Berlin heart VAD Excor

Cite this article as:
Marc Anders. Berlin heart VAD Excor, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3797

Definition:

Paracorporal, pneumatically driven, pulsatile flow mechanical support device driven by a central driving unit (Ikus®) and different sizes of blood pumps (10, 25, 30, 50, 60, 80ml), can be used as RVAD, LVAD or BIVAD.


Aim:

Bridge to transplant or bridge to recovery


Standard settings:

Driving pressures for Systole and Diastole
(Chamber Size / LVAD / RVAD)
10 ml 225 / 175 – 50 / – 50
25 ml 175 / 150 – 50 / – 50
30 ml 175 / 150 – 50 / – 50
50 ml 175 / 150 – 25 / – 25
60 ml 200 / 150 – 25 / – 25
80 ml 225 / 175 – 25 / – 25

Anticoagulation guide:

Medications / Dosing / Target

start UFH+ >24 hr post OP+ no bleeding

+ platelets >20.000

+ normal TEG

start witha) <12 month:
15 U/kg/hr (no bolus) and increase after 6hrs to 28 U/kg/hrb) >12 month:

10 U/kg/hr (no bolus) and increase after 6 hrs to 20 U/kg/hr

aPTT 1.5-2.5 of normal (check every 6 hrs)or Anti-Xa 0.35-0.50 U/ml (draw level 4 hrs after 2nd dose)

start LMWH+ creatinine normal+ no bleeding

or if

+ unable to tolerate PO

+ unstable INRs

+ convert after UFH and no bleeding

start with Enoxaparina) <3 month: 1.5 mg/kg BDb) >3 month: 1 mg/kg BD

or if low INR 2.0-2.7: 1 mg/kg/ OD

or if low INR <2.0:

1 mg/kg BD

Anti-Xa 0.6-1.0 U/ml (draw level 4th after 2nddose until stable)
start Vitamin K Antagonist
(bridge with LMWH)
+ if age >12 month+ enteral feeds tolerated
Warfarin 0.2 mg/kg/day(maximum 5 mg/day) INR 2.7-3.5(use LMWH if unstable INRs)

start Platelet inhibitorsDipyramidole+ if Platelets >40.000

+ postop Day 2 and

ADP >50%

+ Aspirin

+ if platelets >40.0000

+ postop Day 4 and drains removed and ARA >50%

Dipyramidole 1 mg/kg/dose QID (maximum 15 mg/kg/day)Aspirin 1 mg/kg/day ADP activity <50%ARA activity <30%

 


Trouble shooting: always inform PICU consultant for any changes !

Insufficient filling of VAD (VAD Diastole)
Hypovolaemia check Hb and drain losses → replace volume
changes in intrathoracic pressure check CXR (pneumothorax?), ventilation settings → aim for early extubation to increase CO (negative impact of positive intrathroacic pressure)
Tamponade ECHO warranted, inform surgeon ASAP
increased PVR lower PVR (pulmonary hypertension), check right heart function on ECHO
Kink in inflow cannula check for mechanical obstruction: extracorporal / intracorporal (ECHO)
right heart failure(LVAD only) check right heart function with ECHO → inotropic support of right heart (dobutamine, milrinone), →→ NO , RVAD
too low negative vacuum pressure increase negative vacuum pressure (be careful not to suck air in) → driving pressures
VAD rate too high lower VAD rate, decrease % systole

 

Insufficient emptying of VAD (VAD Systole)
increased PVR (in RVAD) lower PVR (pulmonary hypertension)
increased SVR (in LVAD) lower SVR (vasodilators)
Kink in outflow cannula check for mechanical obstruction
systolic drive pressure too low increase systolic driving pressure (→ driving pressures)

References:

[1] J of Cardiovasc Trans Res (2010) 3:612-617: Bryant 3rd: Current Use of the EXCOR Pediatric Ventricular Assist Device

[2] Artif Organs. 2010 Dec;34(12):1082-6: Humpl et al: The Berlin Heart EXCOR Pediatrics-The SickKids Experience 2004-2008

[3] Ann Thorac Surg. 2005 Jan;79(1):53-60; discussion 61: Groetzner et al: Cardiac transplantation in pediatric patients: fifteen-year experience of a single center

[4] J Heart Lung Transplant. 2009 Apr;28(4):399-401. Irving et al: Successful bridge to transplant with the Berlin Heart after cavopulmonary shunt

[5] Am Heart J. 2011 Sep;162(3):425-35.Almond et al: Berlin Heart EXCOR Pediatric ventricular assist device Investigational Device Exemption study: study design and rationale

[6] J Thorac Cardiovasc Surg. 2011 Mar;141(3):616-23, 623: Hetzer et al: Single center experience with treatment of cardiogenic shock in children by pediatric ventricular assist devices

[7] Artif Organs 2012 Jul;36(7):635-9: Sharma et al: Ventricular assist device support in children and adolescents with heart failure: the Children’s Medical Center of Dallas experience


All Marc’s PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or AndroidA list of contributors can be seen here.

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About Marc Anders

AvatarMarc Anders is a paediatric intensivist.

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Author: Marc Anders Marc Anders is a paediatric intensivist.

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