A ventricular assist device (VAD) patient with a VAD Coordinator, featured in a nursing magazine.
Ventricular Assist Devices (VADs) / "Heart Pumps"
Overview
Despite advances in medical care, heart failure remains a leading cause of death and disability. There are over 5 million Americans living with heart failure. Fortunately, there are treatment options for those with severe heart failure. While most patients with mild to moderate heart failure can be treated successfully with medications alone, some patients need advanced therapies that are only available at hospitals that specialize in the treatment of late-stage heart failure. Drexel physicians have a designated Center for Advanced Heart Failure at Hahnemann University Hospital that specializes in advanced therapies such as heart transplantation and the use of "heart pumps" or ventricular assist devices (VADs). These machines help replace the function of the heart and significantly improve heart failure symptoms in most patients that receive them. There are several ventricular assist devices available, both FDA-approved devices and those undergoing testing to gain approval.
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Our Vision
We believe that each of our patients should be treated as an individual when deciding if a ventricular assist device (VAD) is the best treatment option. We know from experience that a VAD is not right for everybody. We also know that there is not one VAD that is right for every patient, so we base our recommendations on the specific needs of the individual. We try to involve our patients and their families in all of the decisions so that everyone is a part of the process.
In our experience, patients who receive a ventricular assist device (VAD) usually have the opportunity to experience a near-normal life again, without the symptoms of severe heart failure. However, the insertion of a VAD is a major operation and recovery is a long process. We have found that the patients with the best outcomes are those who are mentally prepared for the operation and are fully dedicated to doing everything that it takes to make a rapid and full recovery. We ask all of our patients and families to make a commitment to us that matches our commitment to them, so that we can work together to have the best outcome possible.
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What is a Ventricular Assist Device (VAD)?
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The History of Heart Pumps
The first machines to replace the heart were invented over a generation ago. In 1963 a human was first supported on a ventricular assist device (VAD). Their use was very limited in the beginning and they were only designed for short-term use. As technology improved, devices became more reliable, leading to FDA approval of the first VAD in 1994. Since then, there have been significant technical advances so that the VADs of today provide better and more reliable support than those of the past. As a result, VAD operations are common at centers that specialize in their use, such as The Center for Advanced Heart Failure at Hahnemann University Hospital.
Ventricular Assist Devices (VADs) – The Basics
A ventricular assist device (VAD) is a pump that helps the heart pump blood better, allowing the patient's heart to remain in place. Most VADs are designed to pump blood for the left side of the heart, and are called Left Ventricular Assist Devices (LVADs). These machines drain the blood from the left side of the heart (left ventricle) and return the blood to the aorta, where it then goes to all parts of the body. Unlike a VAD, an Artificial Heart is a machine that completely replaces the heart. A patient who gets an artificial heart has his or her own heart removed and the artificial heart put in its place.
A VAD is a better choice for most patients with advanced heart failure who need a machine, since most patients only need the left side of the heart supported. In addition, if the VAD quits working, the patient's own heart is still there, and may be able to keep the patient alive until the VAD can be fixed or replaced. Since several thousand VADs have been implanted and successfully used in patients, there is an abundance of data that help to guide the care of VAD patients.
Ventricular Assist Devices (VADs) – The Types
There are two basic types of ventricular assist devices (VADs). The human heart pumps blood each time that it beats and creates "pulsatile flow." Pulsatile VADs pump the blood in a way similar to the heart. The VAD will fill with blood and then pump it forward. It will then refill and pump again. Each time that it pumps, it makes a pulse that feels just like a normal pulse.
Non-pulsatile VADs (or continuous flow VADs) are very different in that they have a propeller inside that spins to push the blood forward. The propeller spins continuously, so that there is always blood flowing. This design has allowed the VADs to get much smaller in size. Interestingly, since the VAD creates continuous flow, patients may find that they have no pulse. It may also be difficult to measure the blood pressure with a regular blood pressure cuff even when the patient is doing well.
