JACC: HEART FAILURE VOL. -, NO.

-, 2017
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 2213-1779/$36.00

PUBLISHED BY ELSEVIER http://dx.doi.org/10.1016/j.jchf.2017.06.012

STATE-OF-THE-ART REVIEW

Medical Management of Patients With

a Left Ventricular Assist Device for
the Non-Left Ventricular Assist
Device Specialist
Adam D. DeVore, MD, MHS,a,b Priyesh A. Patel, MD,a Chetan B. Patel, MDa,b

ABSTRACT

More than 2,400 continuous-flow left ventricular assist devices (LVADs) are implanted each year in the United States alone.
Both the number of patients living with LVADs and the life expectancy of these patients are increasing. As a result,
patients with LVADs are increasingly encountered by non-LVAD specialists who do not have training in managing advanced
heart failure for general medical care, cardiovascular procedures, and other subspecialty care. An understanding of the
initial evaluation and management of patients with LVADs is now an essential skill for many health care providers. In this
State-of-the-Art Review, we discuss current LVAD technology, summarize our clinical experience with LVADs, and
review the current data for the medical management of patients living with LVADs. (J Am Coll Cardiol HF 2017;-:-–-)
© 2017 by the American College of Cardiology Foundation.

DURABLE LEFT VENTRICULAR ASSIST
DEVICE USE IN 2017
Over the past decade, the use of continuous-flow left
ventricular assist devices (LVADs) has increased
significantly. In the United States alone, approxi-
mately 2,400 LVADs are implanted
compared with only 459 in 2008 (1). More than 16,000
patients have received a continuous-flow LVAD in the
United States (2). These devices are a life-saving op-
tion for advanced heart failure (HF) patients who are
either not eligible for a heart transplant or too ill to
safely wait for a transplant on medical therapy alone.
Survival post-LVAD implantation also continues to
improve with 1-month survival estimates at 95%, and
1- and 2-year survival estimates at 80% and 70%,
respectively (1).
As the LVAD patient population increases, so does
the need for access to general medical and cardio-
vascular care. Providing care for patients with
continuous-flow LVADs is no longer restricted to
advanced HF specialists; however, there are limited
data and guidelines to assist non-LVAD specialists in
annually caring for these patients. In this State-of-the-Art
Review, we discuss current LVAD devices and
equipment and summarize initial management stra-
tegies to assist non-LVAD specialists in providing care
for these complex patients.
CURRENT DURABLE LVADs AND EQUIPMENT
There are currently 2 durable (i.e., able to be dis-
charged home) LVADs approved for adults by the U.S.
Food and Drug Administration: the HeartMate II left

From the aDepartment of Medicine, Duke University School of Medicine, Durham, North Carolina; and the bDuke Clinical Research
Institute, Duke University School of Medicine, Durham, North Carolina. The manuscript was funded by the Duke Clinical Research
Institute. Dr. DeVore has received research funding from American Heart Association, Amgen, and Novartis; and consults for
Novartis. Dr. C.B. Patel consults for Heartware/Medtronic and Thoratec/Abbott. Dr. P.A. Patel has reported that he has no
relationships relevant to the contents of this paper to disclose.

