A PAtient ’ s G uide to the

A ssist

V entriculAr d eVice

Welcome to st. Peter’s hospital Advanced heart disease center As part of our goal in the Advanced Heart Disease Program, the St. Peter’s team provides you with the most advanced and latest treatment options for heart disease, close to home. Our team of experienced surgical professionals is dedicated to providing the highest-quality inpatient and outpatient care with the support you need to maintain the best quality of life possible. We’ve designed this booklet to provide general background information about ventricular assist devices (VAD) to help you in your decision-making about your health. A ventricular assist device is a mechanical heart pump that can be implanted in the chest or worn outside the body. VADs can also be called a ventricular assist system (VAS), heart pump, or left ventricular assist device (LVAD). If it has been determined by your medical team that you could benefit from a VAD, we encourage you to carefully read the information in this booklet and to discuss your decision with your family. Any time additional questions arise, please feel free to speak to a member of your St. Peter’s Advanced Heart Disease team. We look forward to partnering with you in your care. Thank you for trusting St. Peter’s for your health care.

Sincerely, niloo edwards, M.d. Chief of Cardiac and Vascular Services St. Peter’s Hospital

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table of contents heart Failure: What is it? Causes of Heart Failure Treatment Options for Advanced Heart Disease Informed Decision-Making

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Ventricular Assist devices How VADs are Commonly Used Types of VADs Offered at St. Peter’s Hospital Evaluation The VAD Team at St. Peter’s

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the VAd surgical Procedure Prior to Your Surgery Evening Before Surgery Day of Surgery Operating Room Cardiovascular Intensive Care Unit (CVICU) Explanation of Tubes and Lines Pain Management Progressive Care Unit Risk Factors of Surgery Long-Term Care Expectations Establishing Your “VAD Support Group”

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living with a Ventricular Assist device Continuing Care After Discharge Anticoagulation (Blood Thinners)

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Visit st. Peter’s hospital Advanced heart disease center 11 Directions to St. Peter’s Hospital 11 Getting Around st. Peter’s hospital campus Map Helpful Phone Numbers

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lodging options for Patients & Families

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Additional resources

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heart Failure (hF): What is it? heart failure means your heart muscle has weakened and cannot pump blood efficiently throughout your body. this causes: fluid to pool in your legs, feet and ankles; your kidneys to retain excess water and sodium; and fluid to back up into your lungs, leading to shortness of breath. this buildup of fluid is called heart failure. Heart failure can involve the left side, the right side, or both sides of your heart. Heart failure begins with the left side – specifically, the left ventricle, which is your heart’s main pumping chamber. Your physician may refer to your condition as “left-sided” or “left ventricular” heart failure.

eating foods high in cholesterol and fat, and not exercising) also cause or contribute to heart failure. These underlying heart conditions typically develop slowly over many years. That is why it is important to control the risk factors that can lead to heart failure.

Right-sided heart failure can occur independently, or it can be a consequence of left ventricular heart failure. Some five million Americans suffer from heart failure, a condition caused by a weakened heart that cannot pump enough blood to meet the needs of the body.

treatment options for Advanced heart disease

Symptoms include shortness of breath, fatigue, swelling or fluid build-up in your ankles, feet, legs and abdomen. Heart failure is a serious illness that can affect how long you live and your quality of life. It sends more than three million people to the hospital each year. With treatment and lifestyle changes, heart failure can be a very manageable condition.

causes of heart Failure Heart failure often results from the damage of a heart attack, high blood pressure, or other forms of heart disease including valve disorders. All of the behaviors that you probably associate with a heart attack or heart disease (such as smoking, being overweight,

There are several treatment options for patients with advanced heart disease. The most appropriate treatment for each patient is based on the severity of symptoms, the causes and the condition of the other organs.

optimum Medical Management Heart failure management is a team effort that includes you, your family, heart failure physicians and surgeons, and the rest of the advanced heart disease team which includes advanced practice clinicians, nurses, dietitians, pharmacists, and social workers. You will be prescribed medications and treatments to manage your heart failure and other medical problems. s t . P eter ’ s h osPitAl A dVAnced h eArt d iseAse c enter 1

