Left Ventricular Assist Device Management in the Emergency Department

Paul Trinquero, MD; Andrew Pirotte, MD; Lauren P. Gallagher, MD, MA; Kimberly M. Iwaki, MD; Christopher Beach, MD; Jane E. Wilcox, MD

Disclosures

Western J Emerg Med. 2018;19(5):834-841. 

In This Article

Abstract and Introduction

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.

Introduction

Heart failure (HF) produces a significant disease burden in the United States, with over 5.1 million Americans suffering from HF and over $32 billion expended annually. Although survival from HF has improved, the mortality rate at five years is 50%.[1,2] Ventricular assist devices (VAD) have improved survival in patients with advanced HF.[3] Over 22,000 patients with advanced HF have received VADs in the last decade, and implantation rates are expected to increase with newer generation devices.[3] VADs may be used as "destination" (e.g. permanent) therapy or as a "bridge to transplant" (BTT). Patients implanted as "destination therapy" will remain on the VAD for the rest of their lives. BTT patients will remain on their VADs until they undergo heart transplantation.

Many patients with VADs are well informed about their devices and possess adequate VAD self-management skills. This includes contact information for VAD centers and instructions on obtaining assistance when needed. In addition, VAD patients are generally accompanied by a VAD-trained caregiver (e.g. family member). Despite precautionary measures, including close outpatient follow-up and detailed instructions on the device, the incidence of VAD patients presenting to the emergency department (ED) will likely increase due to rising rates of VAD implantation. Thus, emergency physicians must be proficient with the diagnoses and treatment of VAD-related emergencies and general management of VAD patients. Optimal treatment requires understanding of the associated anatomy and changes in cardiovascular physiology associated with VADs, and knowledge of the device itself. This article provides emergency physicians with an overview of the current U.S. Food and Drug Administration (FDA)-approved assist devices and provides a framework for patient assessment, including common VAD-related complications, device troubleshooting, and the management of the unstable VAD patient.

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