Left Ventricular Assist Device Management in the Emergency Department

Abstract

The prevalence of patients living with a left ventricular assist device (LVAD) is rapidly increasing due to improvements in pump technology, limiting the adverse event profile, and to expanding device indications. To date, over 22,000 patients have been implanted with LVADs either as destination therapy or as a bridge to transplant. It is critical for emergency physicians to be knowledgeable of current ventricular assist devices (VAD), and to be able to troubleshoot associated complications and optimally treat patients with emergent pathology. Special consideration must be taken when managing patients with VADs including device inspection, alarm interpretation, and blood pressure measurement. The emergency physician should be prepared to evaluate these patients for cerebral vascular accidents, gastrointestinal bleeds, pump failure or thrombosis, right ventricular failure, and VAD driveline infections. Early communication with the VAD team and appropriate consultants is essential for emergent care for patients with VADs.

Inpatient Cardiac Rehabilitation of LVAD Patients—Updated Recommendations from the Working Group of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases

“…78 In a reanimation emergency, not only must heart-lung reanimation be performed immediately, it should also be ascertained whether or not the cause was a technical problem in the LVAD system which can be fixed quickly. 79,80 A quick way of testing the functional capacity of the LVAD is auscultation via the pump (humming), or by placing the hand over this area (vibrating). 78 For all systems, in an emergency the power supply (rechargeable batteries/ mains) and the connection from the controller to the patient (driveline) should immediately be checked, and if interrupted immediately be reconnected.…”

“…78 Further emergency measures can be found in the literature and should be taught in internal training sessions. 78,79,81 If sufficient emergency treatment of LVAD patients cannot be guaranteed by the rehabilitation clinic, for example, in a case of severe gastrointestinal bleeding, then a clearly defined emergency care chain must be established (evidence level 1c), 2 naming an appropriate and rapid-response intensive care unit. This emergency chain must be agreed to in advance with all contact partners (LVAD coordinators, intensive care unit, implanting center, ambulance, helicopter service, and manufacturer hotline) and be implementable around the clock.…”

Emergent General Surgery Operations in Patients With Left Ventricular Assist Devices

“…[1][2][3][4] This significant societal disease burden has a yearly health care expenditure of over $32 billion. [5][6][7] Over the past decade, left ventricle assist devices (LVADs) have become a viable option as either a bridge to heart transplantation or longterm alternative treatment (destination therapy). [8][9][10] Over 22 000 patients with advanced HF received an LVAD in the last decade, with implantation rates expected to increase as device technology advances.…”

“…[8][9][10] Over 22 000 patients with advanced HF received an LVAD in the last decade, with implantation rates expected to increase as device technology advances. 5,11 With the increasing prevalence of LVAD use, these patients are more likely to develop complications with the device itself but also from the fact that they are living longer with advanced HF and the need for anticoagulation. 8 Many of these complications, which are often related to bleeding, infection, or ischemia, develop outside the thoracic cavity requiring emergency general surgery (EGS) consultation.…”

“…8-10 Over 22 000 patients with advanced HF received an LVAD in the last decade, with implantation rates expected to increase as device technology advances. 5,11…”