Manuscript received April 4, 2017; revised manuscript received June 11, 2017, accepted June 11, 2017.
2 DeVore et al.
Management of LVAD for the Non-LVAD Specialist
ABBREVIATIONS ventricular assist system (St. Jude Medical,
AND ACRONYMS St. Paul, Minnesota) and the HeartWare
ventricular assist device system (HVAD)
AV = aortic valve
(HeartWare, Framingham, Massachusetts).
BP = blood pressure
HeartMate 3 (St. Jude Medical) was recently
CT = computed tomography
compared to HeartMate II in a large, ran-
HF = heart failure domized clinical trial and found to
LV = left ventricle have improved outcomes at 6 months,
LVAD = left ventricular assist although the device currently remains
device
investigational (3).
MAP = mean arterial pressure This review considers the management of
HeartMate II, HeartWare, and HeartMate 3. These
pumps differ in technical design, but all are
continuous-flow pumps and have the following
analogous components: 1) an inflow cannula that is
surgically implanted into the left ventricular (LV)
apex, serving as a conduit for blood from the LV to the
pump; 2) a pump enclosure which houses an impeller
that circulates blood; 3) an outflow graft that carries
blood from the pump to the systemic circulation; and
4) a surgically tunneled driveline that connects the
pump to an external controller that operates and
monitors the pump function. The external controller
is connected by 2 power cables to a battery powered
source or a power module connected to an AC source
while batteries are charging. Batteries can last up to
12 h, and remaining battery life is displayed on the
external controller. The pump will function properly
if only 1 power cable is connected to the external
controller, but an alarm will sound. Additional device
peripherals include a backup controller, spare batte-
ries, chargers, and brand-specific system monitors
that are used to program, interrogate, and trouble-
shoot LVADs (Online Figures 1 to 5).
BASIC LVAD FUNCTION. LVADs move blood from the
LV apex to systemic circulation in a continuous
(nonpulsatile) manner. Pump speed is the funda-
mental parameter that the provider can alter. As
pump speed increases, the impeller within the pump
housing spins more rapidly and circulates a greater
volume of blood, thereby increasing LV unloading
and cardiac output. Contemporary pump design and
operating software are unable to automatically
modulate speed or cardiac output based on physio-
logic demand; therefore, they will operate at the
speed the provider sets, consuming as much power as
needed to maintain that speed.
The system controller monitors power consump-
tion and estimates cardiac output based on speed
and power consumption. This estimated flow is re-
ported on the system controller in liters per minute.
Notably, the flow is an estimated value based on
power consumption at given speeds and may not be
JACC: HEART FAILURE VOL. -, NO. -, 2017
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accurate in the case of physiologic derangements
(e.g., aortic insufficiency or LVAD dysfunction
including pump thrombosis). Additionally, the
controller measures temporal power fluctuations to
give an estimate of pulsatility through the pump,
termed pulsatility index for HeartMate devices and
represented graphically as the HVAD pump flow
waveform for the HeartWare device. Table 1 de-
scribes typical values for pump parameters informed
by clinical trial data and experience at our
institution.
KEY DIFFERERNCES AMONG CURRENT LVADs. Cur-
rent generation LVADs have analogous components,
but there are clinically important differences among
devices. HeartMate II is an axial flow pump with a
larger profile than HVAD and HeartMate 3, conse-
quently implantation in a surgically created pre-
peritoneal pocket is required (Online Figure 1).
HeartMate 3 and HVAD are centrifugal pumps with
smaller profiles and are implanted directly opposing
the heart (Online Figures 2 and 3). HVAD and Heart-
Mate 3 provide more accurate cardiac output esti-
mates during normal operation, given the centrifugal
design, and by using the patient’s manually entered
hematocrit to estimate the serum viscosity. Impor-
tantly, centrifugal flow pumps (i.e., HVAD and
HeartMate 3) have a larger change in flow for a given
pressure gradient change across the pump (i.e.,
afterload minus preload) than the axial flow Heart-
Mate II. Therefore, centrifugal flow pumps are more
sensitive to changes in preload and afterload, and
controlling hypertension is a key element of normal
centrifugal flow pump function.
Both the HVAD and HeartMate 3 have automated
speed modulation capabilities to enhance washing of
the pump and allow possible intermittent ejection
through the native aortic valve (AV). These rapid
speed modulations, termed “Artificial Pulse” for
HeartMate 3 and “Lavare Cycle” for HVAD (available
through software update in Europe), entail slowing
the impeller and then accelerating the pump speed to
the set speed or higher. Automatic speed modulation
may have benefits in preventing pump thrombosis for
HeartMate 3, as well as reducing AV insufficiency and
stroke for HVAD (3,4).
PATIENT ASSESSMENT
Most clinical encounters will require an assessment for
normal LVAD function and an assessment of heart rate
and blood pressure (BP). Later, we discuss unique as-
pects of a patient assessment and common and/or
serious LVAD complications. Each complication
JACC: HEART FAILURE VOL. -, NO. -, 2017
