Approach to the LVAD Patient: Part 1


    Approach to the LVAD Patient: Part 1

    LVAD management is an appropriate topic for a fellowship; not necessarily a TR pearl. But, resuscitating the sick LVAD patient is firmly within our scope of practice, and requires some basic knowledge of LVAD physiology.

    Enter rough sketch of a patient with an LVAD. Excuse my lack of artistic prowess:


    There are a number of variations between LVAD models. The basic idea is, however, conserved. Each LVAD has an inflow cannula in the LV apex, a pump, and an outflow cannula implanted into the ascending aorta. The HeartMateII is probably the most common LVAD we see, and has a “driveline” that goes out to a wearable controller/battery pack.

    Some patients with an LVAD have pulsatile blood flow, and some do not. This depends on a few patient-specific variables. For instance, many patients with significant aortic regurgitation have their aortic valves sewn closed to prevent a reentrant loop of bloodflow through the LVAD (blood goes into the aorta, and is sucked back into the inflow cannula). Patient with closed aortic valves do not have pulsatile flow. Patients with very poor native LV function may also not have pulsatile blood flow (or, at least, very narrow pulse pressures).

    The device will give you a set of numbers once on the monitor provided by the VAD team: power, flow, and pulsatility (“PI”). Pump speed is controlled by the operator; the other numbers are dependent variables. We’ll address these in a future pearl.

    Quick case:

    70M s/p HeartMate II implantation one month ago presents with 3 days of weakness. MAP recorded at triage is 50.

    What does this patient need:

    1. A blood pressure recording. There should be no delay in obtaining a MAP on an LVAD patient. But, because many patients do not have pulsatile blood flow, you can not get a reliable blood pressure reading from a non invasive blood pressure cuff. Instead, you need to use a manual blood pressure cuff with a doppler device over the brachial (or radial) artery. You simply release the pressure until you have flow, and obtain the patient’s MAP.
    2. Invasive blood pressure monitoring. Resuscitating an unstable patient with an LVAD requires an arterial line to obtain frequent, reliable MAP’s; have a low threshold to place one early.
    3. Rule out hemorrhagic shock. Patients with LVAD’s are uniformly anticoagulated, and are prone to GI bleeding (and spontaneous retroperitoneal bleeding). Rectal exam should be performed early. Point of care hematocrit may be useful.
    4. Evaluate for tamponade and acute RV dysfunction. These patients are at risk for tamponade. Place an echo probe on the chest early. RV dysfunction is common in patients with LVAD; the septum is pulled into the LV by the intake cannula, and becomes uninvolved in the RV’s contraction.
    5. Call the LVAD team. This should go without saying, and should happen in parallel with the above.


    Pratt, Alexandra K., Nimesh S. Shah, and Steven W. Boyce. “Left ventricular assist device management in the ICU.” Critical care medicine 42.1 (2014): 158-168.

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • renal handling of water

      If you were on a tea & toast diet, how much water would you need to drink before you develop hyponatremia? I haven’t seen anyone work out the numbers before so here are my calculations. AndRead more

    • acute acidemia physiology

      As alluded to in the first post, don’t be fooled by a “normal” potassium in the setting of DKA because osmotic diuresis and H+/K+ exchange means that total body potassium is actually LOW. You all knowRead more

    • renal handling of potassium

      the first symptom of hyperkalemia is death Earlier post covered temporizing measures to counter hyperkalemia — namely, intracellular shift, increasing cardiac myocyte threshold potential. Give furosemide if the patient still urinates and consider dialysis, but then askRead more

    • bicarbonate revisited

      Previous post reviewed the safety of balanced crystalloids in hyper K. But what was up with serum bicarbonate decreasing with saline administration? This post introduces a new way of looking at the anion gap to possiblyRead more

    • hyperkalemia and balanced crystalloids

      Is it safe to give LR or plasmalyte to a hyperkalemic patient (these balanced crystalloids have 4-5 mEq/L K as opposed to 0 mEq/L K in normal saline)? Postponing the discussion of renal handling of potassium toRead more

    • hyperkalemia physiology

      You’ll likely encounter hyperkalemia on your next Resus / Cardiac shift, and you’ll instinctively treat it. But take a moment to review the fascinating physiology behind the “cocktail”! First, consider how K+ is buffered byRead more

    • Slow down your tachycardia (but not really)

      You’re sitting in resus bemoaning the departure of your most beloved attending when suddenly a patient wheels in without warning. The patient looks relatively stable but the triage RN tells you her heart rate wasRead more

    • Otitis externa: use the ear wick!

      Acute otitis externa (AOE) is a common complaint seen in pediatric as well as adult emergency departments. AOE is typically not accompanied by acute otitis media, although concurrent cases are possible. Also called “swimmer’s ear”Read more