HFA of the ESC position paper on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider Part 3: at the hospital and discharge

Abstract

The growing population of left ventricular assist device (LVAD)‐supported patients increases the probability of an LVAD‐ supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient‐device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD‐supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non‐cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end‐of‐life approaches are described.

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

“…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. 9 Hypotension (MAP less than 60 mm Hg) is associated with organ hypoperfusion and should be avoided.…”

“…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. 9 Hypotension (MAP less than 60 mm Hg) is associated with organ hypoperfusion and should be avoided. 9 The heart rate of patients with LVADs depends on native function or a permanent pacemaker.…”

“…12 Suction events are most commonly due to hypovolemia (hemorrhagic, diarrheal, and/ or vomiting-induced) but also can be due to RV failure, cardiac tamponade, high pump speed, or pulmonary hypertension. 9,12 Treatment varies based on cause, but generally includes fl uid administration, vasopressors, RV optimization, and temporarily reducing the LVAD speed based on consultation with an LVAD specialist until the underlying cause can be identifi ed. 9,12 As LV preload is increased, the alarm will resolve.…”

“…9,12 Treatment varies based on cause, but generally includes fl uid administration, vasopressors, RV optimization, and temporarily reducing the LVAD speed based on consultation with an LVAD specialist until the underlying cause can be identifi ed. 9,12 As LV preload is increased, the alarm will resolve.…”

“…If a pulse is not palpable, inflate a BP cuff in the standard location on the upper arm and use a pencil Doppler to listen for flow return over the brachial artery; the point at which flow 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 flow through the pump and decrease cardiac output, worsening heart failure 9.…”