Heart Failure Association of the European Society of Cardiology position paper on the management of left ventricular assist device‐supported patients for the non‐left ventricular assist device specialist healthcare provider: Part 2: at the emergency department

Abstract

The improvement in left ventricular assist device (LVAD) technology and scarcity of donor hearts have increased dramatically the population of the LVAD-supported patients and the probability of those patients to present to the emergency department with expected and non-expected device-related and patient-device interaction complications. The ageing of the LVAD-supported patients, mainly those supported with the 'destination therapy' indication, increases the risk for those patients to suffer from other co-morbidities common in the older population. In this second part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, definitions and structured approach to the

Clinical considerations for the evaluation of patients with left ventricular assist devices

“…If a pulse is not palpable, infl ate a BP cuff in the standard location on the upper arm and use a pencil Doppler to listen for fl ow return over the brachial artery; the point at which fl ow returns will approximate the mean arterial pressure (MAP). 6,7 Optimal BP management (MAP of 70 to 90 mm Hg) is crucial in these patients because hypertension (MAP greater than 90 mm Hg) is associated with ischemic stroke, intracranial hemorrhage, pump thrombosis, aortic regurgitation, and ventricular dysrhythmias. 6,8,9 The LVAD is particularly sensitive to afterload, and a MAP greater than 90 mm Hg will reduce fl ow through the pump and decrease cardiac output, worsening heart failure.…”

“…• Hold anticoagulation and consider the need for anticoagulation reversal. 7,8,12,20 Anticoagulation reversal should be made in conjunction with a cardiologist experienced in treating patients with heart failure, because of potential adverse outcomes such as device thrombosis. 7 • Consider fl uid resuscitation.…”

“…7,8,12,20 Anticoagulation reversal should be made in conjunction with a cardiologist experienced in treating patients with heart failure, because of potential adverse outcomes such as device thrombosis. 7 • Consider fl uid resuscitation. 20 • Assess for the necessity of transfusion (while considering the potential for antibody sensitization in patients considered for heart transplant).…”

“…8 • Depending on the location of the bleeding, different specialists may need to be consulted. 7 • If bleeding is from a GI source, consider adding a proton pump inhibitor. 12,20 Data are limited on the effectiveness of octreotide in patients with LVADs and bleeding.…”

“…Pump thrombosis is a dreaded complication of LVADs, occurring in 2% to 13% of adults; however, it is almost nonexistent in newer LVADs unless ingestion of material occurs in the device. 7 Risk factors include improper anticoagulation, AF, hypercoagulable states, and infection. 10,11 Thrombi may form in areas of low fl ow such as in the atrium, a dilated LV, on the aortic valve, and in the pump and/or cannulas.…”