Medications play a key role in the treatment of heart failure. Medications alone can result in an excellent quality of life and improved survival.

heart transplant A heart transplant is a procedure in which a surgeon removes a diseased heart and replaces it with a donor heart. During a heart transplant, a mechanical pump circulates blood through the body while the surgeon removes the diseased heart and replaces it with a healthy heart from a recently deceased donor. The surgeon connects the donor heart to the major blood vessels. The procedure takes several hours. To prevent the body from rejecting the donor heart, your medical team will give you powerful drugs (immunosuppressants) immediately after surgery, and you must continue to take them.

Pacemakers and defibrillators Sometimes pacing the heart can help improve both symptoms and function. This is sometimes known as biventricular pacing or cardiac resynchronization therapy (CRT). Unfortunately some patients with HF are prone to lifethreatening abnormal heart rhythm; in these patients, an implantable cardiac defibrillator (ICD) can be placed to shock the patient back into a normal rhythm if necessary.

reparative heart surgery If the congestive heart failure is caused by a problem that can be fixed and the heart damage is not too bad, it can be repaired. This is why early reporting of symptoms and diagnosis is important. For example: if the heart failure is caused by blockages to the arteries that bring blood to the heart (Coronary Artery Disease) it may be possible to 2 s t . P eter ’ s h osPitAl A dVAnced h eArt d iseAse c enter

bypass or stent these arteries to increase the blood supply and improve the function of the heart. However, it is also important to note that repair is only possible if other organs are functioning adequately.

VAd surgery Ventricular assist devices have broadened the treatment options we can offer patients with congestive heart failure. VADs provide patients with: Support until a transplant is available, • Support until the patient’s heart recovers, • An alternative to heart transplantation. •

Ventricular assist devices can improve the quality of life and survival for a patient. They can also significantly reduce time spent in the hospital.

informed decision-Making Our goal is for you and your family to make the best decision for your health, quality of life and lifestyle. We commit to making every effort to educate you and your family about advanced heart disease, treatment options, the surgery, and long-term care following the device implantation. This guide covers items that you, your family and caregiver need to be aware of prior to signing consent for the surgery.

Ventricular Assist devices A ventricular assist device (VAd) is a surgically implanted device for people who have a weakened heart that needs help pumping blood. if your heart is too weak to pump sufficient blood, the VAd takes over much of the work. this allows the heart to rest and sometimes recover, while the pump helps supply the body with needed oxygen and vital nutrients. these devices do not replace your heart — they help the heart.

how VAds Are commonly used Bridge to transplant A ventricular assist device (VAD) may be implanted to temporarily support a heart failure patient while waiting for a heart transplant. As a “bridge to transplant,” a VAD can maintain normal blood circulation and reduce the chances of damage to your other organs while waiting for a donor heart to become available. The ventricular assist device is removed when your new heart is implanted.

destination therapy If you are a heart failure patient who is not eligible for a heart transplant due to advanced age, smoking, cancer, or other health reasons, a VAD can be used as “destination therapy” for longterm support, instead of a heart transplant. Destination therapy can improve your quality of life and allow you to resume many regular activities in your normal surroundings.

Bridge to recovery If a patient’s heart failure is temporary, a VAD can be implanted for a few weeks or months to assist the heart during its recovery period. For example, if you are recovering from heart

surgery, you may have a VAD implanted until your heart is strong enough to pump blood efficiently on its own, or as a “bridge to recovery.”

types of VAds offered at st. Peter’s hospital short-term/emergent care Impella® Thoratec CentriMag® For people who develop sudden heart failure or acute cardiogenic shock, these VADs can be used to restore circulation to prevent damage to vital organs, like the brain, kidneys and liver. These devices may be placed during an emergency surgery or procedure. They also can be used to support a patient during high-risk open heart surgery. After this type of device is inserted into a person, they will be assessed to determine if the heart is getting better or if transplant evaluation or placement of a long-term device is necessary. If it is determined that the patient is a potential candidate for a heart transplant, the patient will be transferred to a transplant center when they are stable.