The Ventricular Assist Devices (VADs) That We Use
At The Center for Advanced Heart Failure, we have several options for patients who need ventricular assist device (VAD) support. This is important since different patients have different needs. Each VAD is designed for a specific use, and there is no one VAD that is suitable for all patients
CentriMag – The CentriMag pump is a ventricular assist device (VAD) that can be used to support the right side of the heart (as an RVAD) or the left side of the heart (as an LVAD). If a patient requires support of both sides of the heart, then two CentriMag pumps can be used together (called BiVADs). The CentriMag is used for short-term support, and often in patients who are critically ill. It is usually used when we expect a patient's own heart to recover after a short period of rest, or when we need to stabilize a patient until they are strong enough so that a long term ventricular assist device (VAD) can be placed.
Thoratec P-VAD – The P-VAD is also used to support the right ventricle, left ventricle, or both (if two of them are used together). This pump is designed for longer-term use, and the patient is usually supported on this device for weeks to months or more. It is used most frequently in patients whose hearts are likely to recover, or who are awaiting transplantation. While patients on this device may be able to go home on this pump, we routinely keep these patients in the hospital until either their heart recovers or they undergo transplantation.
HeartMate XVE (also called "HeartMate I") – The HeartMate was first approved for use in the United States in 1994. It has undergone many design changes and improvements over the years. The first versions were air-driven (pneumatic) and required the patient to push around a large console that would power the device. Newer versions are electrically powered so that they can run on battery power. This allows patients to remain relatively mobile and untethered. Thousands of these devices have been implanted, making it the LVAD with the largest clinical experience to date.
In 2003, the HeartMate I was approved for use as a Destination Therapy device, meaning that it could be used in patients who were not candidates for transplantation, and are expected to remain on the device for the rest of their lives. It has been shown that patients with severe end-stage heart failure lived longer and better lives on the HeartMate I device than on medicines alone.
The HeartMate I is only designed for the left side of the heart, so it can be used as an LVAD only. Unlike the other VADs available, it only requires a daily aspirin as the blood thinner.
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HeartMate II – The HeartMate II is the first non-pulsatile VAD that has been approved by the FDA for long-term use. Its potential advantages over the earlier designs are improved durability, decreased risk of infection, and smaller size. However, it requires blood thinners such as warfarin (Coumadin). This device has been approved for patients who are awaiting transplantation since 2008. In January 2010, it received FDA approval for use as a long-term support device in patients who cannot undergo transplantation, called Destination Therapy.
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How are Ventricular Assist Devices (VADs) Used?
Ventricular assist devices (VADs) are commonly used for one of three indications. When a VAD is placed into a patient, it is done under one of the three indications. While a patient's indication may change over time as their condition changes, they are still placed into one of the following three categories when the VAD is placed.
BRIDGE TO RECOVERY
In this situation, a ventricular assist device (VAD) is placed with the hope that the patient's heart will recover and the VAD can be removed in the future. This situation is sometimes seen when a patient has heart failure immediately after another heart operation, when the heart is weakened by a viral infection or pregnancy, or sometimes if the heart is weakened after a heart attack. In those situations, the main goal of the VAD is to rest the patient's heart until it can recover the ability to support the patient.
BRIDGE TO TRANSPLANTATION
Most of the ventricular assist devices (VADs) are placed in patients who are awaiting transplantation, or are being considered for heart transplantation, and need to be stabilized until a heart can be located for them. Patients who are in this category may or may not be listed for transplantation at the time of VAD placement. If they are not listed, then they may be listed once they meet all of the requirements for transplantation.
The transplantation list can be rather complex to understand. There is one list of all patients awaiting transplantation across the country. This list is maintained by the United Network for Organ Sharing (UNOS). Patients are placed on the list by their local transplant center by blood type and degree of illness. They accrue time on the list as they wait, and may move up or down the list as they improve or decline in health. VADs allow critically ill patients to stabilize while they wait on the list. If you have specific questions about the list, ask your transplant cardiologist or heart surgeon.
DESTINATION THERAPY
Some patients are not appropriate candidates for transplantation for a variety of reasons. In this situation, a ventricular assist device (VAD) may be placed to support them for the rest of their life. Patients may be appropriate for destination therapy instead of transplantation due to preference, age, or other illnesses (like some cancers) that may make them a poor candidate for transplantation. If a patient has a VAD placed for destination therapy, and the reason that they are not a candidate for transplantation is corrected, then they may be listed for transplantation at that time.