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should also be evaluated with a targeted patient his-
tory, physical examination, and initial evaluation.
HISTORY AND PHYSICAL EXAMINATION. Unique
aspects of the patient assessment include evaluation
for normal LVAD function and for common (some-
times occult) complications. The history should
include recent device parameters and alarms (Central
Illustration), symptoms of infection (including of the
driveline) or HF, and signs of hemoglobinuria (e.g.,
dark urine) that could be a harbinger of LVAD
thrombosis. We also evaluate tolerability to antith-
rombotic medications (most commonly aspirin and
warfarin) and ask about signs and symptoms sug-
gestive of melena, because chronic bleeding from
arteriovenous malformations in the gastrointestinal
tract is a common complication.
Unique aspects of the physical examination
include assessments of pulse, BP, auscultation of the
LVAD, examination of the driveline and device con-
nections, and device interrogation for device param-
eters and alarms. A key aspect of measuring pulse and
BP is understanding that the degree of arterial pul-
satility depends on multiple factors, as follows: 1)
underlying LV contractility; 2) AV function (i.e., the
AV can sometimes be intentionally oversewn for
management of aortic insufficiency); 3) LVAD pump
speed; and 4) LVAD preload and afterload. For
example, pulsatility decreases at increased pump
speeds (Central Illustration), consequently, assess-
ments of heart rate often require telemetry or elec-
trocardiography instead of palpation of a pulse, which
is often absent. Similarly, current technology for
noninvasive BP measurement can be unreliable when
there is decreased pulsatility, so Doppler ultraso-
nography is often necessary to measure BP. To mea-
sure, a manual BP cuff is inflated to occlude the
brachial artery, and a Doppler ultrasound probe is
used to auscultate the brachial artery on the medial
aspect of the antecubital fossa as the cuff is deflated.
The pressure at which the sound of blood flow returns
to the brachial artery is recorded and best described
as an opening or Doppler pressure, although in prac-
tice it is often called a mean arterial pressure (MAP). If
a patient has significant pulsatility, then the opening
pressure likely represents systolic BP. If there is low
pulsatility, then the opening pressure gives
reasonable estimate of the MAP. The typical MAP
target is #80 mm Hg to reduce stroke risk and mini-
mize LVAD afterload (5).
Cardiac auscultation can reveal the “hum” of an
LVAD, which is important if there is any concern for
pump dysfunction, as the hum can vary depending on
pump stress or pump stoppage. If there is any concern
DeVore et al. 3
Management of LVAD for the Non-LVAD Specialist
T A B L E 1 Typical LVAD Operating Parameters
HeartMate II HeartMate 3 HVAD
Typical speed, rpm* 8,000–10,000 5,000–6,000 2,400–3,200
Speed adjustment increment, 200 100 20
rpm/increment
Flow, l/min 4–7 4–6 4–6
Power, W 5–8 4.5–6.5 3–7
Pulsatility index (or HVAD, 5–8 3.5–5.5 2–4 l/min/beat
peak to trough)
*Speeds at the lower range or below the clinical ranges shown above indicate a low level of
support is needed and should prompt investigation of native contractility. Speeds above or near
the high range described above should prompt investigation for adequate left ventricular
unloading, including the possibilities of LVAD dysfunction or native valvular disease that could be
affecting unloading.
HVAD ¼ HeartWare ventricular assist device (system); LVAD ¼ left ventricular assist device;
rpm ¼ revolutions per minute.
for infection in patients, careful attention should be
given to the driveline (Online Figures 1 to 3), as most
LVAD infections involve the percutaneous driveline
(6). Typical examination findings of a driveline
infection include drainage or pus, presence of an ab-
scess, or cellulitis.
ROUTINE LABORATORY TESTING AND IMAGING
STUDIES. In addition to usual laboratory testing,
most patients with LVADs require screening evalua-
tion for anemia and subclinical hemolysis. Screening
for hemolysis may be done by either plasma-free
hemoglobin (hemolysis defined by concentration of
>40 mg/dl) or lactate dehydrogenase (hemolysis is
typically defined as values 2.5
the upper limit of
normal, >600 IU, or significantly above baseline)
(5,7).
Multimodal imaging capabilities are essential for
the initial evaluation of LVAD patients, especially
echocardiography due to its ease of access and
portability. Echocardiography can provide important
insights regarding acquired valvular disease, inflow
cannula position and orientation, right and left ven-
tricular function, filling pressures, and effectiveness
of LV unloading. Real-time feedback from echocar-
diography is key for diagnosing and troubleshooting
LVAD dysfunction, including imaging the response to
speed adjustments, provocative maneuvers (e.g.,
Valsalva and positional changes), and pacing adjust-
ments. For example, newly identified AV opening or
a severe mitral regurgitation is suggestive of inade-
quate LV unloading from the pump, potentially from
a speed that is set too low or from LVAD dysfunction.
Adjustment to a higher LVAD speed under echocar-
diographic guidance can provide diagnostic informa-
tion regarding pump dysfunction while optimizing
unloading (8). Importantly, echocardiography has
inherent limitations due to acoustic shadowing from
4 DeVore et al. JACC: HEART FAILURE VOL. -, NO. -, 2017
Management of LVAD for the Non-LVAD Specialist - 2017:-–-