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long-term care

evaluation

thoratec heartMate ii® left Ventricular Assist device

Patients being evaluated for a planned VAD implant will be seen by a large group of healthcare professionals and undergo testing prior to the surgery. Your evaluation will be reviewed by the St. Peter’s Advanced Heart Disease team which includes surgeons, cardiologists, nurses, social workers and others. All of this will help provide the best possible outcome.

The HeartMate II® LVAD (made by Thoratec® Corporation) is currently approved to be used as Bridge to Transpant and as Destination Therapy. LVADs can support a patient for years without symptoms of heart failure.

The tests may include: • Echocardiogram • Pulmonary Function Tests (breathing tests) • Heart Catheterization • CT Scans • Blood Tests • Ultrasounds • EKG Tests will be administered over the course of your care, as needed.

This device requires patients to have a wire or driveline exiting their body through the skin; this is connected to a controller unit and batteries that power the pump. These batteries can last up to 10 hours. With this device, you will be able to be discharged from the hospital to home, rehabilitation or assisted living. Patients with an implanted pump are restricted from some activities, including vacuuming, dusting, and swimming. People can shower with a water-resistant bag that holds the controller and batteries to keep them from getting wet. All patients who are home with this device require a designated care companion with them, and will not be able to drive. Care companions will have to be trained on this device. 4 s t . P eter ’ s h osPitAl A dVAnced h eArt d iseAse c enter

of programs to address the special needs of elderly cardiac patients.

the VAd team at st. Peter’s The healthcare professionals involved in your care include: • Cardiologist • Heart Surgeon • Nurse Practitioner • Nurse • Chaplain • Case Manager • Social Worker • Psychologist • Financial Counselor The team at St. Peter’s is led by Dr. Niloo Edwards. Dr. Edwards has extensive experience in the treatment of patients with advanced heart failure and is an authority in the development

Board-certified in surgery and thoracic surgery, Dr. Edwards specializes in the surgical treatment of end-stage heart disease including transplantation, coronary artery bypass surgery, heart valve repair and replacement, minimally invasive heart surgery, open heart surgery for the geriatric patient, implantation of ventricular assist devices, mitral valve repair, and aortic surgery.

A national leader St. Peter’s Cardiac & Vascular Center has been consistently recognized by independent healthcare quality researchers as one of the best cardiac programs in New York state and in the nation. St. Peter’s is the only hospital in New York state and the northeastern United States to have been designated as a Top 100 Cardiovascular Hospital for 10 years, and one of only five hospitals nationwide to receive the distinction 10 or more years. Named a Blue Distinction Center for Cardiac Care, St. Peter’s continues to set the pace for health care innovations.

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the VAd surgical Procedure A surgical procedure is done to place the VAd in your chest, below your heart, and attach it to your aorta (a large blood vessel which carries blood from your heart to the rest of your body). the procedure to implant a ventricular assist device (VAd) generally takes approximately four to six hours. General anesthesia is required during this operation.

Prior to Your surgery

day of surgery

You (and your family members as well as those individuals who will be actively involved in your care) are required to attend the Cardiac Surgery Pre-operative Teaching class. This class is informational and provides an overview of cardiac surgery at St. Peter’s Hospital. The class is held weekly and is offered at no charge.

Check-in at the registration area for Cardiology, Cardiac, and Vascular Services (this registers you into our patient registration system). The registration area for these services is located on the first floor of the hospital. • Once registered, you and your family members will then proceed to the Egan Family Waiting Lounge. • You will then be taken to the Cardiac Pre-Operative Unit on the first floor of the Patient Pavilion. • In the Pre-Operative Unit, your body hair will be clipped and you will shower with special soap and change into a hospital gown. You will also meet with your cardiac surgeon, as well as clinicians from perfusion, anesthesia and the operating room nurses. Consent forms will be reviewed. •

evening Before surgery Arrival Time: o Hospital staff will call you the night before surgery to tell you what time to come to the hospital. • Skin Preparation: o You will need to shower with the special soap provided – directions will be provided in Pre-Admission Testing. • Eating and Drinking: o After midnight, do not eat or drink anything. An empty stomach is necessary before surgery. o The doctor or nurse practitioner will tell you what medications to take with a sip of water. • Sleep: o Attempt to get a good night’s sleep. •

operating room

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An IV Line will be inserted and a mild sedative will be given. • Similar to an IV line, an A-Line (Arterial Line) will be placed in your wrist or arm to monitor your blood pressure. • A catheter will be inserted into your bladder to drain urine (after you are asleep). •

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A special IV will be placed in your neck to monitor pressure inside your heart. (This is called a SwanGanz Catheter.)

