Posted in Med Surg

A Left Ventricular Assist Device (LVAD) is a mechanical pump that is surgically inserted to assist the left ventricle in pumping blood to the body. The device is often used as a temporary measure for patients with severe heart failure while they await a heart transplant – often called “bridge-to-transplant therapy.” However, it can also be utilized long-term for individuals who are not able to have a heart transplant. In this case, it is referred to as “destination therapy.” In some patients (such as those with acute ischemic heart failure) heart function may improve enough over time to allow for LVAD weaning. 

How does an LVAD work?

For the purposes of simplicity, this article references the HeartMate3™, which is manufactured by Abbott. You can get a wealth of resources and information on their website.

The HeartMate3™ includes both internal and external components. The internal component is the LVAD itself. The inflow conduit of the LVAD is attached directly to the apex of the left ventricle, while the outflow conduit is attached to the ascending aorta. The device pumps blood from the left ventricle into the ascending aorta, thereby “assisting” the left ventricle and improving cardiac output. The HeartMate3™ can provide a flow rate of 2.5 to 10L/minute which is enough to meet the body’s demands.

The external components consist of a driveline that provides power to the LVAD, the rechargeable batteries and the controller. All of these items are worn by the patient at all times with a specially designed bag, a belt and vest combo, or a belt and neck-strap combo. The goal is to provide the patient with as much freedom of mobility as possible so they can resume their normal activities of daily living and enjoy improved quality of life.

The device is placed via a 4 to 8 hour surgical procedure that involves the patient being placed on cardiopulmonary bypass. After surgery, patients will be taken to a cardiovascular surgery ICU where they typically stay for about 4 to 5 days, assuming no complications occur. During this time, the patient is ideally weaned off any medications that have been utilized to maintain cardiac output and undergoes tests to measure heart function such as EKG and echocardiogram. Patients will begin working with physical therapy as soon as they are stable enough, often post-op day 1.

After the ICU, patients will be transferred to a step-down cardiac care unit where they typically stay for 14-21 days.  During this time they will continue to increase mobility as tolerated and learn the vast amount of information that is needed for the care and maintenance of the device. 

What are some complications of having an LVAD?

Specific complications related to the LVAD itself are device malfunction or failure and the formation of thrombi which can lead to stroke. Some other associated complications are bleeding (including hemorrhagic stroke and GI bleeding), right ventricular failure, cardiac arrhythmias, and infection.

So now that you have some background on LVADs, let’s go through this topic using the Straight A Nursing LATTE method. Learn more about the Straight A Nursing LATTE method and grab the template to follow along here.

L: How does the patient LOOK?

Because the HeartMate3™ provides adequate cardiac output for most individuals, as long as it is functioning optimally the signs and symptoms of heart failure should be significantly decreased and can even be absent.

The patient will have a dressing in the abdominal area through which the driveline exits. This driveline will be anchored to the body a few inches from the insertion site to ensure it doesn’t become dislodged. 

The patient will be wearing their equipment (controller and two batteries) in some kind of specialized carrying device – this could be a bag, a holster with belt attachment or a holster vest.

  • Because of the anticoagulation necessary for all patients with an implanted device, this patient may bruise easily.
  • If there are signs of heart failure present, these can include generalized weakness, dyspnea, pulmonary edema and JVD. 

A: How do you ASSESS the patient with an LVAD?

Patients with an LVAD come into the hospital for reasons not at all related to their device or even their cardiac status, so you should know how to assess and care for them especially if you work in a cardiac unit, the ER or the PACU. General assessments for the patient with an LVAD involve monitoring the device, monitoring cardiac function, and measuring MAP.

