Practical management of long-term mechanical circulatory support devices
- Donna Mancini, MD
Donna Mancini, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Icahn School of Medicine at Mount Sinai
- Section Editors
- Sharon A Hunt, MD
Sharon A Hunt, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Heart Transplantation
- Professor of Medicine
- Stanford University School of Medicine
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
Continuous flow ventricular support devices (used primarily as left ventricular assist devices [LVADs] and less frequently for biventricular support [BiVAD]) are increasingly used for the management of patients with end stage heart failure (ie, stage D, refractory heart failure requiring specialized interventions) both as a bridge to transplantation and as destination therapy [1-4]. LVADs have been shown to prolong survival in this clinical setting (see "Intermediate- and long-term mechanical circulatory support", section on 'Clinical evidence') [5-7], but there are several complications associated with mechanical circulatory support device (MCSD) therapy. The postoperative course is complicated by frequent readmissions for bleeding, infection, pump thrombosis, right heart failure, and device malfunctions that require proper attention and management.
In North America, the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) collects clinical data on patients receiving MCSD therapy. The International Society for Heart and Lung Transplantation (ISHLT) issued guidelines for MCSD therapy in 2013 .
In this topic, we will review ventricular assist device complications and long-term outpatient management, focusing on care of patients with continuous flow devices such as the HeartMate II (HMII), which are the most commonly used devices today.
Indications for intermediate- and long-term device placement, mechanical options, and clinical trial data supporting device use are discussed separately. (See "Intermediate- and long-term mechanical circulatory support".)
Physical examination — Continuous flow devices greatly alter the physical exam in supported patients. This presents a major challenge to physicians and first responders in assessing these patients. Continuous flow left ventricular assist devices (LVAD) supported patients frequently have no palpable pulse and blood pressure may not be measurable by auscultation. Heart sounds are obscured by the hum of the device. Additionally, high placement of the external driveline can impede examination of the liver and assessment of hepatic congestion.
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- OUTPATIENT FOLLOW-UP
- Physical examination
- Device interrogation
- ANTITHROMBOTIC THERAPY
- EXERCISE PERFORMANCE
- Exercise parameters
- Cardiac rehabilitation
- COMPLICATIONS OF VADS
- - Causes and sites of bleeding
- - Evaluation for acquired VWD
- - Prevention and management of bleeding
- Perioperative management
- Management of ongoing risk of bleeding
- Right heart failure
- Aortic regurgitation
- Technical problems and device failure
- Neurologic complications
- Abdominal complications
- Ventricular arrhythmias
- MEDICAL MANAGEMENT
- Heart failure therapy
- SUMMARY AND RECOMMENDATIONS