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Who Can Get a Ventricular Assist Device?
The decision to offer a patient a ventricular assist device (VAD) is usually complex, and there is no way to absolutely define who can and cannot get a VAD. However, there are some general guidelines that we use.
A candidate for a VAD should:
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have severe heart failure with symptoms at rest or with minimal exertion
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be under the care of a cardiologist who is an expert in heart failure, and be on all of the appropriate medicines for heart failure
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have no options for treatment of heart failure other than the use of a VAD
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be able to tolerate the operation to place the VAD
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have adequate social support to handle the demands of life on a VAD
A candidate for a VAD should not:
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have other illnesses that are life-threatening that cannot be corrected by the VAD
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be on dialysis
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be unable to tolerate blood thinners
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have heart failure that can be treated with medicines alone
Keep in mind that these are only guidelines that we use to try to determine if a patient is appropriate for VAD support. These guidelines have been developed based on the results seen in thousands of patients who have been treated with VADs, and are designed to help ensure that VADs are only used in patients who have a reasonable chance of being helped with a VAD instead of medical therapy. Because every patient is an individual, we will assess each patient based on their own situation and needs.
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Life After Ventricular Assist Device (VAD) Placement
The main purposes of ventricular assist device (VAD) placement are to:
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save the life of a critically ill patient
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relieve the patient's symptoms of heart failure
Our goal with each patient is to return them to as near a normal life as possible with the ventricular assist device (VAD). While each patient is different, most patients with a long-term VAD are able to:
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return home
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spend time alone. Patients are taught to care for the VAD themselves, and usually do not need constant supervision
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walk and perform mild exercise activities
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return to work (within certain limitations)
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travel. All travel needs to be prearranged with the VAD coordinator to make sure that plans are made for a potential emergency. There is a small risk for any travel away from the Philadelphia area since the VAD patient will not be able to return immediately to Hahnemann if there is a problem. If there is another VAD center at your destination, we will make them aware of your travel plans. If your travel will take you to an area without a VAD center, you will need to take responsibility for any VAD-related events that occur when you are away from immediate care options
However, there are limitations in what a ventricular assist device (VAD) patient is allowed to do. Most of the limitations are for the safety of the patient. They include:
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no bathing or showers. Sponge baths are OK. This is to limit infection of the driveline site
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no contact sports or other activities that may lead to a fall or a heavy impact to the body. The VAD is a machine, and can be permanently damaged by excessive contact. The skin around the driveline can get infected if the driveline is handled roughly, and the driveline may break if bent or crushed. Any of these events could be life-threatening and/or require another operation to try to fix
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no driving. We are concerned about the safety of you and others if your VAD should fail while you are behind the wheel
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no heavy drinking or use of mind-altering drugs
As part of the care of our ventricular assist device (VAD) patients, we require that each patient:
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maintain a daily diary of the VAD numbers (flow, power, etc.). We teach each patient and their family what to record and when to contact us for changes
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call us immediately for any change in their condition, or any alarms from the VAD
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follow up with us in our clinic on a regular schedule. Appointments occur at least weekly in the beginning, and progress to monthly as the patient continues to improve. The actual frequency of visits varies according to the medical needs of the patient
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continue to take their heart failure medicines as prescribed, since most patients still need medicines to control their blood pressure or get rid of excess fluid
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follow any fluid and salt restrictions that are placed by the cardiologists. While most patients can tolerate fluid and salt better after a VAD than before, most can still get into heart failure if they overuse water or salt
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notify us well in advance of any travel plans. While travel is possible in most cases, arrangements need to be made in case of emergencies, and this takes time
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Educational Resources
There are a variety of places to get information about ventricular assist devices (VADs) and heart failure. We have included links to a few sites that we feel are accurate and informative.
Heart Failure - Information from the American Heart Association about heart failure.
Patient Manuals for the VADs - A good source for information about the care and use of the machine that you have or are considering.
Patient Stories - Information from other patients who have undergone VAD surgery across the nation.
To make an appointment, please call 215-762-7802.
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