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you know long wait times and decreased availability of donors has led doctors to seek new methods to support a failing heart here to discuss something called ventricular assist device or vads we have joseph shukis
is a patient living with a ventriclar assist device vad doctor george batsides who is a chief of cardac surgery at rwj university hospital audrey kleet is a vad coordinator
at morristown medical center and finally sharon holman is a senior occupational therapist at kessler institute for rehabilitation i want to thank all of you for joining us this is interesting
other than the fact that ventricular assist device is a hard thing to say doctor it is huge important and groundbreaking no? absolutely these devices are mechanical circulatory support systems that help support patients
with failing hearts you know we - in the united states i think there's about 2000 transplants done a year 2000? 2000 a year 2200 roughly worldwide it's about 5,000 so there's probably about 100,000 patients in the us alone
that could benefit from a device like this part of it is getting the word out these patients have failing hearts for a multitude of reasons whether it's mi's heart attacks whether it's idiopathic we don't know the cause or viruses
these patients present what we call class three or class four heart failure like mister shukis he said he was kinda doing his living his life canoeing or kayaking and riding his bike and maybe he would you know get into these coughing fits and spells
he couldn't breathe and over i guess about the next year he started having shortness of breath more and more frequently he was admitted for a chf congestive heart failure when you get to that situation and we do an ultrasound of the
heart and see if the heart is failing the function's down less than 30 percent or so medications work to some degree but after that either the patient can listed for a transplant where they truly have a failing heart or we can implant one of these
devices to support his circulation so joe - it's intersting joe he's 76 years of age right 76 years old 76 years you look fabulous [laughter] um you had a heart attack
yes 2012 you're working now you're taking care of yourself you're doing all the right things yeah traditional let's just say other than the vad the ventricular assist device
before that device before that it wasn't happening for you you were'nt getting the relief that you needed you weren't getting the help you needed how do you make the decision yes i'm going with this i'm gonna have this device if i can do this i know we have
some video team but doctor can you just let me have that um why don't... let... i'm gonna hold this up and as we talk about this as we come in bob morris our director as you shoot this this is inside you right now
yes it is the decision was made by you and your family along with your medical team yes to go with it why? uh well i did some tests at robert wood johnson
on me i think it was a swan test mm hmm and one side of my heart was able to take that both sides of my heart i guess you know were failing? were failing right and i thought well you know
what is my alternative? what was it? i wouldn't be here today if doctor bastides... you're pretty confident of that? he is right? yeah most of these patients when they get to the point
where they're hospitalized for recurrent bouts of chf... when they have... chf - congestive heart failure? when they have this weakened heart state again from heart attacks sometimes we see patients with viral myocarditis there's a host of things that
can cause it in his case it was prior mi prior heart attack myocardio...? myocardio influction ...influction right so once they have that and they come in there are some medicines we call them ianotropes
that can help the heart squeeze and we can send paients home and i believe we started him on some and they do help for some time but it's limited we can go up on the dosing eventually they can't help it anymore the quality of life i mean
here's the thing and we're about to show some video here you were taking care of yourself doing all the right things but you couldn't do the things i understand this you told our producers you couldn't do the things that you wanted to do?
okay now today you have this in you right? what are you able to do today? i'm able to do everything except bike that's the only thing i can't o at this point and kayaking? and kayaking
which you had done before? i have to stay out of the water okay and we'll talk about why the water in a moment do you walk a lot? yes i do you know weather permitting you drive? you shop? you live your life
i cook you cook? yeah i love to cook before that how much of that could you do? i could do a lot until i was about 70 i would say 69 70 years of age and you were a cyclist?
yeah i put a lot of miles on a lot of miles thousands of miles um paula our producer are we ready to show that video? why don't we take a look at the video that really brings this to life we'll come back and talk about it a little bit more
talk this through doctor for us so this is a picture of the heartmate ii it's implantable left we sow the device to the apex of the left ventricle and we... you sow it?