  • Auscultate the heart – you should hear a humming sound.
  • Monitor EKG – patients with an LVAD will be on telemetry monitoring even if the reason for their hospitalization is not cardiac related.
  • Assess pulse, knowing that the radial pulse may be weak or even absent.
  • Obtain blood pressure reading using the palpation method (if a radial pulse is present) or a Doppler if there is no pulse present. To obtain a Doppler reading:
    • Listen at the brachial artery for arterial flow. It will not sound pulsatile, but will instead be a constant flowing sound.
    • Inflate a manual blood pressure cuff until the flowing sound goes away.
    • Slowly deflate the cuff as you listen for the return of arterial flow.
    • The point at which you hear arterial flow is the MAP (mean arterial pressure).
    • View demo video here
  • Make note of the device settings and flow rate – there most likely is a dedicated area on the flowsheet to chart this data.
  • Assess for adequate perfusion by assessing the patient’s mental status, capillary refill and skin signs.
  • Monitor for any cardiac arrhythmias, which are not uncommon in patients with an LVAD.

General monitoring for a patient with heart failure involves listening to heart and lungs, monitoring for edema, measuring daily weights, and getting a full set of VS. For more information about caring for patients with heart failure, check out Right-Sided vs Left-Sided Heart Failure: Episode 57.

T: What TESTS will be ordered for a patient with an LVAD?

Tests utilized after LVAD implantation will be aimed at monitoring heart function and for signs of complication, such as infection. These include

  • EKG – many patients with an LVAD have atrial or ventricular arrhythmias
  • Echocardiogram to assess cardiac function
  • CBC to monitor for infection
  • BMP to monitor and maintain electrolyte balance
  • BNP – will be elevated in heart failure
  • INR will be monitored in patients taking warfarin
  • PTT will be monitored in patients taking heparin

T: What TREATMENTS are provided for a patient with an LVAD?

Patients with an LVAD will likely be taking medication to help manage their heart failure as well as anticoagulation therapy. 

  • Diuretics to maintain fluid balance – a common one is furosemide.
  • Beta-Blockers such as metoprolol or propranolol keep the heart from beating too fast, which reduces its workload. Beta blockers have an added benefit of blocking the heart’s response to stress hormones which can contribute to heart dysfunction.
  • ACE inhibitors block hormones that cause vasoconstriction, easing the workload on the heart.
  • Angiotensin receptor blockers (ARBs) also work to dilate vessels, making it easier for the heart to pump effectively.
  • Digoxin makes the heart beat more slowly while increasing the force of contractions to improve cardiac output.
  • Aldosterone blockers (ex: spironolactone) help the body maintain sodium and fluid balance.
  • Anticoagulant medications include warfarin, heparin and aspirin and are used to prevent thrombotic events. The patient could alternatively be using a direct-acting oral anticoagulant (DOAC) such as apixaban.
  • Phosphodiesterase inhibitors decrease pulmonary hypertension, which reduces workload on the right side of the heart.

After implantation surgery, your patient will also receive physical therapy as their heart failure has likely led to significant physical deconditioning. The goal is to increase activity level and gain as much independence and mobility as possible.

If an LVAD patient becomes unresponsive, follow your facility’s protocols for this emergency. Common protocols include the following:

  • Check for secure connections and adequate power. If the device becomes disconnected, alarms will sound. 
  • If the LVAD is not functioning and cannot be started, follow ACLS protocols and call the VAD coordinator and get expert help there immediately. If you are caring for an LVAD patient and need immediate help, the CVICU is an excellent resource if your hospital has one.
  • If the LVAD has power but the patient still shows signs of poor perfusions, general protocol is to perform chest compressions and follow ACLS guidelines. Again, you will always follow your facility’s protocols. Call the VAD coordinator or get immediate expert help from the CVICU, RRT or a cardiologist.

E: How do you EDUCATE the patient/family with an LVAD?

There is a lot of patient education that occurs with LVAD implantation. Prior to discharge, you’ll want to be sure that the patient understands how to manage their device, how to respond to warning signals from the controller, how to change the power source, and how to care for the driveline site. Other key teachings include:

  • Monitoring at home involves tracking their blood pressure, temperature, weight and LVAD device data daily and to take these measurements at the same time every day.
  • How to change the driveline dressing – this is a sterile procedure.
  • How to take all medications and that some doses may be adjusted or new ones added.
  • How to recognize complications such as infection, bleeding and stroke.
  • How to follow bleeding precautions – use an electric razor, avoid activities that increase the risk of falling, avoid use of NSAIDS.
  • The importance of carrying a backup controller and fully-charged batteries.
  • Regular exercise is encouraged, but they will likely need to start slow and progress gently. Swimming and contact sports must be avoided.

