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Paget's disease of the bone

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Indications

  • Bridge to recovery
  • Bridge to transplantation
  1. Cannot be weaned from CPB
  2. Despite maximal pharmacological support
  3. and use of IABP

 

Principles

  1. Provide flow to support the circulation
  2. Rests the heart to allow metabolic and functional recovery

 

Device Principle effects Indications Technique Management
LVAD - Left ventricular assist device
  • Provide systemic perfusion
  • Decompress LV: LV wall stress reduced by 80%
  • 40% decrease in myocardial demand
  • Flow dependent on intravascular volume and RV function
On maximal medical support with:
  • Cardiac index <1.8L/min/m2
  • Systolic BP <80mmHg
  • PAWP / LAP >20mmHg
  • Drainage: LA / LV
  • Return of blood: aorta
  • LA catheter inserted for accurate monitoring of left-sided filling pressures

  • Flow intitiated to achieve systemic flow of 2.2L/min/m2
  • LA pressure 10-15mmHg
  • Adequacy of perfusion is assessed by mixed venous oxygen saturations
  • Stop inotropes (decrease myocardial demand)
  • Vasopressors may be needed to maintain MAP >75mmHg
  • Heparinise to achieve ACT 175-200seconds

Inadequate flow due to:

  • Improper position of draining cather
  • RV failure
RVAD - Right ventricular assist device
  • Provide pulmonary blood flow 
  • Decompress RV (RV infarction, pulmonary hypertension etc)

On maximal medical support with

  • RAP >20mmHg
  • LAP <15mmHg
  • No TR
  • Drainage RA
  • return of blood: Pulmonary artery
  • Flow initiated to achieve rate of 2.2L/min/m2
  • LA pressure to 15mmHg
  • Maintain high RA pressure 5-10mmHg
  • Heparinise (as above)

Inadeqaute flow due to:

  • Improper position of catheter
  • Cardiac tamponade (compression of RA)
BiVAD - Biventricular assist device        

 

 

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