we sow it to the apex of the left ventricle and it is inserted... there's a little canulic it's inserted to the apex and the device the inside of the device is basically an impeller or a fancy screw that drives this it sucks the bloos through the
left ventricle and propels it to the aorta you see that graph sown to the large artery that leaves the heart the blood will then go to the aorta and feed the rest of the body all the organs so it's under the... okay now let's... i want to bring the
two of you in here this has got to be i'm thinking this through now for joe okay improved the quality of his life but aren't there other people involved that have to be helpful whether it's joe or anyone else who's living with
vad right? jump in when joe was first identified by his medical team he had to meet a group of multidisciplinary practitioners so surgeons and cardiologists and nurses nurse practitioners therapists physical therapists
occupational therapists nutritionists so he had to meet a whole team of people just to and that's why you're a vad coordinator? correct which i didn't think that title existed but go ahead oh absolutely
but it needs to exist? it needs to exist talk about that to support the patient and the caregiver along the continuum of their care from the time that they're first identified for this particular therapy
for example? give a concrete example as to what has to be coordinated for example when joe and his caregiver were first considering this therapy they needed to understand more about
living with the therapy and joe specifically what he needed to do for himself every day and his caregiver what he or she may need to do to help him every day with his therapy so intense amount of teaching needed to be done to help him and his caregiver realize this
you gotta break it down he's attached to this device he's attached to this device for he's attached to it the rest of his life and that being said it's more than just a bunch of pills every day he needs to take care of a piece of wire that comes out of his
skin called a driveline a driveline? to make sure that that is kept intact and able to support the device inside of him that's helping him to live so let me try this joe without being too intrusive i met your wife
on the way in she's very vocal she was telling me she's your biggest fan you know she is she'll give you a review of your performance after the show and i'm sure she'll give me a review of mines well is it too intrusive if i asked u
to open up the left side can we get this guys on camera? that's the controller that's the controller? so this controller is actually the brains of the operation there's two computers inside this particular controller that drive the device inside
tell it what to do and the only way this computer knows what to do is through a device that we have in the hospital but we set it up initiy in the operating room along with the surgeon and then tweak the device over time throughout the patient's
initial recovery and then do the continuum of their care he has to have this attached to him for the rest of his life? he has to have this for the rest of his life is joe controlling this? joe is not controlling this this little controller is
controlling the device inside of him it's set up by his health care team and where are the batteries? probably under his arms woah this bother you? no does not bother you?
it... the weight bothers me a little bit i'm not used to... a little bit heavier than norma? yeah i'm not used to the weight at this point so i'm still caning it a littlet as an occupational therapist i absolutely... yeah explain your role here
at kessler so i'm an occupational therapist as occupational therapy we look at anything and everything that you have to do every day so we can say that's a wide variety and it differs depending on the individual but we look at basic activities of daily living
so things from getting dressed and taking a shower all the way to more complex tasks like engaging in leisure activities or skills needed to return to work so for somebody with... who's come to us with a bag what we would look at is initially you
know that education and functional endurance being able to participate in those daily tasks while managing the components that joe just shows you those various components of the lvad one of the things that's very difficult at first and it takes
a lot of training... trained individuals who have just had this is being able to take a shower because like we just saw that's attached to him there's batteries those cannot get wet so there was at one point i believe there still is like a waterproof briefcase
if you will so you have to... yeah it's like a little briefcae yeah so we do a lot of training on that and you have to be able to have the dexterity to take the batteries out put them in that briefcase be able to zip everything up and put the lines where they're
supposed to be do you do it alone? does your wife help you? my wife helps me a little bit not enough? no no enough i just want to make sure cause you know are you complaining about that?
no not really the only thing i complain about is the weight of the batteries that's the only thing that's the thing? how much did you keep saying that john how much do they weigh? a couple pounds you know i'm trying to walk in
that snow and the ice out there oh yeah we're doing this show in the winter you know what i mean that's not easy it's not easy for the rest of us it must be harder for you right?
it is a little bit harder but the shower is an issue? it's not that bad i thought it was gonna be worse than it is but the bag fits up on a rack okay where the shampoo and
everything else goes and the wires come out and they can get wet in other words that... and what happens if they get wet? doc what happens if they get wet? nothing happens nothing?
