Q: What are the indications for referral for LVAD implantation?
A: The indications for referral for LVAD implantation are as follows:
- Two or more hospitalizations for heart failure in the past six months
- Intolerance of heart failure medications
- No benefit from cardiac resynchronization via a biventricular pacemaker
- On, or being considered for, inotropic support
- Class 4 heart failure and ineligibility for transplant
- Cardiac cachexia
Q: What is the timeline after referral?
A: When we first see a patient referred for LVAD implantation, a comprehensive review is initiated. Multiple baseline tests are obtained, and patients are evaluated by all specialty services including renal, gastroenterology, pulmonary, psychiatry, nutrition, and social services, in order to ensure there are no contraindications to implant. A decision is made regarding implant as a "bridge to transplant" (BTT) versus "destination therapy" (DT). For outpatients, this process may take weeks to months. For patients who are unstable or clinically deteriorating, the process is fast tracked. Some patients require inotropic support or an intra-aortic balloon pump (IABP) prior to VAD implantation.
Q: What do I look for in my LVAD patients during their office visit?
A: Patients are seen initially weekly, then monthly, in our LVAD outpatient clinic. However, we ask that they also follow up with you. During the office visit with you,
- When obtaining vital signs, remember your patient may not have a palpable pulse; mean blood pressure (BP) may be obtained with a Doppler. Goal mean arterial pressure (MAP) ranges from 65 to 85.
- Patients can develop aortic insufficiency with long-term VAD support, so onset of a new diastolic murmur would be a concern, and should prompt an echocardiogram and communication with our VAD team.
- Gastrointestinal bleed can also occur in up to 15-20% of patients on long-term VAD support. Reports of tarry stools or signs of anemia would be a concern, and should prompt communication with our VAD team.
Our VAD coordinators are available at all times. Please call 631-617-2541 with questions or concerns.
Q: What kind of routine post-operative testing should I do for my LVAD patient?
A: A baseline EKG and echocardiogram are performed prior to the patient's discharge from the hospital. These should be repeated annually, or if clinically indicated. In addition, at Stony Brook, we perform the "6-minute walk test" at several intervals postoperatively to assess functionality and quality of life. Patients with an automatic implanted cardiac defibrillator (AICD) should have their device interrogated at regular intervals.
Q: How does Stony Brook's LVAD program interface with heart transplant programs?
A: We have excellent relationships with three of the New York-based transplant programs: Columbia University, Montefiore Medical Center, and Mount Sinai Medical Center. Our "bridge to transplant" patients have been evaluated and are listed for transplant at all three centers. As of January 2013, two of our patients have received heart transplants at Montefiore, and they are doing well.
Q: What devices do you implant?
A: We implant the HeartMate II LVAD, manufactured by Thoratec. This was the first FDA approved device for both "bridge to transplant" (BTT) and "destination therapy" (DT).
Heartware is a new smaller continuous-flow LVAD approved by the FDA in October 2012 for BTT. We will begin offering this pump to appropriate patients as the company rolls out support to implant centers.
Q: How do I contact the LVAD service with urgent concerns?
A: The LVAD phone is staffed 24 hours a day, 7 days a week, and we are happy to take your calls at any time. The LVAD phone number is 631-617-2541.