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

Ryan P. McKillip, MD; Anand Gopalsami, MD; Magdeline Montoya, MD; Gene Kim, MD; James J. Walter, MD; Colleen Juricek, MS; Eric Shappell, MD MHPE

Disclosures

Western J Emerg Med. 2018;19(6):907-911. 

In This Article

Results

Of the 349 patients with LVADs during the study period, there were 838 total encounters by 158 patients. Of these, 620 encounters made by 143 patients with LVADs (116 HeartMate II™, 27 HeartWare™) met inclusion criteria. The median number of encounters made by each patient was three (range 1–32, standard deviation [SD]=5.3). Patients were mostly male (109, 76.2%), with a median age of 60 (SD=13.2) at time of first encounter. Among the encounters, 431 (69.5%) resulted in admission, 187 (30.2%) resulted in discharge, one patient left against medical advice, and one left without being seen. Interrater agreement was 100% on primary categories and 90% when secondary categories were included. The most common category was bleeding, occurring 182 (29.4%) times. Of these, 104 (104/182, 57.1%) were GI bleeding, and 57 (57/182, 31.3%) were epistaxis. Average international normalized ratio (INR) for these patients was 2.3 (N=162, SD=1.5), compared to 2.1 (N=352, SD=1.0) in other encounters in which INR was measured (P=0.08). Other common categories included 127 (20.5%) infections, 68 (11.0%) heart failure exacerbations, 56 (9.0%) pain, 45 (7.3%) other, and 40 (6.5%) arrhythmias (Figure).

Figure.

Number of emergency department (ED) presentations by category from patients with left ventricular assist devices in a five-year period. Device-specific presentations are highlighted in black.
CHF, congestive heart failure.

No patients required cardiopulmonary resuscitation or died in the ED. Compared to other encounters, it was less common for bounce-back encounters to be device-specific (7/161 [4.3%] vs. 45/459[9.8%], P<0.01), and more common to be related to pain (25/161 [15.5%] vs. 31/459 [6.8%], P=0.02).

Device-specific Encounters

Fifty-two encounters (8.4%) were device-specific (Table). In the majority of these encounters, patients presented with abnormal device readings/alarms (37, 6.0% of all encounters). Patients with device-specific presentations were admitted 44 times, with seven discharges. One patient left against medical advice. Pump thrombosis occurred in 23 cases and presented with an abnormal device reading/alarm (10) or a non-specific complaint such as hematuria (6), dyspnea (3), abnormal lab value (3), or chest pain (1). Average initial INR in patients with pump thrombosis was 1.9 (N=18, SD=0.6) compared to 2.2 (N=496, SD=1.2) when measured in other encounters (P=0.17). Average lactate dehydrogenase in patients with pump thrombosis was 2142 (N=14, SD=989) compared to 451 (N=188, SD=347) when measured in other encounters (P<0.001). Interventions for device-specific presentations included anticoagulation regimen adjustment (16, 30.8%), pump exchange (9, 17.3%), hardware repair (6, 11.5%), and device settings adjustment (4, 7.7%).

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