Managing the Patient with an LVAD

Nov 11

By William Caputo, MD

Why it matters

Few presentations are as intimidating as a patient with a left ventricular assist device (LVAD), especially one who is unresponsive or whose device is alarming. Calling the LVAD center and arranging emergent transfer is necessary, but it is not a management plan on its own. The emergency physician has to assess perfusion and begin resuscitation at the bedside.

What an LVAD does

The LVAD uses a motor to take over most of the forward output (effectively the "ejection fraction") of the failing left ventricle.

Indications

Bridge to transplant
Destination therapy
Bridge to recovery (for example, cardiomyopathy)

**Figure 1.** LVAD components: pump, inflow cannula, outflow graft, driveline, controller, and batteries.

Assessing perfusion

Because flow is largely continuous, standard pulse and blood pressure assessment can be unreliable. Assess perfusion with:

Capillary refill
Skin color
Doppler mean arterial pressure (MAP)
Urine output
Mentation

Doppler MAP

Use a Doppler (manual cuff with Doppler probe) to obtain a Doppler MAP. It is the most reliable non-invasive measure of perfusion in LVAD patients.
Normal LVAD MAP: 70–90 mmHg. A MAP below 65 mmHg is hypotensive.
When in doubt, place an arterial line.

ED work-up, LVAD emergencies, and cardiac arrest

The figures below and the linked PDF cover the ED work-up, common LVAD emergencies, and an LVAD cardiac arrest algorithm.

**Figure 3.** ED work-up of the LVAD patient: labs, imaging, and ECG.

**Figure 4.** LVAD emergencies and cardiac arrest in a patient with an LVAD.

**Figure 5.** LVAD cardiac arrest algorithm.

Clinical pearls

Caputo pearl: Doppler MAP is your vital sign. Get it early, and place an arterial line if the reading is uncertain.
Assess the whole patient (mentation, skin, capillary refill, urine output), not only the device.
Contact the patient's LVAD center early, but begin resuscitation without waiting for them.