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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Kirklin JK, Naftel DC, Kormos RL, et al. The Fourth INTERMACS Annual Report: 4,000 implants and counting. J Heart Lung Transplant 2012; 31:117.
- McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
- McKelvie RS, Moe GW, Cheung A, et al. The 2011 Canadian Cardiovascular Society heart failure management guidelines update: focus on sleep apnea, renal dysfunction, mechanical circulatory support, and palliative care. Can J Cardiol 2011; 27:319.
- Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:1810.
- Miller LW, Pagani FD, Russell SD, et al. Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 2007; 357:885.
- Aaronson KD, Slaughter MS, Miller LW, et al. Use of an intrapericardial, continuous-flow, centrifugal pump in patients awaiting heart transplantation. Circulation 2012; 125:3191.
- Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009; 361:2241.
- Feldman D, Pamboukian SV, Teuteberg JJ, et al. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant 2013; 32:157.
- Bennett MK, Roberts CA, Dordunoo D, et al. Ideal methodology to assess systemic blood pressure in patients with continuous-flow left ventricular assist devices. J Heart Lung Transplant 2010; 29:593.
- Lanier GM, Orlanes K, Hayashi Y, et al. Validity and reliability of a novel slow cuff-deflation system for noninvasive blood pressure monitoring in patients with continuous-flow left ventricular assist device. Circ Heart Fail 2013; 6:1005.
- Tochikubo O, Nishijima K, Ohshige K, Kimura K. Accuracy and applicability of the Terumo ES-H55 double-cuff sphygmomanometer for hospital use. Blood Press Monit 2003; 8:203.
- Baddour LM, Bettmann MA, Bolger AF, et al. Nonvalvular cardiovascular device-related infections. Circulation 2003; 108:2015.
- Slaughter MS, Pagani FD, Rogers JG, et al. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant 2010; 29:S1.
- Peura JL, Colvin-Adams M, Francis GS, et al. Recommendations for the use of mechanical circulatory support: device strategies and patient selection: a scientific statement from the American Heart Association. Circulation 2012; 126:2648.
- Starling RC, Moazami N, Silvestry SC, et al. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med 2014; 370:33.
- Jaski BE, Lingle RJ, Kim J, et al. Comparison of functional capacity in patients with end-stage heart failure following implantation of a left ventricular assist device versus heart transplantation: results of the experience with left ventricular assist device with exercise trial. J Heart Lung Transplant 1999; 18:1031.
- Haft J, Armstrong W, Dyke DB, et al. Hemodynamic and exercise performance with pulsatile and continuous-flow left ventricular assist devices. Circulation 2007; 116:I8.
- Kugler C, Malehsa D, Tegtbur U, et al. Health-related quality of life and exercise tolerance in recipients of heart transplants and left ventricular assist devices: a prospective, comparative study. J Heart Lung Transplant 2011; 30:204.
- Nascimbene A, Neelamegham S, Frazier OH, et al. Acquired von Willebrand syndrome associated with left ventricular assist device. Blood 2016; 127:3133.
- Potapov EV, Stepanenko A, Krabatsch T, Hetzer R. Managing long-term complications of left ventricular assist device therapy. Curr Opin Cardiol 2011; 26:237.
- Eckman PM, John R. Bleeding and thrombosis in patients with continuous-flow ventricular assist devices. Circulation 2012; 125:3038.
- http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm457327.htm (Accessed on August 11, 2015).
- Park SJ, Milano CA, Tatooles AJ, et al. Outcomes in advanced heart failure patients with left ventricular assist devices for destination therapy. Circ Heart Fail 2012; 5:241.
- Demirozu ZT, Radovancevic R, Hochman LF, et al. Arteriovenous malformation and gastrointestinal bleeding in patients with the HeartMate II left ventricular assist device. J Heart Lung Transplant 2011; 30:849.
- Warkentin TE, Greinacher A, Koster A. Heparin-induced thrombocytopenia in patients with ventricular assist devices: are new prevention strategies required? Ann Thorac Surg 2009; 87:1633.
- Uriel N, Pak SW, Jorde UP, et al. Acquired von Willebrand syndrome after continuous-flow mechanical device support contributes to a high prevalence of bleeding during long-term support and at the time of transplantation. J Am Coll Cardiol 2010; 56:1207.
- Meyer AL, Malehsa D, Bara C, et al. Acquired von Willebrand syndrome in patients with an axial flow left ventricular assist device. Circ Heart Fail 2010; 3:675.
- Crow S, Chen D, Milano C, et al. Acquired von Willebrand syndrome in continuous-flow ventricular assist device recipients. Ann Thorac Surg 2010; 90:1263.
