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1
Q

what are two options for palliative inotropes

A

dobutamine and milrinone

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2
Q

what drug class is dobutamine

A

beta adrenergic beta1 receptor agonist

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3
Q

what drug class is milrinone

A

phosphodiesterase inhibitor (PDE3)

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4
Q

what is the dosing for dobutamine

A

2.5-25 mcg/kg/min (usually 10)

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5
Q

what is the dosing for milrinone

A

0.125-0.5 mcg/kg/min

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6
Q

which has a longer half life, dobutamine or milrinone?

A

milrinone, and it is prolonged in renal dysfunction

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7
Q

which is a more potent vasodilator, dobutamine or milrinone?

A

milrinone is a more potent vasodilator, it can cause hypotension

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8
Q

how is milrinone beneficial in patients with RV dysfunction

A

decrease in pulmonary pressures

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9
Q

dobutamine on B1 receptors causes ____

A

increased contractility (CO)

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10
Q

dobutamine on B2 receptors causes ____

A

vasodilation (decreased MAP)

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11
Q

what is required for palliative inotropes?

A

go home with an implantable defibrillator because they can cause Vtach/VFib

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12
Q

palliative inotropes are associated with NO difference in ____

A

mortality

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13
Q

palliative inotropes are only to improve ____

A

functional status/quality of life

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14
Q

name 3 complications with palliative inotropes

A

central line infections, defibrillator shocks for VT/VF, cost

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15
Q

what are some considerations for dobutamine

A

use with beta blockers is controversial, may worsen tachycardia

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16
Q

what are some considerations for dobutamine

A

use with beta blockers is controversial; may worsen tachycardia

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17
Q

what are some considerations for milrinone

A

hypotension especially with renal dysfunction, may worsen ventricular dysrhythmias

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18
Q

name 3 risks for mechanical support

A

bleeding, thrombosis, infection

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19
Q

what is the intra aortic balloon pump (IABP)

A

inflatable balloon inserted into the descending aorta (femoral or axillary insertion) that is set to inflate in ratio to ventricular contractions

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20
Q

what are the pharmacological considerations for IABP

A

there is an anticoagulation debate but most centers use parenteral heparin or DTI

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21
Q

what are the settings for IABP

A

1:1 which is one inflation for every contraction, and 1:3 which is one inflation for every 3 contractions

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22
Q

what are the indications for IABP

A

temporary support during cardiogenic shock, PCI, acute ischemia (MI, unstable angina), bridge to transplant/device

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23
Q

what are 2 advantages for IABP

A

relatively quick insertion, hemodynamic improvements

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24
Q

what are the hemodynamic improvements from IABP

A

increased diastolic BP, decreased myocardial oxygen demand, improved coronary perfusion, afterload reduction, modest improvement in CO