While in the operating room, your family can wait in the Egan Family Waiting Lounge. They will receive periodic updates about your progress from the nurse navigator.

cardiovascular intensive care unit (cVicu) Immediately after the surgery, you will be moved to the CVICU, located on the first floor of the hospital pavilion. • A specially-trained ICU nurse will care for you at this time. • After a nurse has settled you in, your family will be able to visit you on this unit (approximately 1½ hours after your arrival). • Length of stay in the CVICU will depend on your body and healing process. The average stay is two to four days. • As you improve you will be transferred to the Progressive Care Unit (also on first floor of the pavilion). You will remain here until discharged from the hospital. •

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Teaching and learning how to care for the device will begin in the CVICU and continue in Progressive Care.

explanation of tubes and lines endotracheal tube & Mechanical Ventilator The endotracheal tube passes through your mouth, into your windpipe. This is attached to a ventilator which breathes for you while you are asleep. This remains in place until your team feels that you are ready to have it removed. (The average time is one to three days.) As you wake up, the machine will make a lot of noise. You will not be able to talk while this is in place. You will be asked to cough and breathe deeply once it is removed. You will be asked to use a breathing machine called an incentive spirometer. It is important to do this 10 times every hour. This helps prevent you from getting pneumonia.

heart Monitor Five stickers with wires will be placed your chest. These wires are attached to the monitor behind you. This is used by your team to monitor your heart rhythm. When you move, the monitor will create noise. You and your family should not be nervous if something beeps. Your team is monitoring you both in your room and at the desk outside of your room.

chest tubes There will be drainage tubes coming out of your body, and these will be attached to a box on the floor. These are placed to drain excess fluid from the area around your heart. This is monitored to make sure you are not s t . P eter ’ s h osPitAl A dVAnced h eArt d iseAse c enter 7

bleeding. These tubes will be removed once it is determined by your team that they are no longer needed.

intravenous lines (iV) These provide a way for your team to give you fluids, blood, medications, and antibiotics. They will remain in place until it is determined you do not need them.

level. It is important to take pain medication if needed as it can help the healing process. With your pain level appropriately managed, you will be better able to take deep breaths and cough – which is essential to your rapid recovery.

Progressive care unit Once transferred to Progressive Care, the focus of your care will be on getting you home. • Walking and moving soon after surgery is essential to a rapid recovery. An exercise physiotherapist will be helping you meet this goal. • A heart monitor will still be attached to your chest, which is called telemetry. • VAD education is required for discharge. The team will help you meet this goal. Before you can leave, both you and your designated caregiver need to demonstrate that you can take care of the VAD and the dressing changes. • Most patients leave the hospital within two to four weeks after their VAD implantation surgery. They can return to their job within one to three months, depending on the nature of their work. •

Bladder catheter This is a tube inserted into your bladder to drain urine from your body. It too will be removed when it is no longer needed (approximately two to four days after your procedure).

swan-Ganz catheter This measures pressure inside your heart and lungs at different areas. This will be removed before you go to the Progressive Care Unit.

