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Today, we're going to learn about LVAD!
Certain patients with CHF (NYHA III-IV) may qualify for a device called “LVAD” or Left Ventricular Assist Device”.  We had a presentation by Dr. Paul Saunders to tell us more about it as we have several LVAD patients here.  If you ever have an LVAD patient come to the ED, be sure to call 718-283-5CHF (Maimo Specific)
This is either a bridge to a heart transplant or in patients who are not candidates for transplant, a destination therapy.  People have lived for 10 years on this therapy.
It’s a pump that circulates the blood from the left ventricle to the aortic outflow tract with a rotor.  It has a battery that lasts for 10 hours and otherwise is plugged into the wall.
Because it’s a rotor and not really a pump in the traditional sense, you may not feel a pulse; this is normal.  For some patients you may feel a pulse as their heart still contracts strongly enough.
So…how do you get a blood pressure on someone who seems to have no pulse and just a whirring machine pumping their blood.
Get the Doppler and the Manual BP Cuff- the automated ones won’t work for this.
Inflate the cuff and hold the doppler to the brachial artery.  When you hear the doppler, that is your MAP.  This MAP may be 5-10mmHg higher than the one you would obtain with an arterial line (ideal).
TARGET MAP IS 70-90mmHg.
Depending on what the patient is there for, you can also get labs including coagulation factors.  ALWAYS get an EKG (should be normal) and ALWAYS call the LVAD team.
Usual Presentations:
  • GI Bleed- actually get small bowel AVMs
  • Epistaxis
  • Fluid Overload
  • CVA, intracranial hemorrhage
  • Driveline infections
  • Hypovolemia
  • Arrhythmias
  • Cardiac arrest
If the patient is in cardiac arrest, you can still give ACLS medications.  However, at our institution we do not do CPR (There’s controversy over this, see the link at the end).  Whatever happens, DO NOT DISCONNECT THE PUMP.
If the patient is in V-fib, they may be still complete alert and appear to be fine or just tired.  It is okay to defillibrate the patient in conjunction with the LVAD team.
Of note, INR goals are usually 2.0-2.5 unless they have a propensity for bleeding.
  • Complications
    • Stroke- patient may have a thrombo-emobolism or alternatively a hemorrhagic stroke as they must be anti-coagulated, usually on Coumadin and aspirin.
    • Pump thrombosis
    • Epistaxis
    • Driveline infections
    • Other bleeding e.g. GI Bleed 2/2 anticoagulation
  • Acquired Von-Willebrand Disease
A final note- if the patient comes in with the pump disconnect, do NOT reconnect unless they know when it disconnected as it may have clotted.  CALL THE LVAD team.  The flow may move retrograde through the pump.
Major credit to Dr. Paul Saunders for the great presentation!