C E NT R AL IL L U STR AT IO N Unique Aspects of Evaluating a Patient With an LVAD

DeVore, A.D. et al. J Am Coll Cardiol HF. 2017;-(-):-–-.

Key aspects of evaluating a patient with an LVAD include assessing recent device parameters and alarms and for common and/or serious complications such as infection,
heart failure, LVAD thrombosis, and gastrointestinal bleeding. The figure also displays the impact of continuous-flow LVAD speed on blood flow pulsatility. As LVAD speeds
increase, more blood flows though the LVAD instead of being ejected through the aortic valve. Therefore, at higher pump speeds, there is a lower pulse pressure. Lower
pulsatility has an impact on the assessment of pulse and blood pressure on physical examination. See Online Figures 1 to 5 for brand-specific images of device components.
GI ¼ gastrointestinal; HF ¼ heart failure; HVAD ¼ HeartWare ventricular assist device; LVAD ¼ left ventricular assist device; RPM ¼ revolutions per minute.
JACC: HEART FAILURE VOL. -, NO. -, 2017 DeVore et al. 5
- 2017:-–- Management of LVAD for the Non-LVAD Specialist

LVAD components, particularly for patients with

T A B L E 2 Suggested Approach to Suspected LVAD Infection
apically-positioned centrifugal flow pumps (i.e.,
HVAD or HeartMate 3), which can significantly limit Initial Evaluation Initial Management

2-dimensional and spectral Doppler analysis from
apical imaging windows. Comprehensive guidelines
for echocardiographic imaging of LVAD patients are
also available (9).
Electrocardiogram-gated computed tomography
(CT) angiography and nuclear imaging also play
important roles in the evaluation of LVAD patients.
Contrast-enhanced gated CT scans timed for opacifi-
cation of the LVAD inflow and outflow cannulas allow
excellent visualization of LVAD components outside
of the metallic pump housing, particularly the
outflow graft, and can help with the diagnosis of
cannula malposition and outflow graft narrowing,
kinking, or thrombosis (10). In cases of suspected
infection, nuclear imaging with radioisotope-tagged
white blood cells can help identify the presence and
extent of infection.
Obtain local wound culture
Obtain blood cultures. Consider other
evaluations (e.g., urine culture if
non-LVAD-related infection is also
suspected).
If percutaneous driveline infection is
suspected, obtain a chest and abdomen
ultrasonogram or CT to assess for
abscess and/or driveline stranding.
If bacteremia or sepsis is present, assess for the
source of bacteremia by using a chest and
abdomen CT and transthoracic or
transesophageal echocardiogram.
Remove driveline dressing. Do not express
wound immediately and clean exit site
(typically with chlorhexidine soap). Irrigate
the area until clean and then dry the area
before expressing drainage and collecting
specimen.
Review prior culture data and consider
empirical antibiotic therapy after blood
cultures are obtained. The most common
pathogens are Gram-positive organisms
(e.g., coagulase-negative staphylococci and
S. aureus), although Gram-negative
organisms, fungal infections, and
polymicrobial infections also occur.
Many patients will also need warfarin held and
bridging with unfractionated heparin if
surgical intervention is necessary.
Depending on results, surgical evaluation for
driveline debridement and infectious
diseases consultation may be needed.

