CARDIOMYOPATHY

&
LVAD

Presenter: Ms Elby John

 INTRODUCTION

• Group of diseases that primarily affect the heart

muscle
• Not the result of congenital, acquired valvular,
hypertensive, coronary arterial, or pericardial
abnormalities.
• Incidence: 50,000
• Deaths: 27,260
 TYPES
• PRIMARY
– Disease of the myocardium with unknown cause.
– Familial

• SECONDARY
– Disease of the myocardium of known cause/ associated
with systemic disease
 CAUSES
• Infective • Connective tissue
– Viral disorders
– Bacterial – Systemic lupus
erythematosus
– Fungal
– Polyarteritis nodosa
– Protozoal
– Rheumatoid arthritis
– Metazoal – Progressive systemic sclerosis
– Spirochetal – Dermatomyositis
– Rickettsial
• Familial storage disease • Infiltrations and
– Glycogen storage disease granulomas
– Mucopolysaccharidoses – Amyloidosis
(Hurler syndrome) – Sarcoidosis
– Hemochromatosis – Malignancy
– Fabry's disease
 Contd…
• Muscular dystrophy
• Toxic reactions
– Alcohol
– Radiation
– Drugs
• Peripartum heart disease
 Clinical Classification of
Cardiomyopathies
• Dilated: Left and/or right ventricular enlargement

• Restrictive: Endomyocardial scarring or myocardial

infiltration

• Hypertrophic: Disproportionate left ventricular

hypertrophy, typically involving septum more than free
wall
 Dilated cardiomyopathy
• Clinically apparent in the 3rd or 4th decade
• Familial or due to infectious or toxic agents
• Reversible form -alcohol abuse, pregnancy,
cocaine use and chronic uncontrolled
tachycardia.
• Genetic mutations
 Clinical Features
• Tachycardia
• Ventricular dysrhythmias
• Clot formation systemic emboli
• Syncope
• Narrow pulse pressure, raised JVP
• CX Ray - enlargement of the cardiac silhouette due to LV
dilatation, pulmonary edema
• ECG - sinus tachycardia /atrial fibrillation/ ventricular
arrhythmias, low voltage, intraventricular and AV conduction
defects
• Echocardiography – LV dilation with thin walls, systolic
dysfunction, hypokinetic heart
• Transvenous endomyocardial biopsy
 Treatment

• Inotropic agents
• Nitroglycerine
• Diuretics & sodium restricted diets
• Anticoagulants
• Avoid – alcohol, Ca channel blockers, NSAIDS,
Antiarrhythmics
 Treatment

• Implantable cardioverter defibrillator (ICD)

• Biventricular pacing (Cardiac
Resynchronization Therapy)
• Cardiac transplantation
• LVAD
• Stem cell transplantation
 DRUGS

– Doxorubicin(Adriamycin)
– Trastuzumab (Herceptin)
– High-dose cyclophosphamide
– Imatinib mesylate
 Hypertrophic Cardiomyopathy

• Disproportionate LV hypertrophy, often with

hypertrophy of the interventricular septum more
than the free wall.
• Dynamic LV outflow tract pressure gradient

• Diastolic dysfunction

• Positive family history

 Clinical Features
• Commonly manifest in late adolescence or early
adulthood.
• Usually have relatives with known disease
• First clinical manifestation may be SCD
• Symptomatic
– Dyspnea
– Diastolic ventricular dysfunction impairs ventricular
filling elevated LV diastolic, left atrial, and pulmonary
capillary pressures.
– Syncope, angina pectoris and fatigue
Physical examination
• Fourth heart sound(S4)
• Hallmark of obstructive HCM - systolic murmur
– due to the mitral regurgitation that usually
accompanies obstructive HCM
• ECG
– LV hypertrophy and widespread deep, broad Q
waves
• Arrhythmias
 Contd…
• Echocardiogram