Pain Management You will experience some pain from the incisions made to the chest. Pain medication will be administered as needed either in your IV line or by mouth if you are able to swallow. Please let the nurses know if you are in pain, and be honest about your pain

When you are discharged from the hospital to go home with a device in place, you will need: To be trained on the device and proper driveline care; • To pass a short, written and handson skills test; • To have family members and friends to be trained on the device, if they will be alone with you. (This is set up and planned with your VAD Coordinator.) •

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risk Factors of surgery Infection • Excessive bleeding, which may need reoperation • Thromboembolism (blood clots that form and can travel to other parts of the body), which could result in a stroke or loss of a limb or organs and could require surgery • Mechanical failure (the pump or one of the parts may stop working) or malfunction • Neurological dysfunction or stroke (brain or nerve damage resulting in difficulty or inability to wake up or difficulty moving parts of the body) • Hemolysis (the destruction of blood cells) • Pulmonary dysfunction (the lungs fail to oxygenate the body) • Kidney failure • Liver dysfunction (the liver fails to filter blood) • Death •

long-term care expectations Companion/caregiver support (education and training for VAD for you and your companion/caregiver required) • Maintain electrical power with grounded outlets • Ongoing costs related to care may not be covered by insurance; However, there are options your team will discuss with you • Competent driveline site care (the patient and caregiver will have to demonstrate proper care of the site prior to discharge to ensure safe care and prevention of infection) o Driveline infections may require long-term antibiotic therapy and are the most significant issue with the VAD if not cared for properly •

Blood thinners require periodic blood tests to check levels • Follow-up clinic visits as scheduled, and maintenance checks of equipment • It is necessary for you to have someone who can drive you to your medical appointments because you will be advised not to drive •

establishing Your “VAd support Group” The staff will train you on how to use your VAD. We will also ask that you establish your “VAD Support Group.” This group will consist of four to five family members and friends who will become trained on the device. Training can be done during a routine visit or can take place during formal sessions with a VAD Coordinator usually for two, four-hour sessions. While on battery, you are able to do normal daily activities such as shopping, traveling, attending events, etc. During sleeping hours, attach the device to AC power.

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living with a Ventricular Assist device VAds need battery power or Ac power to keep the pump running. the VAd has 48 hours of battery power and batteries last 10 to 12 hours. there is also a stationary power base unit (PBu) for the device.

continuing care after discharge Follow-up appointments are necessary for your team at St. Peter’s to see you and to evaluate your equipment. Your follow-up appointments will be scheduled on a frequent basis, soon after you are discharged from the hospital. You also will have 24-hour access to a healthcare provider within your team at St. Peter’s Hospital for questions and emergencies.

At home: Frequent blood tests are needed (one to two times per week) • Once the level is regulated, these tests will be once every two to four weeks • Dosage of warfarin may change due to how thin or thick your blood is; This will be determined by blood test results •

When to call:

Local EMS and fire departments will be educated on the VAD and how to respond to potential emergencies that could happen. Your primary care physician and cardiologists will be encouraged to receive education and/or training on the VAD.

Anticoagulation (Blood thinners) You will have to be on blood thinners while this device is in place. These blood thinners make your blood less likely to form a clot. While in the hospital: You will receive an IV form of these blood thinners, called heparin • Once you are taking medications by mouth, a pill form (warfarin) will be started •

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If you experience, any unusual bleeding (Could be from any place on your body) • If you experience black, tar-like stools •

directions to st. Peter’s

Visit st. Peter’s hospital Advanced heart disease center

From the North: Follow the northway (I-87) south to Western Ave. (Rt. 20). Turn left onto Western Ave. and follow it approximately 2.8 miles to S. Manning Blvd. Turn right on S. Manning Blvd. and follow it approximately one mile to the St. Peter’s entrance on the left.

in the immediate discharge period, patients will follow up with the clinicians in the st. Peter’s Advanced heart disease center located in suite 110B, 319 s. Manning Blvd. in Albany, on the st. Peter’s hospital campus. Follow-up visits will occur every one to two weeks. once the patient and provider are comfortable with the patient’s progress, these appointments will be scheduled for every one to two months.