COMMON AND/OR SERIOUS CT ¼ computed tomography; LVAD ¼ left ventricular assist device.

LVAD COMPLICATIONS

Adverse events with contemporary, continuous-flow
LVADs are lower than older, pulsatile LVADs,
although the rate of adverse events remains unac-
ceptably high (11). More than 50% of patients are
readmitted for adverse events in the first 6 months
post-LVAD implant, and patients experience an
average of 3.5 adverse events (most commonly
bleeding, infection, and/or arrhythmia) in the first
year post-implantation (1). By 2 years post-implant,
approximately 80% of patients have experienced a
major adverse event (1). We focus here on common
and/or serious complications that occur outside of the
perioperative period. The reader may refer to other
reviews and guidelines that discuss perioperative
medical management and complications (5,12). The
management of LVAD complications should occur in
consultation with advanced HF providers, although
the following discussion may assist with initial eval-
uation and management.
LVAD INFECTIONS. Most LVAD infections involve
the percutaneous driveline (6) and can range in
severity from a local skin infection to a systemic
infection that involves the LVAD pump. Patients and
caregivers are educated about specific instructions for
regular dressing changes and monitoring for signs
and symptoms of infection at the driveline exit site.
Nevertheless, data suggest that many driveline in-
fections are unavoidable, resulting from trauma to
the driveline exit site (e.g., accidentally dropping a
controller or battery pack) (13).
The evaluation for infection includes driveline
drainage culture, blood cultures, and imaging
(Table 2). In particular, blood cultures are important to
evaluate for occult bloodstream infections, because
LVAD patients can present with atypical signs and
symptoms. Imaging the internal course of the driveline
up to the pump can be accomplished with ultraso-
nography or CT. We prefer CT scans with or without
contrast to evaluate the extent of driveline and/or
pump pocket infections. The most common pathogens
are Gram-positive skin flora (e.g., coagulase-negative
staphylococci and Staphylococcus aureus), although
Gram-negative organism (e.g., Pseudomonas spp.
and Enterobacteriaceae), fungal, and polymicrobial
infections also can occur (6,14,15).
NONSURGICAL BLEEDING. Nonsurgical bleeding is a
common complication after LVAD implantation and a
familiar cause for hospital readmission (16). There are
multiple reasons for nonsurgical bleeding, for
example: 1) use of antithrombotic therapy; 2) acquired
coagulopathy, especially von Willebrand factor defi-
ciency from degradation of high-molecular-weight von
Willebrand factor multimers as they move through and
are sheared by the pump; and 3) formation of arterio-
venous malformations in the gastrointestinal tract,
nasopharynx, brain, and other tissues, which seems
related to continuous blood flow and an associated
abnormal regulation of angiogenic factors (17).
Our general approach to treatment is to hold
antithrombotic therapy, control the source of
6 DeVore et al. JACC: HEART FAILURE VOL. -, NO. -, 2017
Management of LVAD for the Non-LVAD Specialist - 2017:-–-

F I G U R E 1 Evaluation and Management of Gastrointestinal Bleeding

Proposed approach to the initial evaluation and management of gastrointestinal bleeding. CT ¼ computed tomography; GI ¼ gastrointestinal;
LVAD ¼ left ventricular assist device; RBC ¼ red blood cell.