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25
what is a contraindication to IABP
aortic disease
26
what are some complications from IABP
infection, hematoma/bleeding (device requires heparin), thrombocytopenia, vascular complications, aortic dissection
27
what is the impella heart pump
a percutaneous LVAD with femoral or axial insertion
28
what are the four different impella device types
2.5, 5.5, CP, RP
29
what is the impella 2.5
delivers 2.5 L/min of CO`
30
what is the impella 5.5
delivers 5.5 L/min of CO
31
what is the impella CP
delivers 3.5 L/min of CO
32
what is the impella RP
delivers 4 L/min of flow for RV
33
indications for impella
6 hours or less for support during PCI, 6 days or less for support during cardiogenic shock, often used for much longer when patients are bridge to transplant
34
femoral insertion of impella
can be done in the cath lab by interventional cardiologist
35
axillary insertion of impella
must be done by cardiothoracic insertion
36
advantage to axillary insertion of impella
patients can mobilize
37
what is unique about impella pharmacotherapy
need a dextrose based purge solution (with either heparin or sodium bicarb) as well as parenteral anticoagulation with heparin or DTI
38
how should you titrate anticoagulation for impella
anti-Xa target range of 0.2-0.4 IU/mL or corresponding institutional aPTT range
39
improper anticoagulation or purge solution with impella can result in?
device failure and hemolysis
40
what is the ECMO
extracorporeal membrane oxygenation: percutaneous support by where blood is pumped through an extracorporeal oxygenator (supplies blood with oxygen, removes carbon dioxide)
41
2 major types of ECMOs
vevovenous (v-v) and venoarterial (v-a)
42
v-v ECMO
provides only PULMONARY support
43
with the v-v ECMO, deoxygenated venous blood is pumped through the oxygenator and returned oxygenated to ______
venous circulation
44
the v-v ECMO is used in _______
respiratory distress syndrome (ARDS)- lung failure
45
the v-a ECMO provides ______
cardiopulmonary support
46
with the v-a ECMO, deoxygenated venous blood is pumped through the oxygenator and returned oxygenated to ____
arterial circulation
47
the v-a ECMO is used in ______
cardiogenic shock
48
what pharmacotherapy is required with ECMO
anticoagulation with heparin or DTI
49
it is imperative to monitor for _______ with the ECMO
peripheral limb ischemia
50
what else should you treat with the v-a ECMO
it provides retrograde blood flow into the aorta resulting in increased afterload so you should treat with an afterload decreasing agent such as vasodilators
51
what are two types of total artificial hearts
syncardia, carmat
52
what is syncardia
pneumatic (air-driven) implantable device that provides biventricular support)
53
total artificial hearts are _____ ONLY
bridge to transplant
54
you can have a stroke volume of ___ or ___ with syncardia
50cc or 70cc
55
the contraction frequency with syncardia is adjusted to provide _____
appropriate cardiac output
56
what thrombotic prophylaxis does syncardia require
multi-modal: aspirin, heparin transitioned to warfarin, dipyramidole, pentoxifylline
57
what does the carmat provide
hydroelectric ventricular contraction
58
why does carmat have less intense anticoagulation needs than syncardia
it has 4 biological valves (bovine), biocompatible ventricular lining
59
what pharmacotherapy is used for carmat
treatment dose LMWH until hospital d/c then prophylactic dose LMWH
60
types of LVAD flow
continuous flow, pulsatile
61
types of LVAD continuous flow
axial flow, centrifugal flow
62
what is the name of the pulsatile LVAD
heartmate XVE, it's off the market
63
what is the name of the axial flow LVAD
heartmate II, it's off the market
64
what is the name of the centrifugal flow LVAD
heartmate III (only one on the market)
65
definition of left ventricular assist device (LVAD)
serves as a permanent prosthetic left ventricle to deliver oxygenated blood to peripheral circulation
66
components of LVAD
pump, driveline (delivers power and settings to pump), external battery
67
pharmacologic considerations for LVAD
prosthetic device (infection, thrombosis), requires anticoagulation/antiplatelet therapy (bleeding, thrombosis), blood pressure management (don't have a pulse)
68
blood from the _____ enters the LVAD. the LVAD then pumps blood into ____
left ventricle. aorta (to the body).
69
what pharmacotherapy did heartmate XVE require when it was on the market
only aspirin 325 mg daily
70
what were some complications with heartmate XVE
infection, bleed, thrombosis (pump, stroke), pump failure
71
what pharmacotherapy did heartmate II require when it was on the market
aspirin 325 mg daily and warfarin titrated to goal INR 2-3, antibiotics around the time of implant
72
what advantage did heartmate II carry over heartmate XVE
it was a smaller pump, simpler surgical procedure, improved device durability
73
what are the three components of virchow's triad
hypercoagulable state, circulatory stasis, vascular wall injury
74
how do LVADs cause a hypercoagulable state
increased thrombin production by interaction between blood and device components (blood touches metal, wants to clot)
75
how do LVADs cause circulatory stasis
LVAD recipients may have stasis due to lack of LV function
76
how do LVADs cause vascular wall injury
the implantation requires major surgery
77
how do LVAD recipients have circulatory stasis
due to lack of LV function
78
how can LVADs lead to clot
platelet activation through tissue injury, clotting cascade activation
79
what drugs are needed to prevent clots for LVAD
antiplatelet (aspirin, p2y12, dipyramidole) to prevent platelet thrombus, anticoagulant (heparin, LMWH, warfarin, DOACs?) to prevent platelet thrombus
80
aspirin mechanism
inhibits COX-1 resulting in lack of thromboxane A2 production
81
P2Y12i mechanism
prevent platelet activation downstream of aspirin; inhibit ADP production resulting in reduction of platelet-based thrombin
82
dipyramidole mechanism
inhibits breakdown of cAMP resulting in reduced activation and aggregation
83
what is the primary antiplatelet choice in LVAD
aspirin (given the increased risk of bleeding with P2Y12i)
84
when is DAPT reserved for with LVAD
patients with history of pump thrombosis
85
anticoagulation for LVAD
heparin infusion w/ low aPTT goal (50-80s) for bridging to therapeutic warfarin (goal INR=2-3 regardless of device)
86
when is INR goal for LVAD different?
patients with GI bleeding, patients with history of pump thrombosis
87
what is INR goal for LVAD patients with GI bleeding
1.8-2.5
88
what is INR goal for LVAD patients with history of pump thrombosis
2.5-3.5
89
how do you monitor for hypertension with continuous flow devices??
the patients do not have a pulse so you monitor by MAP
90
MAP=
1/3(SBP) + 2/3(DBP)
91
what is considered HTN based on MAP?
anything above 85/90? is considered hypertension with a VAD and may increase stroke risk
92
how do axial flow pumps work
they have an impeller (similar to a boat propeller) that helps draw blood from LV through a cannula into the aorta)
93
how do centrifugal flow pumps work
they use magnetic levitation (mag-lev) with a bladed disk in the pump cavity to deliver blood from LV to aorta)
94
stroke risk factors with LVAD
MAP > 85 mmHg, INR<2, aspirin dose <81 mg daily
95
how was HVAD better than heartmate II
pump size was smaller, further simplification of the surgical procedure, less pump thrombosis risk, but similar to increased stroke risk
96
heartmate III advantages
fully magnetized levitation technology, results in improved hemo-compatibility with patients (reduced pump thrombosis)
97
LVAD complications
hemocompatibility (bleeding, thrombosis), infectious, right ventricular failure, pump malfunctions
98
bleeding complications with LVAD
hemorrhagic stroke, GI bleeding, epistaxis
99
thrombosis complications with LVAD
ischemic stroke, pump thrombosis
100
infectious complications with LVAD
driveline infection, infected device

Cardio (26 decks)

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