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

Discussion

Specialized LVAD education and preparation initiatives for ED providers should focus on the most common and most critical presentations in this population. This study provides an evidentiary basis for such interventions by characterizing the frequency and nature of ED encounters for patients with LVADs. GI hemorrhage and epistaxis made bleeding the most common reason for presentation to the ED in our study, accounting for more than one in four visits. This is congruent with the results of previous studies.[6,7] Risk factors for bleeding in this population include anticoagulation, development of arteriovenous malformations, and acquired von Willebrand disease.[2] It is, therefore, extremely important that ED providers be familiar with the workup and management of bleeding complications in this population.

Infection was the second most common presentation category in our study, often presenting as bacteremia associated with a driveline infection. This is consistent with the known high risk of infection in this population, including the risk of sepsis developing in as many as 20% of patients within one year of device implantation.[1] Heart failure exacerbations ranked third in prevalence. The importance of familiarity with the management of these conditions in this population is underscored by the frequency of these presentations.

We identified device-specific presentations in 8.4% of ED visits. Although the majority of these encounters presented with an abnormal device reading/alarm, more than one in four had normal device readings. About half of the device-specific presentations were due to pump thrombosis. Thrombosis should be suspected in cases of abnormal device readings (e.g., increased power, increased calculated flow), worsening heart failure, and hemolysis, often in the setting of subtherapeutic anticoagulation.[8] Importantly, in our study, patients with pump thrombosis more often presented with a non-specific complaint than an abnormal device reading or alarm. Approximately one in 50 patients who presented with a non-specific complaint such as hematuria or dyspnea ultimately were diagnosed with pump thrombosis after admission for further testing. These data highlight the importance of vigilance in pursuing this diagnosis in patients with LVADs presenting to the ED.

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