bleeding, and transfuse blood products as needed with atrial arrhythmias (20,21). Approximately one-
(while recognizing the potential for antibody sensiti- half of all LVAD patients have atrial fibrillation in
zation in patients considered for heart trans- observational studies (22), and as many as 22% to 59%
plantation). Patients rarely need active reversal of have reported ventricular arrhythmias (23). Impor-
antithrombotic therapies, unless there is life- tantly, many LVAD patients may tolerate ventricular
threatening hemorrhage such as intracranial tachycardia for hours due to continuous hemody-
hemorrhage. Gastrointestinal bleeding related to namic support provided by the LVAD. Our initial
arteriovenous malformations is the most common evaluation of LVAD patients with ventricular tachy-
presentation for nonsurgical bleeding and can occur at cardia is similar to that of patients without an LVAD,
any time after implantation (18). Figure 1 outlines our including an assessment of hemodynamic stability
general approach to evaluation and management. with vital signs and obtaining an electrocardiogram if
Notably, many patients develop recurrent gastroin- able. Cardioversion can be safely performed for pa-
testinal bleeding, and a review of prior endoscopic tients requiring urgent therapy by placing external
procedures is an important aspect of the initial eval- defibrillator pads in the usual locations, although
uation, although the diagnostic and therapeutic yield pads should not be placed over the LVAD pump.
of endoscopy remains high with repeated in- There is no need to stop or disconnect the LVAD
terventions (19). before external cardioversion.
When evaluating a patient with ventricular tachy-
ATRIAL AND VENTRICULAR ARRHYTHMIAS. Both cardia, the mechanism of arrhythmia is important to
atrial and ventricular arrhythmias are common post- consider. For example, contact from the inflow can-
LVAD implantation. Approximately 20% of patients in nula to the LV can occur when the LV is completely
the HeartMate II Destination Therapy trial presented decompressed by continuous inflow, possibly from
JACC: HEART FAILURE VOL. -, NO. -, 2017
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F I G U R E 2 Neurological Emergencies
Proposed approach to neurologic emergencies. ICH ¼ ischemic hemorrhage; LDH ¼ lactate dehydrogenase; SDH ¼ subdural hematoma; other
abbreviations as in Figure 1.
dehydration or an excessively high speed (24).
This scenario can be clarified by a history suggestive
of hypovolemia and confirmed by echocardiogram
and/or LVAD interrogation, which may demonstrate
low pulsatility index (HeartMate devices) or low
HVAD flow waveform (HeartWare device).
contrast, another possible mechanism is scar related
to myocardial fibrosis. The initial treatment strategies
for these 2 scenarios can be quite different, ranging
from optimization of fluid status to initiation of
antiarrhythmic medications.
LVAD MALFUNCTION OR FAILURE. LVAD malfunc-
tion or failure may result from a variety of causes,
including electrical malfunction and thrombosis. Me-
chanical pump failure is less common in continuous-
flow devices than previous generation LVADs.
Electrical malfunction typically presents with LVAD
alarms or pump stoppage, and initial management
involves checking to ensure device connections are
DeVore et al. 7
Management of LVAD for the Non-LVAD Specialist
secure, reviewing LVAD alarms, and evaluating LVAD
flow and patient stability. Management of suspected
electrical malfunction typically requires consultation
with an LVAD specialist. If the provider and patient
are put in the position of attempting to change a
In controller, which results in an obligatory temporary
LVAD stoppage, then one must first determine the
patient’s hemodynamic dependence on LVAD support
(e.g., patients with an oversewn AV are more depen-
dent on LVAD flow than patients with a normal func-
tioning AV). Controller exchange should be performed
quickly by well-trained personnel to prevent compli-
cations related to lack of native ejection for these
patients during temporary pump stoppage.
LVAD thrombosis can occur on the inflow cannula,
pump, or outflow graft. HeartMate II was noted to
have higher-than-expected rates of thrombosis in a
large observational study (25) and higher rates of
device malfunction requiring surgical replacement in
clinical trials compared with HVAD (16.2% vs. 8.8%,
8 DeVore et al. JACC: HEART FAILURE VOL. -, NO. -, 2017
Management of LVAD for the Non-LVAD Specialist - 2017:-–-