as long as the batteries and the controller don't get wet you're smiling why are you smiling? the wires can get wet the issue is getting the site where the dryline exits the body that wire that
communicates with the device inside the issue is getting that wet jump back in doctor that's a little bit the achilles heel of the whole device here that area if it's... if there's trauma to him if he gets pulled a lot we've had very active
patients that they really pull on that because they're doing their daily activities and theye moving around and they don't pay attention to that for a while if that gets pulled a lot and there's trauma they can get infected i mean that's the big issue
we've been very fortunate our program to not have too many infections in that area but that's the one thing i'm very careful about that so let me ask you something how fortunate do you feel that you have had this
opportunity i don't want to say a second life but you say how fortunate? very what would you say to folks joe who say hey listen listen i'm not sure who's a candidate clinically or not doctor that's your world
but someone who said listen i've tried everything and i'm nt i don't want... we're not here o promote cause again i don't know who is and who's not but have you i mean if you don't want to talk about this joe i understand have you almost given up?
not quite close? yeah do you see that a lot doctor? yeah absolutely um you know it's a tradeoff and i'm just going from patient experiences um you know they tell me that their quality of
life is good with these it's a tradeoff they have the device they have the driveline the batteries tradeoff? tradeoff for where they were before but most of the patients if not all of them we put this device in they're very happy
that they made that decision how many? we in our program we place about 15 a year we have short term devices and intermediate length devices and these long term implantable devices woah woah woah explain that
again... three different vads? for three different types of patients with three different types of prognosis situations what? absolutely so the way i break it down is the short term vad is for the patient that comes in with full blown
cardiogenic shock from say a massive heart attack those patients are in shock they're a hypoprofused low flow state what's that? low flow state to the brain to their kidneys to all their organ systems
got it because the heart's not pumping properly so in those patients we currentl use three separate devices in our institution depending on the patient scenario and implant them as quickly as we can
now those patients those devices are used as a bridge basically a bridge to decisions what i like to think we implant them we see how the patient does do they recover? and what's the next step so... does it buy you time?
it buys the patient time and those patients sometimes then we will explant them because their heart just needs a few weeks to rest whether it's they get a stent to open up the coronary or we do some bypasses for the coronary or if it's the valve
sometimes it's due to valve pathology once we understand where we're going with the patient we can explant them we can transition them to a... explant means? taking them out and they go on their way we can take them list them for transplant
potentially in the acute setting it they're recoveredy fully and they and we think they can tolerate a transplant and they don't have many options you know joe's case here his right heart has to work for this device to work some patients
their right heart doesn't work because of the shock and what happens if that's the case? so if that's the case they stay in the hospital with the intermediate length vads where they can live a few months and they ambulate
they walk through the hospital they sit outside their bodies devices and it buys them time to get their transplant but joe has a destination vad right so that's the big difference so it's there that's it?
that's it and that's where we are at this point in ventricular assist therapy we have vads that we patients where we transition them into a we call them this destination vad where they get their machine placed and that's the remaining years
of their life how long will this vad last? so we currently have about i think 15 patients out in the community with destination vads our longest running is four years the company has about i think about 16,000 or 17,000 vads implanted
wow and their longest patient out is a little over eight years so they can last and the technology continues to change or let me ask you this we talk about the preparation i want you both to jump in cause you're on the
preparation angle and you're on the rehab...? rehab getting back home okay how do you actually prepare a patient and his or her family for what they're about to face when in fact they don't really know what that is until they actually
face it? one of the most helpful preparation options that utilize at our center is to pair a like patient and caregiver with a patient who is living on an lvad so in so say someone talks to joe
would he be helpful in that process? without a doubt talk about it so to go and talk to a patient and their caregiver that's considering this type of therapy there are options as doctor bastides
was laying out for patients even if that option is just comfort care something we call palliative care to be on these medicines for the rest of their life they do not necessarily need to choose a surgical option in getting the ventricular
assist device so one of the things we like to do to help them make an informed decision about this is bring another patient in who's been living on their vad and just facilitate a discussion between those two patients without any of us medical
professionals in the room that way they can be open and honest really understand what is this all about? that must be very powerful to answer a lot of questions and relieve some of the anxiety because the anxiety
often comes from the unknown i imagine even though everyone's experience is different um on the other end once it happens go ahead so the patient will typically come to you know if they're
not going home directly from the hospital they will come home to an inpatient rehab setting and it's really an interdisciplinary approach like we were speaking about before we work together with the patient and their family with everybody
by the way describe kessler we have a relationship with the kessler foundation okay yes which is tied to the institute but go ahead describe it it's an inpatient rehabilitation setting where a lot of patients come we have a variety
of different types of patients that come but we do have a cardiac program we accept lvad patients then we have a stroke program brain injury program all those got it but is there something unique about i guess there's something unique about every
patient dealing with whatever he or she is dealing with but i'm thinking about people and lvad by the way why is there not a vad and an lvad is it two different things? it's just a habit it's the left ventrical it's the left ventrical versus
the right one i just... that's my... [laughte] okay so the vad right? the ventricular assist device? is there something unique about the rehab process that those patients go through that we need to better understand?
