End-stage left sided heart failure may be treated with implantation of a Left Ventricular Assist Device (LVAD). In the April 2019 EMRAP issue,  Haney Mallemat, MD and Anand Swaminathan, MD discuss how to handle patients who have an LVAD. The free podcast recording can be found here. The following is a summary of recommendations.

Blood pressure and pulse:

LVAD patients have no palpable pulse. The motor provides a continuous mean arterial pressure (MAP).
  • Checking a blood pressure requires a manual cuff and a doppler over the brachial artery. Only one sound will be heard.
  • Auscultating over the motor also confirms it is running.
  • Insertion of an arterial line can be helpful during a resuscitation to obtain an accurate MAP.
  • Goal MAP is 70-90.
    • MAP >90 may be harmful to the pump.
    • MAP <70 may be harmful to the patient.

Hypotension Differential (MAP<70):

  • Hemorrhagic shock
  • Hypovolemia
  • Right ventricular infarction
  • Sepsis
  • Pump thrombus (10% of patient will experience)

Alarms:

  • Check status lights to be sure device is on, and battery has some power left.
  • Push button next to display and scroll through the alarm notifications
    • Suction event: inflow has been occluded by ventricular wall. Device programming will try to help by reducing suction. Give fluids.
    • Low Battery: connect a new battery or if available, connect to wall power.
    • Driveline Disconnected: check cable from battery pack to patient’s skin.
    • LVAD Stopped

Treatment:

  • Resuscitate with fluids.
  • Check labs: CBC, Chemistry, PT/INR, Type and Screen, LDH+ Haptoglobin (to detect hemolysis).
  • Antibiotics, if infection suspected:
    • Look for common sources like pneumonia or UTI
    • Look for redness or drainage from the driveline insertion point at the skin.
    • Broad spectrum antibiotics are a good start as LVAD patients are frequently in the hospital. (MRSA, resistant pseudomonas, etc.)
    • Cover for GI bacteria if the pump is implanted in the abdomen.
  • Bedside US is very helpful
    • Assess IVC and RV size, may signal hypovolemia.
    • Assess for pump thrombus- RV dilation, thrombus in LV. Treat aggressively.
  • EKG: Patients can still experience ACS.
    • Treat STEMI, especially STEMI involving the RV.
    • Consult local cardiology and involve LVAD team early.
  • Cardioversion / Defibrillation
    • Does not hurt the pump.
    • If possible (location known), do not place pads directly over pump.
    • Treat VT/VF
    • Tachycardia from A. Fib may effect RV which is responsible for LV filling and priming the pump.
  • Blood products:
    • Give blood to minimum Hgb of 7
    • Give cross-matched blood if possible to reduce antibody exposure.
    • Control hemorrhage when possible.
  • Anticoagulation Reversal:
    • This is problematic for the pump.
    • Patient typically on coumadin + anti-platelet agent.
    • Patients have an acquired Von Willebrand factor deficiency because the molecule is large and is cleaved in the pump.
    • Patients also develop AV malformations throughout the GI tract.
    • Consult LVAD team to discuss INR and reversal goals.
  • CPR
    • Can be performed if you are sure pump is not functional.
    • Chest or abdominal compressions can be used. PubMed
Resources:

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