Contact Us St. Peter’s Hospital Advanced Heart Disease Center (518) 525-5037 Niloo Edwards, MD (518) 525-2525 John D. Filippone, MD (518) 458-2000 Jeffrey Uzzilia, MD Lance Sullenberger, MD (518) 292-6000 Mary Ann Rifenberick, ACNP (VAD Coordinator) (518) 525-5655 Cathleen Daley, RN (Advanced Heart Disease Nurse) (518) 525-8539

From the South: Follow the NYS Thruway (I-87) north to exit 24. Take the far-right exit to Western Ave. (Rt. 20). Turn left onto Western Ave. and follow it approximately 2.8 miles to S. Manning Blvd. Turn right on S. Manning Blvd. and follow it approximately one mile to the St. Peter’s entrance on the left. From the East: Follow I-90 west to exit 4 (Rt. 85 Slingerlands). Follow Rt. 85 approximately 2 miles to the Krumkill Rd. exit. Turn left at the top of the ramp. Turn right at the immediate light onto Bender St./Krumkill Rd. and follow it to the next light. Turn left at the light onto New Scotland Ave. for approximately one mile. Turn right onto S. Manning Blvd. St. Peter’s entrance will be on the left. From the West: Follow the NYS Thruway (I-90) east to exit 24. Take the far-right exit to Western Ave. (Rt. 20). Turn left onto Western Ave. and follow it approximately 2.8 miles to S. Manning Blvd. Turn right on S. Manning Blvd. and follow it approximately one mile to the St. Peter’s entrance on the left.

interactive Map St. Peter’s has an interactive map on its website. Please visit: http://www.sphcs.org/MapsDirections

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Getting Around st. Peter’s hospital campus

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* Main Entrance – The Main Entrance is located on the ground floor of the hospital. The Main Entrance features a host of services including the valet parking station, the Concierge Desk and the Jazzman’s Café with ample seating in the Massry Family Atrium. The hospital’s new Chapel is located here providing a quiet and peaceful space for patients and visitors. Parking & Valet Service – Complimentary parking is available only to the person transporting you on the days of your admission and discharge. Hospital patients and visitors may use

St. Peter’s Hospital Advanced Heart Disease Center

valet parking at the Main Entrance without any extra charge during business hours on weekdays. You will be charged the normal daily parking fee, however. For our visitors, parking is available in our main parking garage. In addition to a daily parking fee, discount weekly, bi-weekly and bi-monthly parking permits are available to patients’ families and friends. You can buy a permit at the Protective Services Office on the Hospital’s first floor near the cafeteria. The phone number for Protective Services is 525-1225.

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Cardiovascular Surgery – All of these services are located on the first floor of the hospital pavilion. The waiting area (known as the Egan Family Waiting Lounge) is located just off of “Main Street” at the hospital. “Main Street” on the First Floor – In addition to the cardiovascular surgery department, the hospital’s “Main Street” features many amenities including the food court, ATMs and an expanded gift shop.

helpful Phone numbers The following phone numbers may be helpful for you and your loved ones. Main Number (518) 525-1550 Emergency Department (518) 525-1315 Mercy Me Gift Shop (518) 525-1649 Patient Information (518) 525-1571 Patient Relations (518) 525-1192 Protective Services (Security) (518) 525-1522 Spiritual Care (518) 525-1602

lodging options for Patients & Families Becky’s house: A home Away from home Becky’s House was established as a home-away-from-home for those families who must travel a distance. Becky’s House is available on a first come, first served basis. Becky’s House provides six bedrooms and shared bathroom facilities for the use of patients and families. In addition, Becky’s House offers the use of kitchen and laundry facilities and local telephone services. We are dedicated to making every effort to accommodate families and patients with special needs. Parking can be arranged for guests across the street from Becky’s House. Becky’s House is located at 296 Hackett Blvd., Albany. St. Peter’s staff or a family member may call (518) 438-1212 to inquire about room availability and registration.

hotels in the capital region There are a number of lodging options in the Capital Region. The following website offers several options in the area: www.albany.com

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Additional resources information on the internet The following websites provide information on ventricular assist devices which you may find helpful. http://www.sphcs.org/VADs http://www.thoratec.com http://www.heart.org/HEARTORG/ Conditions/HeartFailure/ Heart-Failure_UCM_002019_ SubHomePage.jsp http://www.hearthope.com/ http://www.mylvad.com

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315 South Manning Boulevard / Albany, New York 12208 / 1-800-HEART-76 • 1-800-432-7876 www.sphcs.org

08/2012