Analysis of Patients with Ventricular Assist Devices Presenting to an Urban Emergency Department

Abstract

IntroductionLeft ventricular assist device (LVAD) insertion is an increasingly common intervention for patients with advanced heart failure; however, published literature on the emergency department (ED) presentation of this population is limited. The objective of this study was to characterize ED presentations of patients with LVADs with a focus on device-specific complications to inform provider education and preparation initiatives.MethodsThis was a retrospective chart review of all patients with LVADs followed at an urban academic medical center presenting to the ED over a five-year period (July 1, 2009, to June 30, 2014). Two abstractors reviewed 45 randomly selected charts to standardize the abstraction process and establish a priori categories for reason for presentation to the ED. Remaining charts were then divided evenly for review by one of the two abstractors. Primary outcomes for this study were (1) frequency of and (2) reason for presentation to the ED by patients with LVADs.ResultsOf 349 patients with LVADs identified, 143 (41.0%) had ED encounters during the study period. There were 620 total ED encounters, (range 1 to 32 encounters per patient, median=3, standard deviation=5.3). Among the encounters, 431 (69.5%) resulted in admission. The most common reasons for presentation were bleeding (e.g., gastrointestinal, epistaxis) (182, 29.4%); infection (127, 20.5%); heart failure exacerbation (68, 11.0%); pain (56, 9.0%); other (45, 7.3%); and arrhythmias (40, 6.5%). Fifty-two encounters (8.4%) were device-specific; these patients frequently presented with abnormal device readings (37, 6.0%). Interventions for device-specific presentations included anticoagulation regimen adjustment (16/52, 30.8%), pump exchange (9, 17.3%), and hardware repair (6, 11.5%). Pump thrombosis occurred in 23 cases (3.7% of all encounters). No patients required cardiopulmonary resuscitation or died in the ED.ConclusionThis is the largest study known to the investigators to report the rate of ED presentations of patients with LVADs and provide analysis of device-specific presentations. In patients who do have device-specific ED presentations, pump thrombosis is a common diagnosis and can present without device alarms. Specialized LVAD education and preparation initiatives for ED providers should emphasize the recognition and management of the most common and critical conditions for this patient population, which have been identified in this study as bleeding, infection, heart failure, and pump thrombosis.

Patterns of emergency department utilization for LVAD patients compared with non-LVAD patients

“…Broadening this definition to include bleeding and stroke, known complications of continuous-flow LVADs, still accounts for fewer than 1 in 5 LVAD ED presentations. This pattern is similar to that described previously in the literature, and is likely a manifestation of 24-hour care provided by the LVAD team and coordinators at our center and many others, which can facilitate expedited direct admission to LVAD trained units for suspected device-related complications and malfunctions [3] , [4] , [5] . The overall admission rate from the ED in our study is similar to those of prior evaluations, suggesting that the overwhelming majority of LVAD presentations to the ED result in admission [5] , [6] .…”

Costs Associated with Recurrent Epistaxis in a Patient with a Ventricular Assist Device

“…1 Studies have demonstrated that the most common presenting complaint to the emergency department in a patient with a VAD is mucosal bleedingg. 2 While most otolaryngologists are aware of the frequency of epistaxis in this population, to our knowledge the cost of this complication has not been reported. In this case report, we document financial costs of epistaxis in a patient with a VAD over a 16-month period.…”

Targeted Evaluation of Patients With Left Ventricular Assist Devices and Shock or Hypotension

“…Bleeding is the most common reason for ED presentation among patients with left ventricular assist devices, and gastrointestinal bleeding, occurring in 15% to 30% of patients, is the most common source, followed by epistaxis. 17 These patients have several reasons for developing bleeding complications: they are often receiving aspirin and warfarin, the continuousflow state results in arteriovenous malformations, and the pump causes an acquired von Willebrand's disease. [18][19][20][21][22] Gastrointestinal bleeding occurs more…”

“…26,27 Among patients presenting to the ED with pump thrombosis, the average INR in one study was 1.9 compared with 2.2 in those without a thrombosis. 17 Although lactate dehydrogenase level can also be elevated in multiple processes, it can also raise suspicion for pump thrombosis because of the active hemolysis. 11 In the same ED study, 14 patients with pump thrombosis had an average lactate dehydrogenase level of 2,142 units per liter (U/L) compared with 158 patients without thrombosis, who had an average lactate dehydrogenase level of 451 U/L.…”

“…11 In the same ED study, 14 patients with pump thrombosis had an average lactate dehydrogenase level of 2,142 units per liter (U/L) compared with 158 patients without thrombosis, who had an average lactate dehydrogenase level of 451 U/L. 17 Last, electrolyte and acid-base derangements should be addressed to prevent dysrhythmia and optimize cardiac function.…”