i just hink it's very unique in that it's a life chang operation you know you have to be... the patient then has to be going home dealing with these this piece of equipment so it takes a lot of education a lot of education and different disciplines so
nursing from you know from nursing to all the different therapies to nutrition and working on your diets with a cardiac history why does that matter? to you know remain healthy why diet matter? to remain healthy and keep an
appropriate diet as you really? continue with your vad but does he have certain... excuse me for interrupting certain restrictions? well i tell my patients and he may recall that after surgery i give him the first
month eat whatever you want and that's the only time a doctor will... do one month right? [laughter] do one month [laughter] one to two months my point with that is just get some proteins and nourishment into their
body to heal their wounds so they need to just take in calories that you know barring if you have some diabetic issues you know you want to watch your sugars but really just taking calories and protein to supplement them so they can heal
at that point moving forward it's you know they're... it's up to the patient i think everyone knows what a heart healthy diet is to some degree i don't give him too many restrictions with this i say go out and live your life
you know go enjoy your life but you know you want to do it with moderation too um really it's important to remember that these are patients who are chronically living with heart failure they're in a chronic state of heart failure
so the c in congestive heart failure is not just for congestive it's also for chronic time out joe's not fixed? joe's not fixed he's what? this is a therapy to treat his
heart failure hold on but i'm looking at him and i'm thinking looks great presents really well he's in great... he looks like s in great shape physically but what? but his heart is not fixed as you said this is a therapy
to help him it's when medicines fail this is a surgicl therapy that we have to help joe and patients like him how do you see it joe? 75 to 80 percent of what i was and you were? i was up there you know as far as...
percent wise before if you feel 75 to 80 percent of what you were it's a hard thing to say i mean it's also... you were nowhere near that? no no i lost a lot and i lost a lot of weight you did?
yeah i lost my taste for food i couldn't taste coffee could not taste it it tasted like dish water you have any idea why? i have no idea why my doctor could... leading up to it not post surgery right
just leading up to it is the heart failure i mean we call it cardiac cachexia these patients just kinda... cardiac cachexia? cachexia... they just kinda waste i lost 70 pounds 70?
70 pounds yeah i went from 220 to 150 hmm what's your weight at now? cause you're not 220? 188 i was gonna say you like your weight where it is right now?
and you're... i'm just where i want to be and your... and you manage your diet well? oh yeah and going back to the family issue again i'm curious about this because it is... it does require family involvement
if a patient you know joe does have his wife and your other family members involved? no just my wife and i okay if someone doesn't kids are all gone you know i'm sorry they're elsewhere if someone does not have
a caregiver someone who's directly involved how much more challenging is that? a lot more challenging because part of the vad coordinator's role is to manage these patients along with the rest of the team over the time period
from when they're initially identified throughout their life on the device it makes them a much more riskier situation that they dont have somebody regularly to rely on outside the hospital and they... go ahead i was going to say we did have
an individual who was on his own so we were doing so much education so much training making sure he could you know change the batteries take them out let them charge overnight while he was sleeping and make sure he was
fully independent and there was actually an instance during one of the hurricanes where we were out of power temporarily at night in the middle of the night in that time before the generators kicked on he had you know
tremendous amount of fear but then his instincts kicked in and he was able to switch himself in essence the... back to battery power in the middle of the night in the darkness before the generators kicked back on and although that was a very
very scary event for him it kind of gave him a sense of that control that i got this i could do this even if i was at home just now by myself i had the instincts and you guys are giving me the training to be able to do it a few seconds left
reason to be hopeful? reason to be hopeful is this device has saved many lives um and it's giving them a good quality of life and these patients with failing hearts the future is very bright with these devices the next generation's right around the
corner they're even smaller hopefully we'll get to the point and i think it's very soon that we'll have a totally implantable device with cutaneous charging systems i appreciate all of you being here i wish you nothing but the best joe thank you very much
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