To vad or not to vad and when

1. KellyAnn Light-McGroary, MD, FACC
Cardiomyopathy Program and Palliative Med Program
University of Iowa Hospitals and Clinics
ACC 2015
San Diego, Sunday, March 15th

2. 
I have no disclosures that are specifically relevant to
this presentation.
Disclosures

3. 
 To review the goals of mechanical circulatory
support
 To discuss how patients and providers approach the
decision
 To outline the essential elements of preparedness
planning/palliative consult in ACT and the impact
on decision making.
Objectives

4. 
LVAD Candidate Pool
 250,000-500,000 ESHF pts in terminal phase of disease
(ACC Stage D = refractory to MM)
 Mean survival 3.4 months
Inotrope dependent = up to 94% 1 yr mortality
 80,000-150,000 pts/yr could benefit from HT
 HT performed approximately 2,200/yr
 LVAD as DT is available alternate
Lietz et al; J Card Surg 2010;25:462-471

5. 
Goals of MCS
 Improve survival
 Reduce hospitalizations
 Improve quality of life
 Improve likelihood of successful transplantation

6. 
What the medical team sees
when deciding about MCS:
Medical team considerations:
 Age
 Co-morbid conditions
 Anticipated survival
 Risk scores
 Bleeding risks
 Social support
 Right ventricle, right ventricle, right ventricle!

7. 
What is the right timing?
 “Too Early” vs. “Too Late”
 Sick enough to recognize the benefit
 Well enough to minimize risks/burdens

8. 
What the patient often hears
when deciding about MCS:
Patient approach:
 Receive MCS and live
 Decline MCS and die
Ideally, a patient would understand the exchange of
end-stage HF problems for bleeding risks, infections,
and/or stroke
Song, ISHLT 2012
Swetz, et al, Cardiology Research & Practice 2012

9. 
Preparedness Planning for
Advanced Cardiac Therapies
How do we bring these
two partners together?

10. 
 Step 1: Goals of Care and Expectations
 What are they hoping for, where are their values?
 Can MCS or transplant actually help the achieve those
goals?
 GOC set the stage for the entire discussion; it is the
foundation for many challenging issues.
 Understanding goals of care can help manage
expectations, ie “realistic hope”
Essential Elements of
Preparedness Planning

11. 
 Step 2: Advanced Care Planning and Identification
of Surrogate Decision Maker
 What have they already done?
 Consider Honoring Your Wishes, Five Wishes, etc
(robust advanced care plans)
 Include surrogate in discussions including
responsibilities and how to approach this role
 Normalize this as part of routine health care
Essential Elements of
Preparedness Planning

12. 
 Step 3: Preparedness Discussion for Patient and
Family
 Discuss what to expect during the perioperative
period including possible challenges and expectations
for patients and providers.
 Discuss long term benefits and complications
including:
 Infection
 Bleeding issues
 Ongoing HF/RV failure
 Renal failure/dialysis
 Discussion around device deactivation
Essential Elements of
Preparedness Planning

13. 
1. Rizzieri et al. Philos Ethics Humanit Med 2008;3:20
2. Goodlin S. J Card Fail. 2004:54;200-9
Critical Step is discussing QOL and
Care Trajectory after DT

14. 
Long term care and QOL considerations
in DT patients
 Caregiver misperceptions
 Frequent clinic visits
 Insurance/financial
 Geographical limitations
due to power source
 Limited local resources
− Local medical
community likely
unprepared to care for
DT patients
 Caregiver burnout
 EOL issues
− Inevitable
− Ethical aspects of
withdrawing DT
support
− Palliative care
These considerations emphasize
the need for a “preparedness
plan.”

15. 
At our institution, all VAD and
HT patients undergo palliative
medicine-facilitated
“preparedness planning”
Major components of “preparedness
planning” for DT patients
Swetz et al; Mayo Clin Proc 2011;86:493-500

16. 
What does palliative medicine specifically
offer to VAD patients?
 Medical decision-making
 Establish goals of care
 Coordinate care
 Manage symptoms
 Psychosocial and
spiritual support
 Assure comfort, QOL
and dignity
 Prognosis
 Ethics
 Technical assistance
 Active care of dying
patients and loved ones
 Bereavement support
Swetz et al; Mayo Clin Proc 2011;86:493-500

17. 
 CP is a 64 y/o man with a history of an ischemic
cardiomyopathy/prior CABG, Stage D, NYHA Class IV.
 In September presented in progressive biventricular failure.
 Inotrope dependent by October but not thriving
 Implanted in early November as DT HM2 VAD after
palliative/preparedness planning consult.
 Goals: live longer but most importantly be able to fish, go
to grandson’s sporting events and stay out of hospital.
Case Presentation

18. 
 After implant developed mesenteric ischemia felt to be
due to embolic event from VAD .
 By December developed recurrent GI bleeds that were
aggressive and difficult to control.
 Multiple unsuccessful GI/IR procedures.
 Multiple transfusions and hemodynamic instability.
 Off anticoagulation he had stroke and VAD thrombosis.
Full resolution of stroke with heparin.
 Ongoing low level hemolysis.
 Has been an inpatient 80% of the last 3-4 months.
 Reactivated on the list as a 1A 2 weeks ago and
transplanted 4 days ago
Case Presentation

19. 
 What have his thoughts been about VAD?
 Has it met expectations?
 Did he feel prepared?
 How have his symptoms been managed?
 What is the impact on his family?
 How is he suffering?
Case Presentation

20. 
 Goals of Care are critical as the foundation of
deciding appropriateness of VAD and timing.
 Ensuring that patients and surrogates understand
ahead of time the possible decision points helps to
create a road map for even the unexpected.
 Managing expectations for the team and the
patient/family can be successful through structured
preparedness planning.
Summary