump disconnect, do NOT reconnect unless they know when it disconnected as it may have clotted.  CALL THE LVAD team.  The flow may move retrograde through the pump.
Major credit to Dr. Paul Saunders for the great presentation!
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Endocarditis

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Alison Leung, Patrick Charles, and I attended the conference held at Mt Sinai tonight and the over arching theme was cardiac echo.  Of particular note were cases of a 30ish yoM presenting w/ 4 days of chest pain and found to have a malignant pericardial effusion and a man from Pakistan with TB and lung consolidation/pneumonias on echo.  Many images were obtained with TEE. For the sake of brevity, this pearl is going to focus on ENDOCARDITIS as several great examples were shown.  My examples will be from the internet with references.

Figure 1. Mitral valve vegetation shown by echocardiogram. The vegetation is the mass seen in the dark space between the left atrium (LA) and left ventricle (LV). RA indicates right atrium; RV, right ventricle.

How do we diagnose it?  DUKE CRITERIA!

For diagnosis the requirement is:

•2 major and 1 minor criteria or

•1 major and 3 minor criteria or

•5 minor criteria

MAJOR CRITERIA

•Positive blood cultures for infective endocarditis

•Typical microorganism for infective endocarditis from 2 separate blood cultures (per EMRA SOP is 3 cultures 2 minutes apart and taken prior to antibiotic administration provided the patient is stable

▪ Viridans streptococci, Streptococcus bovis, and HACEK group or

▪Community-acquired Staphylococcus aureus or enterococci in the absence of a primary focus or

▪Persistently positive blood cultures, defined as recovery of a microorganism consistent with infective endocarditis from:

▪2 blood cultures drawn 12 hours apart or all of 3 or most of 4 or more separate blood cultures, with first and last drawn at least 1 hour apart

•Evidence of endocardial involvement

▪Positive echocardiogram for infective endocarditis

▪oscillating intracardiac mass on valve or supporting structures or in the path of regurgitant jets or on implanted material in the absence of an alternative anatomical explanation or

▪abscess or

▪new partial dehiscence of prosthetic valve or new valvular regurgitation

MINOR CRITERIA

•Predisposing heart condition or intravenous drug use

•Fever: 38°C

•Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions

•Immunologic phenomena:

▪Glomerulonephritis

▪Osler nodes

▪Roth spots

▪Rheumatoid factor

•Microbiologic evidence: positive blood culture but not meeting major criterion as noted previously or serologic evidence of active infection with organism consistent with infective endocarditis

•Echocardiography findings consistent with infective endocarditis but not meeting major criterion as noted previously

Some great videos since I am unable to paste them into the email:  https://www.ultrasoundoftheweek.com/uotw-60/

Pearls from EMRA:

1Consider a loading dose of vancomycin 25-30mg/kg for seriously ill patients

2TEE may be necessary to assess for vegetation and degree of heart failure

3Implanted devices should not have the pocket sampled; definitive treatment requires exploration

Native Valve:

Common Organisms:  Viridans group streptococci, Staph aureus, Streptococcus species, Enterococcus species

Treatment Option 1:  Oxacillin/nafcillin 2g IV q4h AND gentamicin 1mg/kg IV TID  AND ampicillin 2g IV q4h.  Aminoglycosides with a Beta Lactam=synergy!.  No aminoglycosides alone, please!

Treatment Option 2:  Vancomycin 15-20mg/kg IV BID and gentamicin 1mg/kg IV TID

Treatment Option 3:  Daptomycin 6mg/kg IV daily

Prosthetic Valve:

Common Organisms:

<2mos Post-Op:  Coagulase-Negative staphylococci, S. aureus

>2 mos Post-Op: Coagulase-Negative staphylococci, viridian’s group streptococci, S. aureus,  Enterococcus species

Treatment:  Vancomycin 15-20mg/kg IV BID AND Rifampin 30mg po or IV TID AND gentamicin 1mg/kg IV TID

 

IV Drug Users:

Common Organisms:  Staph Aureus

Treatment Option 1:  Vancomycin 15-20mg/kg IV BID

Treatment Option 2:  Daptomycin 6mg/kg IV daily

 

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ATRIAL FIBRILLATION!  Rhythm Control and Cardioversion

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This POTD is inspired by a septic man in Resus today who required cardioversion.  If you're curious, he looked fantastic after his heart stopped going 240 beats per minute and settled in to the 90s. From NPR:  “This patient was wearing a Fitbit fitness tracker that had a heart rate monitor and connected wirelessly to his smartphone. With his permission, the doctors checked the data on the phone and figured out that the episode of arrhythmia had begun only about two hours before he showed up at the ER.

"We were able to hook him up to the pads, put him to sleep, give him a little shock, and let him wake up and go home," Sacchetti says.”

ATRIAL FIBRILLATION!  Rhythm Control and Cardioversion

  • Atria are beating chaotically:  “irregularly irregular”
  • Can do rate control, rhythm control, or possibly cardioversion in the ED
  • Nonpharmacologic Rhythm Control:
  • Ablation by EPS
    • radio frequency
    • cryoballoon
    • laser surgery
  • Reversible causes have already been addressed (e.g. HTN, hyperthyroidism, alcoholism, heart failure, sleep apnea)

Cardioversion

  • When to use:  New onset a fib within 48 hrs or patient is unstable
  • Contraindications:  Can’t confirm it’s been less than 48 hours.  In these cases, pt to be anti-coagulated for 3 weeks prior to outpatient cardioversion.
  • How to do it:  First sedate patient (e.g. with etomidate) and then shock at 100J—>200K—300J—360J

AF without Structural Heart Disease

  • Okay in HTN without LVH
    • Flecainaide or propafenone as first line
  • Be wary in the elderly due to CAD (and likely structural disease)
  • Others used include Amiodarone, Sotalol, Dronedarone.
    • In SAFE-T and AFFIRM Trials, Amiodarone >> flecainaide, propafenone, or sotalol

AF with Structural Heart Disease

  • Amiodarone, Sotalol, and Dofetilide usually first line
  • CAD:  Sotalol>> dronedarone, dofetilide, and amiodarone. Flecainide and propafenone are contraindicated in this population.
  • LVH:  Sotalol, flecainaide, propafenone may cause arrhythmia.  Dronedarone or Amiodarone are options

A little bit about Amiodarone

  • Low dose of 100 to 200mg po daily but can use higher doses
    • Low incidence of torsades
    • Made need less rate control as has beta blocker and CCB activity.
    • Unfortunate toxicity
      • Check LFTs, TFTs (has iodine), and Lung function
      • Blue Man Syndrome (Argyria)
  • Most effective
  • Most likely to have long term complications
  • May interfere with warfarin, thus increasing risk of stroke
  • Class III Drug
  • Prolong QT
  • Slows Heart Rate and AV node conduction (like CCB, Beta blockers)
  • Prolongs refractoriness (is that a word?  It is now) via K+ and Na+ blockade
  • Slows intracardiac conduction via Na+ blockade
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