F I G U R E 3 HF Profiles

Proposed heart failure profiles to guide initial evaluation and management. For refractory cases, consider extracardiac causes of volume
overload such as a peripheral shunt, cirrhosis, or nephrotic syndrome. AI ¼ aortic valve insufficiency; BP ¼ blood pressure; DOE ¼ dyspnea on
exertion; HF ¼ heart failure; IVC ¼ inferior vena cava; JVP ¼ jugular venous pressure; LV ¼ left ventricular; LVEDD ¼ left ventricular
end-diastolic dimension; MCS ¼ mechanical circulatory support; MR ¼ mitral regurgitation; PCWP ¼ pulmonary capillary wedge pressure;
PI ¼ pulsatility index; PND ¼ paroxysmal nocturnal dyspnea; RHC ¼ right heart cardiac catheterization; RV ¼ right ventricular.

respectively) (26) or HeartMate 3 (7.7% vs. 0.7%,
respectively) (3). Thrombosis presents in various
degrees of severity, including asymptomatic eleva-
tions in plasma-free hemoglobin or lactate dehydro-
genase, clinical evidence of hemolysis, LVAD alarms
for changes in power or flow, and isolated left-sided
or biventricular HF. Initial management includes
evaluating current antithrombotic
including international normalized ratio and anti-
platelet therapy dose, stabilizing the patient; and
in select cases, planning for emergent surgical
interventions or thrombolytic agents. Echocardio-
graphic ramp studies (8) may also be used to evaluate
LVAD dysfunction related to thrombosis, and CT
angiography may be performed to evaluate the
outflow graft.
NEUROLOGICAL EMERGENCIES. Ischemic and hem-
orrhagic strokes remain the most dreaded adverse
events following LVAD implantation, occurring with
an annual incidence of approximately 9% (27).
Ischemic and hemorrhagic strokes cause significant
morbidity and are associated with high rates of mor-
tality (28). The risk of stroke and death among patients
appears to be bimodal with highest risks in the peri-
operative period and increasing approximately 1 year
later (29). Figure 2 displays our approach to managing
strategies neurological emergencies. Similar to stroke in non-
LVAD patients, early patient recognition and urgent
medical evaluation, including brain and vascular im-
aging, are key steps in the evaluation. One must also
consider whether LVAD thrombosis (i.e., evaluate
LVAD pump parameters, evaluate for hemolysis, and
obtain echocardiography) could be an embolic source
in patients with ischemic or hemorrhagic stroke.
HEART FAILURE. Acute right ventricular failure post-
LVAD implantation is common and well described,
including associated risk factors and outcomes
(30–32). Heart failure that occurs late after LVAD
JACC: HEART FAILURE VOL. -, NO. -, 2017
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implantation is a distinct entity with an emerging
evidence base, especially for late right HF (33–35).
In an analysis of data from the HeartMate II Destina-
tion Therapy trial, patients with late right HF had
worse outcomes at 2 years than those without,
including worse quality of life, poorer functional
capacity, increased rehospitalizations (median: 6
[range 2 to 19] vs. 3 [range 0 to 27], respectively), and
decreased rate of survival (58  8% vs. 71  2%,
respectively) (35).
We propose 3 patient profiles as a conceptual
framework to guide initial evaluation and manage-
ment of LVAD patients presenting with HF (Figure 3).
We use the patient’s history and physical examina-
tion, an echocardiogram, and/or an invasive hemo-
dynamic assessment to determine if HF
biventricular, isolated left-sided, or isolated right-
sided. We also ensure accurate assessment of the
MAP and evaluate for LVAD dysfunction.
When evaluating HF, one must understand the role
of continuous AV insufficiency, which can develop
de novo or from exacerbation of underlying AV pa-
thology and is more common with contemporary,
continuous-flow LVADs than older, pulsatile LVADs
(36). Aortic insufficiency most likely occurs due to
commissural fusion of the AV leaflets from immobility
