LVAD Part V: The Coding LVAD Patient

Left ventricular assist devices (LVADs) have moved from being a bridge to a heart transplant to destination therapy for patients with severe heart failure. Although their use in the general public has increased, they still provide a challenge to the emergency medicine (EM) physician. This series aims to cover the basics of how the EM physician approaches the care of these patients.

 

Some important numbers to consider:

• 5.7 million patients in the USA have heart failure, half of which will die within 5 years [1].
• LVAD use is expanding with over 22,000 being placed to date.
• With a presentation rate to the hospital of 3 per patient LVAD year [2,3].

The Coding LVAD Patient

Follow typical ACLS protocols in the coding LVAD patient but replace pulse checks with doppler MAP checks. Call for extracorporeal membrane oxygenation (ECMO) cannulation if available, and involve surgeons and the LVAD team as soon as possible. Chest compressions in one small study (n=8) did not increase the risk of device malfunction or displacement, although there is a theoretical risk. Device manufacturers generally write that compressions are contraindicated, although most experts recommend compressions if the alternative is death [3]. However, it is critical not to perform compressions unless absolutely sure the patient is not perfusing. Staff should be reminded not to expect a pulse. 

Defibrillation is applicable and useful as some arrhythmias will decrease flow through the heart and increase the risk of pump thrombosis.

With the exception of careful confirmation of no perfusion before starting compressions, normal ACLS can proceed as indicated. There is no LVAD-specific contraindication to intubation and mechanically ventilating. Another point regarding the coding LVAD patient is that care should be taken when moving the patient and removing clothing to avoid severing or kinking the driveline. Treat the driveline in these patients as you would the endotracheal tube in a patient with a difficult airway.

Conclusions

As LVADs become more common, the probability of caring for an LVAD patient continues to increase too, and physicians should be prepared. The devices are complex and require a team of surgeons, heart failure cardiologists and critical care specialists to manage these patients. It is recommended to always contact the patient’s LVAD center or manufacturer since they can provide greater insight into the potential problems that can occur with the devices. Never reverse anticoagulation without a multidisciplinary discussion with the LVAD team.

Did you miss our previous posts? Check out the LVAD introduction, LVAD diagnostic evaluation, LVAD Complications and Non Device Pathology.

For an on-the-spot clinical reference, use ALiEM’s Paucis Verbis card for LVAD complications.

References:

1. Heart Failure Factsheet. Division for Heart Disease and Stroke Prevention. Published June 16, 2016. Accessed June 11, 2018.
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3. Vierecke J, Schweiger M, Feldman D, et al. Emergency procedures for patients with a continuous flow left ventricular assist device. Emergency Medicine Journal. 2016;34(12): 831-841.  PMID 27852651
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10. Wasson LT, Yuzefpolskaya M, Wakabayashi M, et al. Hypertension: an unstudied potential risk factor for adverse outcomes during continuous flow ventricular assist device support. Heart Fail Rev 2015;20:317–22. PMID 25283767
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12. Stulak JM, Lee D, Haft JW, et al. Gastrointestinal bleeding and subsequent risk of thromboembolic events during support with a left ventricular assist device. J Heart Lung Transplant 2014;33:60-4. PMID 24021944
13. Lampert BC, Eckert C, Weaver S, et al. Blood pressure control in continuous flow left ventricular assist devices: efficacy and impact on adverse events. Ann Thorac Surg 2014;97:139-46. PMID 24075484
14. Bedi M, Kormos R, Winowich S, McNamara DM, Mathier MA, Murali S. Ventricular arrhythmias during left ventricular assist device support. Am J Cardiol 2007;99: 1151–3. PMID 17437746
15. Andersen M, Videbaek R, Boesgaard S, Sander K, Hansen PB, Gustafsson F. Incidence of ventricular arrhythmias in patients on long-term support with a continuous-flow assist device (HeartMate II). J Heart Lung Transplant 2009;28:733–5. PMID 19560703

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