There are many many more patient teaching guidelines. This website from UCSF has an excellent FAQ about living with a VAD.

TL;DR

  • An LVAD is pump that helps the heart pump blood out to the body
  • The patient will probably not have a palpable pulse
  • You’ll measure MAP instead of a systolic/diastolic BP and you’ll do this using a Doppler
  • The patient will be taking anticoagulants
  • The patient will have an external controller and a driveline that exits the abdomen and is anchored at a site distal to the dressing.

For more articles on cardiovascular nursing, check out the collection here.

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REFERENCES

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Chahine, J. (2021). Left Ventricular Failure. https://www.ncbi.nlm.nih.gov/books/NBK537098/

Chavey, W. E. (2000). The Importance of Beta Blockers in the Treatment of Heart Failure. American Family Physician, 62(11), 2453–2462.

Cleveland Clinic. (n.d.). Left Ventricular Assist Devices (LVAD). Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/17192-left-ventricular-assist-devices-mechanical-circulatory-support-mcs

Eisen, H. (2019). Left Ventricular Assist Devices (LVADS): History, Clinical Application and Complications. https://dx.doi.org/10.4070%2Fkcj.2019.0161

Griffin, R. M. (n.d.). Medications for Heart Failure. WebMD. https://www.webmd.com/heart-disease/heart-failure/features/turning-to-drugs-for-heart-failure

Guglin, M. (2020). Evaluation for Heart Transplantation and LVAD Implantation. Journal of the American College of Cardiology, 75(12), 1471–1487.

Gustafsson, F. (2017). Left ventricular assist device therapy in advanced heart failure: Patient selection and outcomes. European Journal of Heart Failure, 19, 595–601. https://doi.org/doi:10.1002/ejhf.779

Li, S., & Mahr, C. (2022). Anticoagulation in the HeartMate 3 left ventricular assist device: Are we finally moving the needle? ASAIO Journal, 68(3), 323–324. https://doi.org/10.1097/MAT.0000000000001689

Loforte, A., Bottio, T., Attisani, M., Suarez, S. M., Tarzia, V., Pocar, M., Botta, L., Gerosa, G., Rinaldi, M., & Pacini, D. (2021). Conventional and alternative sites for left ventricular assist device inflow and outflow cannula placement. Annals of Cardiothoracic Surgery, 10(2), 28188–28288. https://doi.org/10.21037/acs-2020-cfmcs-28

Long, B., Robertson, J., Koyfman, A., & Brady, W. (2019). Left ventricular assist devices and their complications: A review for emergency clinicians. The American Journal of Emergency Medicine, 37(8), 1562–1570. https://doi.org/10.1016/j.ajem.2019.04.050

Loyaga-Rendon, R. Y., Kazui, T., & Acharya, D. (2021). Antiplatelet and anticoagulation strategies for left ventricular assist devices. Annals of Translational Medicine, 9(6), 521. https://doi.org/10.21037/atm-20-4849

MyLVAD. (n.d.). LVAD Medications | MyLVAD. https://www.mylvad.com/patients-caregivers/lvad-lifestyle/living-lvad/lvad-medications

Rezale, S. (2014, May 29). Left Ventricular Assist Device. REBEL EM – Emergency Medicine Blog. https://rebelem.com/left-ventricular-assist-device/

Stanford Health Care. (n.d.-a). Left Ventricular Assist Device (LVAD). Stanford Health Care. https://stanfordhealthcare.org/medical-treatments/l/lvad.html

Stanford Health Care. (n.d.-b). Recovery. https://stanfordhealthcare.org/medical-treatments/l/lvad/what-to-expect/recovery.html

Trivitt, R. (2020, January 22). Recovery Unit LVAD Training: Implantable Ventricular Assist Device.

University of California San Francisco. (n.d.). FAQ: Living with a Ventricular Assist Device (VAD). Ucsfhealth.Org. https://www.ucsfhealth.org/Education/FAQ Living with a Ventricular Assist Device