with associated remodeling and/or trauma from high-
pressure continuous flow from the outflow cannula
(37), resulting in a futile circuit from valvular insuf-
ficiency that reduces LVAD efficiency and leads to HF
symptoms. That is, blood travels from the LV through
the pump, into the aorta, back through the AV, and
again into the LV. Due to the continuous nature of AV
insufficiency, even a small regurgitant orifice can lead
to a large volume of regurgitant blood flow. Aortic
insufficiency should be assessed by echocardiogra-
phy; management typically involves BP control and
evaluation for AV intervention (transcatheter or sur-
gical AV replacement or surgical oversewing).
UNRESPONSIVE PATIENTS AND
CARDIOPULMONARY RESUSCITATION
Care for an unresponsive LVAD patient requires unique
considerations compared with the standard approach
to advanced cardiovascular life support: 1) assessment
for normal LVAD power and function is essential
(evaluate device connections, check device parame-
ters and alarms, and auscultate for LVAD hum) (38);
2) assessment of pulse and BP is limited by continuous-
flow physiology; 3) there are limited data for the safety
and efficacy of chest compressions in LVAD patients,
although device manufacturers caution about
DeVore et al. 9
Management of LVAD for the Non-LVAD Specialist
potential dislodgement of the inflow tract/outflow
graft during compressions; and 4) the initial patient
survey should consider the previously-mentioned
complications (e.g., infection, bleeding, neurological
emergencies).
PROCEDURES FOR PATIENTS ON AN LVAD
Because patients with LVADs live longer, more LVAD
patients are requiring minor procedures and noncar-
diac surgery. These procedures should be coordinated
with an LVAD specialist. Specific attention should
be given to the perioperative management of
antithrombotic therapy and BP monitoring as the
available data highlight an increased risk of bleeding,
higher frequency of intraoperative hypotension, and
is
a risk for acute kidney injury when these patients
undergo noncardiac surgery (39,40). As mentioned
previously, there are multiple reasons for the
increased risk of bleeding beyond the risks of
antithrombotic therapy, and the risk may be under-
estimated by providers who are unfamiliar with
LVADs. For example, in a study of patients who
underwent noncardiac operations, including abdom-
inal surgeries, thoracic surgeries, and endoscopic
procedures at the Mayo Clinic, 15% of operations
required red blood cell transfusions, 9% required
fresh frozen plasma, and 6% required platelets (39).
CONCLUSIONS
The number of ambulatory LVAD patients is
increasing, as is their life expectancy. Non-LVAD
specialists will increasingly encounter LVAD pa-
tients and should be armed with the tools to provide
initial assessment and management for these com-
plex patients. Co-management of these patients will
also become increasingly important as research and
device innovations allow us to overcome the chal-
lenges preventing expansion of LVAD therapy to
more patients such as the high rate of adverse events,
the care required for devices with external battery
sources, and cost.
ACKNOWLEDGMENTS The authors thank Erin
Campbell, MS, for editorial contributions and Jon-
athon Cook for assistance with images. Ms. Campbell
and Mr. Cook did not receive compensation for their
contributions. Ms. Campbell is an employee at the
institution where this study was conducted.
ADDRESS FOR CORRESPONDENCE: Dr. Adam D.
DeVore, Department of Medicine, Duke Clinical Research
Institute, 400 Pratt Street, NP-8064, Durham, North
Carolina 27705. E-mail: adam.devore@duke.edu.
10 DeVore et al.
Management of LVAD for the Non-LVAD Specialist
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KEY WORDS heart failure, left ventricular
assist devices, mechanical circulatory
support
A PPE NDI X For supplemental figures, please
see the online version of this article.