LVAD Poutpourri

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    LVAD Poutpourri

    This is the last segment of the LVAD-oriented series of pearls. There are a number of LVAD-related complications to be aware of.

    Disclaimer: I am an emergency medicine resident, not a heart failure fellow. This is my synthesis of a potpourri of LVAD-related complications and emergent management options.

    Power shortage:

    Make sure the pump has enough battery life. This information is available on the controller.

    Pump thrombosis:

    Patients with LVAD’s can have clots inside the pump, and anywhere else with low flows (aortic valve, left ventricle). To prevent these complications, patients are anticoagulated (target INR 1.5-2.5) and placed on aspirin. Despite anticoagulation, 8-10% of people with LVAD’s ultimately have ischemic strokes. High power (pump is working harder to produce set speed), or changes in PI can clue  you in to the possibility of pump thrombosis. Hemolysis increases with pump thrombosis, and relevant laboratory studies should be sent when you are concerned about this diagnosis (LDH, haptoglobin, bilirubin). Management often involves anticoagulation with heparin; thrombolysis and emergent device exchange are options for refractory cases. Ultimately, discuss management with your LVAD team.

    Infection:

    After cardiac failure, infection is the second most common cause of death in patients with LVAD’s. The driveline (line that travels out of the body to the controller) and pump pocket are commons sites of infection. Gram positive organisms are the most common culprits of infection, though Pseudomonas aeruginosa is a gram negative pathogen of concern in this patient popultation. Initiating broad spectrum antibiotics is appropriate until culture data is available. CT can be useful in assessing for collection.

    GI bleeding: 

    GI bleeds are common in this population. Rectal exam early in the unstable patient. Hold anticoagulation. Tread lightly when considering actively reversing anticoagulation; discuss options with specialists early.

    Arrhythmia:

    Patients with LVAD’s are prone to arrythmias, and can appear reasonably stable (e.g. awake, talking, vfib). ECG early. Address the situation.

    Tamponade:

    Patients with LVAD’s are anticoagulated and have a holes in their hearts; they are prone to pericardial bleeding. Place a probe on the chest early.

    RV failure: 

    The septum is sucked into the LV (literally) and has less of a role in RV contractility. RV failure is relatively common in patients with LVAD’s, and is complicated to manage. Inotropes and pulmonary vasodilators may have a role. Pump speed can be adjusted. Again, management decisions should be made with the LVAD team involved.

    Suction events:

    The walls of the LV can get sucked into the inflow cannula, and the chamber can collapse. PI and flow will both decrease, and the device should alarm. This is generally addressed by the device decreasing its speed without operator input in order to try to release the wall. Hypovolemia puts a patient at risk for suction events – bolus fluids if this is a recurring problem

    References: 

    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.

    Slaughter, Mark S., et al. “Clinical management of continuous-flow left ventricular assist devices in advanced heart failure.” The Journal of Heart and Lung Transplantation 29.4 (2010): S1-S39.

     

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