– LV hypertrophy
– Septal thickening
– Ground glass appearance of septum
– SAM of the mitral valve, with mitral regurgitation
– LV cavity typically is small
 Treatment
• Strenuous activities should be proscribed
• β adrenergic blocking agents
• Calcium channel blockers
• Avoid
– Drugs that decrease preload (nitrates, diuretics,
morphine)
– Drugs that increase contractility (β agonists, digitalis,
dopamine)
– Alcohol
• Atrial fibrillation
– Anticoagulants
 Contd…
• Surgical myotomy/myectomy of the hypertrophied
septum

• Alcohol septal ablation

• ICD (Implantable Cardioverter Defibrillator)

• Endocarditis prophylaxis
 Restrictive Cardiomyopathy
• Abnormal diastolic function
• Most common cause - Amyloidosis
– Hemochromatosis
– Glycogen deposition
– Endomyocardial fibrosis
– Sarcoidosis
– Hypereosinophilic disease
– Scleroderma
– Following mediastinal irradiation
– Neoplastic infiltration
 Clinical Features
• Exercise intolerance and dyspnea
• Dependent edema, ascites, and an enlarged,
tender, and often pulsatile liver.
• Raised JVP
• Kussmaul's sign
• S3 & S4 heard
 Treatment
• Aimed at diminishing heart failure

• Chronic anticoagulation

• Excision of fibrotic endocardium

 Cardiac transplantation
• Orthotopic procedure

• Heterotopic procedure
LEFT VENTRICULAR ASSISTIVE
DEVICE(LVAD)
 DEFINITION
•The left ventricular assistive device(LVAD) is a mechanical
pump that is implanted inside the person chest to help a
weakened heart ventricle to pump blood throughout the
body. It is implanted under the skin .
•It helps to pump blood from the left ventricle of the
HEART to rest of the body .
•A control unit and battery pack are worn outside the body
and are connected to the LVAD through the skin.
•Unlike a total artificial heart ,LVAD does not replace the
heart .
 INDICATIONS OF LVAD
• Dilated Cardiomyopathy
• Transplant client who are in danger of dying before a
donor heart is available
• Heart failure does not responsive to standard
Cardiac treatments.
• Heart failure following various forms of heart surgery
• End stage heart failure
• Improvement of survival rate and better quality of life
 RISK FACTORS WITH LVAD

•BLOOD CLOTS:

•BLEEDING:

•INFECTION:

•DEVICE MALFUNCTION:

•RIGHT HEART FAILURE:

 PREPRATION
Before the LVAD is implanted its likely that the patient will stay
in the hospital for preparation of surgery . They may need test
or procedures before the surgery including .
• ECHOCARDIOGRAM:To determine the pumping function of
heart, checkout the function of valves
• CHEST XRAY:To see the size and shape of the heart and
lungs
• BLOOD TESTS:
• ELECTROCARDIOGRAM: Checkout the heart rhythm before
the surgery
• CARDIAC CATHETERIZATION: Reveals the pressure in
heart and arteries..
 PROCEDURE
• The procedure to implant the LVAD is an a open heart
surgery that usually take for four to six hours.
• The patient will be sedated during the procedure.
Connected to a ventilator during surgery .
• A small incision will be made at the center of the chest and
the chest bone(sternum)is separated and the ribcage is
opened for the surgery .
• Heart is stopped during the surgery and will be connected
to a heart lung bypass machine which keeps oxygenated
blood flowing to the body during surgery.
• Once the VAD is implanted and working properly will
takeout of the bypass machine and the VAD can begin
pumping blood flow to the heart.
 AFTER THE PROCEDURE
• After the operation patient was shifted to ICU for
further critical care management.
• The patient will be fed with fluids and medication
through the IV line. And a urinary catheter will be in
place for to drain out the urine.
• And the chest tubes are placed to drain fluid and
blood.
• Patient lungs are not immediate work after the
surgery so the patient connect the ventilator for few
day.
• After few days the patients is shifted to regular room.
 NURSING MANAGEMENTS
• Monitor cardiac output and hemodynamic status
• Perform range of motion exercise to maintain
muscle strength and joint flexibility
• Monitor airway sounds and suction or assist the
client to deep breath and cough
• Monitor anti coagulation especially during weaning.
• Monitor specific device related problems.
• Infection: Especially pneumonia related to
immobility

