Left Ventricular Assist Devices (LVADS) - a podcast by Scott D. Weingart, MD FCCM

LVAD Emergencies

These patients are super-complicated, luckily I got Zack Shinar, MD from Sharp Memorial in San Diego to try to wade through the morass.

All Situations



* Call the patient's VAD coordinator ASAP

* These patients may not have a palpable pulse. Listen over the heart to hear if the motor is working. Then use mental status, skin color/temp, and the machine flashing Low Flow as indicators that perfusion badness is occurring. Do a bedside echo. The MAP should be ~65 on manual doppler BP, Automated BP devices may give you a MAP as well. A-line MAP is the most accurate.

* Try not to cut or yank out the drive-line, 'cause that is embarrassing.



Poor Perfusion



* When in doubt, consider a fluid bolus. VADS love volume. If you need to improve hemodynamics with a working LVAD, consider preload augmentation and possibly afterload reduction (if MAP is high).

* Consider inotropes--if you think it is right heart failure, give dobutamine. If you think the patient is septic and has markedly reduced afterload, consider norepinephrine.





* On echo:

* Big RV, small LV=pulm hypertension or right heart strain/stemi. Correct hypoxemia and acidosis, consider volume, screen for RV STEMI, consider inotropes.

* Small RV-give volume

* Big RV & LV-pump failure or pump thrombosis.



Consider pump thrombosis--Signs of pump thrombosis are LVAD is hot, working hard, with high RPM, low flow, dilated RV/LV, and low MAP. Zack would give a bolus of 5000 U of Heparin in the decompensating LVAD that he thought was secondary to thrombosis (or if he just couldn't figure out what was wrong with a failing device). He would also consider tPA if he really thought it was pump thrombosis and the patient was decompensating and peri-code.



On ECHO, a dilated RV/LV could be from pump thrombosis or non-working pump (electrical issue for example).if you think that is the problem, heparinize.

Machine Not Running

Check batteries. Make sure all of the lines are connected.

Bleeding

These folks are prone to bleeding from the anticoag (and probably additional plt dysfunction from the device if I had to guess). So if they have altered mental status or neuro findings--consider hemorrhagic stroke.

Patient appears Infected

Drive-line infection-look at the site at entry to the skin. If the patient appears septic and you can't find a source, consider it a device infection until proven otherwise. Don't yank the device. Treat for health-care associated infection covering both hospital gram negatives and MRSA.

Patient is Coding

We need to AVOID CPR until the patient needs it and at point, what is the alternative? Can you rip out the device with CPR-yes! Many of the CT surgeons recommend not to do CPR, but you can't get deader than dead (I was not a philosophy major, so I could be wrong). Avoid CPR if at all possible, some of the 1st gen devices had hand-pumps you could use--the current generation don't. If you're the point where there is NOTHING else to do except CPR you need to use your clinical judgment.



Here is Zack's clinical judgment:

CPR is not recommended by the manufacturers secondary to potential cannula dislodgement.  I would not do CPR unless the pump was NOT working and the patient had lost their BP (MAP of 0).  This is the one scenario where you have to perfuse the brain no matter what the cost.  All other scenarios I would focus on how to get that pump operating better (at all).

Joe Bellezo then adds:

Just agreeing with Zack's thoughts on this. My approach to this is 'Look, Listen, and feel" - assuming a comatose LVAD patient.



Look: ...at all the connections. Everything connected? Ok. Look at the controller.

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