NUEM - July 5, 2016 - By Bode J - Edited by: Ketterer A, Pham D & Rich J - Expert Commentary: Nakano J.
Citation: [Peer-Reviewed, Web Publication] Bode J, Ketterer A, Pham D, Rich J (2016, July 5). LVAD Management In The ED [NUEM Blog. Expert Commentary by Nakano J]. Retrieved from http://www.nuemblog.com/blog/LVAD-management/
"Left Ventricular Assist Devices (LVADs) are surgically implanted pumps that essentially “take over” the job of the failing left ventricle, restoring normal blood flow to the body. These devices accomplish this by sucking in blood from the ventricle via a pump and propelling the blood into the aorta. The first VAD was implanted in 1984 and with an ever increasing number of patients with heart failure and fewer donor organs available, they have grown in popularity ever since. The landmark 2001 REMATCH paper demonstrated a significant survival increase [52% vs 25% at 1 year, p=0.002] with an improved quality of life. However, these earlier generation pulsatile VADs were insufficiently durable, usually lasting only 1-2 years. With advances in LVAD technology, currently over 90% of LVAD-supported patients will survive to 1 year post-implantation with the newer generation continuous flow LVADs and a minority of patients will continue to thrive on LVAD support for ten years or more...
Final ThoughtsIn summary, VAD patients often present with normal medical problems just as in non VAD patients and should be treated accordingly. However, VAD patients may also present with highly complex conditions and require specialist input and intervention as soon as possible...
Here are a few quick pearls for Emergency Department management:
- Call for help immediately - this is the time to bring the specialists on board
- ABCs still apply. Get a blood pressure (and arterial line if you need one), and check an EKG.
- VADs are preload dependent, i.e. they can only pump blood if enough blood reaches them in the first place. Fluids are likely helpful but you can usually assume some degree of RV dysfunction so approach cautiously. When in doubt in the unstable patient, start an inotrope or pressor.
- LVADs are a contraindication to magnetic resonance imaging.
- In patients with continuous-flow pump devices, absence of a peripheral pulse is expected.
- Sometimes, even in LVAD patients, a hangnail is just a hangnail."