• Bleeding: From anticoagulant use

• Right Side Heart Failure

• Thromboembolism

• Device malfunction
 Nursing management
Decreased cardiac output related to heart failure or
dysrhythmias secondary to cardiomyopathy
• Assess BP for hypotension & respiratory rate for tachypnea
• Assess HR & rhythm for tachycardia.
• Document the rhythm strips & if dysrhythmias occur, note the
changes
• Auscultate heart for changes in heart sounds
• Monitor lung sounds for crackles and presence of coughing
• Monitor intake and output regularly
• Assess for change in mental status
 Contd…
• Assess peripheral pulse for strength and quality
• Administer prescribed medications and evaluate
responses
• Encourage physical and psychological rest
• Encourage clients to eat small meals and rest
afterwards
Excess fluid volume related to decreased cardiac
output, GFR, increased aldosterone and sodium and
water retention.
• Monitor intake and output every 4 hrly
• Weigh patients daily
• Assess for the presence of peripheral edema
• Assess for jugular vein distension, hepatomegaly and
abdominal pain
• Follow low sodium diet and fluid restriction
• Auscultate breath sounds 2 hrly for the presence of
crackles and monitor for sputum production
• Administer diuretics as ordered and evaluate
effectiveness
Impaired gas exchange related to fluid in the
alveoli
• Auscultate breath sounds 2 hrly
• Encourage client to turn, cough and deep breath ;use incentive
spirometer 2 hrly
• Administer oxygen as ordered
• Assess respiratory rate and rhythm
• Assess for cyanosis 2 – 4 hrly
• Provide fowler’s position to facilitate breathing and observe for PND
• Monitor pulse oximetry
• Obtain ABG if ordered
• Administer diuretics as ordered
Angina related to decreased cardiac output and
coronary perfusion secondary to heart failure in
cardiomopathy
• Assess for the manifestations of angina
• Assess respirations, BP, & HR with each episode of chest pain
• Obtain a 12 lead ECG each time chest pain recurs
• Administer nitrates, monitor response, notify if pain does not
abate in 15 – 20 min
• Provide care in a calm environment that minimizes anxiety
• Instruct patient to avoid physical exertion if pain occurs
• Stay with patient until discomfort is relieved.
Ineffective tissue perfusion related to
decreased cardiac output
• Note color and temperature of skin 4 hrly
• Monitor peripheral pulses
• Provide a warm environment
• Encourage active range of motion exercises
• Monitor urine output
• Protect skin from trauma
Risk of sudden cardiac death related to profound
reduction in cardiac output and dysrhythmias
secondary to HCM

• Avoid physical exertion, competitive sports and very

strenuous activities
• Administer β blockers and calcium channel blockers
• Avoid diuretics, digitalis, nitrates,, vasodilators, and β -
adrenergic agonists
• Insertion of an ICD should be considered in patients with
a high-risk profile for SCD
Risk for activity intolerance related to
decreased cardiac output

• Space nursing activities

• Schedule rest periods
• Monitor client’s response to activities
• Increase activity as tolerated
• Instruct client to avoid activities that increase cardiac
workload
Anxiety related to decreased cardiac output, dyspnea,
diagnosis of cardiomyopathy and fear of death

• Provide a calm environment

• Encourage client to ask questions, clear doubts and
vent out their fears
• Explain all procedures and routine regimens
• Provide emotional support to patient and family
member
• Encourage additional support systems if available.
 SUMMARY
• Definition
• Types
• Causes
• Clinical classification
• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathy
• Cardiac transplantation
• LVAD and its care
• Nursing management
 references
• Harrison's principles of Internal Medicine , Fauci,
Braunwald, Kasper, Hauser, Longo, Jameson:The
McGraw-Hill Companies, 17th edition, Chapter 231
• Medical Surgical Nursing, Black JM, Hawks JH;7th
edition, volume II
• http://en.wikipedia.org/wiki
• http://www.wrongdiagnosis.com