- Heilmann C, Geisen U, Beyersdorf F, et al. Acquired Von Willebrand syndrome is an early-onset problem in ventricular assist device patients. Eur J Cardiothorac Surg 2011; 40:1328.
- Crow S, Milano C, Joyce L, et al. Comparative analysis of von Willebrand factor profiles in pulsatile and continuous left ventricular assist device recipients. ASAIO J 2010; 56:441.
- Uriel N, Han J, Morrison KA, et al. Device thrombosis in HeartMate II continuous-flow left ventricular assist devices: a multifactorial phenomenon. J Heart Lung Transplant 2014; 33:51.
- Kirklin JK, Naftel DC, Kormos RL, et al. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) analysis of pump thrombosis in the HeartMate II left ventricular assist device. J Heart Lung Transplant 2014; 33:12.
- Mehra MR, Stewart GC, Uber PA. The vexing problem of thrombosis in long-term mechanical circulatory support. J Heart Lung Transplant 2014; 33:1.
- Nassif ME, Patel JS, Shuster JE, et al. Clinical outcomes with use of erythropoiesis stimulating agents in patients with the HeartMate II left ventricular assist device. JACC Heart Fail 2015; 3:146.
- Uriel N, Morrison KA, Garan AR, et al. Development of a novel echocardiography ramp test for speed optimization and diagnosis of device thrombosis in continuous-flow left ventricular assist devices: the Columbia ramp study. J Am Coll Cardiol 2012; 60:1764.
- Drakos SG, Janicki L, Horne BD, et al. Risk factors predictive of right ventricular failure after left ventricular assist device implantation. Am J Cardiol 2010; 105:1030.
- Matthews JC, Koelling TM, Pagani FD, Aaronson KD. The right ventricular failure risk score a pre-operative tool for assessing the risk of right ventricular failure in left ventricular assist device candidates. J Am Coll Cardiol 2008; 51:2163.
- Fitzpatrick JR 3rd, Frederick JR, Hsu VM, et al. Risk score derived from pre-operative data analysis predicts the need for biventricular mechanical circulatory support. J Heart Lung Transplant 2008; 27:1286.
- Pak SW, Uriel N, Takayama H, et al. Prevalence of de novo aortic insufficiency during long-term support with left ventricular assist devices. J Heart Lung Transplant 2010; 29:1172.
- Takeda K, Takayama H, Colombo PC, et al. Late right heart failure during support with continuous-flow left ventricular assist devices adversely affects post-transplant outcome. J Heart Lung Transplant 2015; 34:667.
- Cowger J, Pagani FD, Haft JW, et al. The development of aortic insufficiency in left ventricular assist device-supported patients. Circ Heart Fail 2010; 3:668.
- Hatano M, Kinugawa K, Shiga T, et al. Less frequent opening of the aortic valve and a continuous flow pump are risk factors for postoperative onset of aortic insufficiency in patients with a left ventricular assist device. Circ J 2011; 75:1147.
- McKellar SH, Deo S, Daly RC, et al. Durability of central aortic valve closure in patients with continuous flow left ventricular assist devices. J Thorac Cardiovasc Surg 2014; 147:344.
- Birks EJ, Tansley PD, Yacoub MH, et al. Incidence and clinical management of life-threatening left ventricular assist device failure. J Heart Lung Transplant 2004; 23:964.
- Yuzefpolskaya M, Uriel N, Chow DS, et al. Prevalence and timing of bend relief disconnection in patients supported by the late version HeartMate II left ventricular assist device. J Heart Lung Transplant 2013; 32:320.
- Tsukui H, Abla A, Teuteberg JJ, et al. Cerebrovascular accidents in patients with a ventricular assist device. J Thorac Cardiovasc Surg 2007; 134:114.
- Kato TS, Schulze PC, Yang J, et al. Pre-operative and post-operative risk factors associated with neurologic complications in patients with advanced heart failure supported by a left ventricular assist device. J Heart Lung Transplant 2012; 31:1.
- Korn-Lubetzki I, Oren A, Asher E, et al. Strokes after cardiac surgery: mostly right hemispheric ischemic with mild residual damage. J Neurol 2007; 254:1708.
- Kato TS, Ota T, Schulze PC, et al. Asymmetric pattern of cerebrovascular lesions in patients after left ventricular assist device implantation. Stroke 2012; 43:872.
- Garan AR, Yuzefpolskaya M, Colombo PC, et al. Ventricular arrhythmias and implantable cardioverter-defibrillator therapy in patients with continuous-flow left ventricular assist devices: need for primary prevention? J Am Coll Cardiol 2013; 61:2542.
- Garan AR, Iyer V, Whang W, et al. Catheter ablation for ventricular tachyarrhythmias in patients supported by continuous-flow left ventricular assist devices. ASAIO J 2014; 60:311.
- 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
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS