Left ventricular assist device

Mechanical Circulatory Assist Device

OBJECTIVESUnderstand the types of VADsDescribe indications for and components of a ventricular assist device.

Discern assessment findings of pts with a VAD from other emergency pts

Be proficient in the care of a pt with a VAD

A mechanical circulatory assist device that is used to support heart function and blood flow in people who have weakened hearts. Most common are LVADS (left ventricular assist device) there are also RVADS (right ventricular assist device) and BIVAD (biventricular assist device).

The LVAD takes blood from the left ventricle to the aorta and then to the body and vital organs, just as a normal healthy heart would.

The RVAD takes the blood from the right ventricle pump blood to the pulmonary artery. This is the artery that carries blood from the heart to the lungs to pick up oxygen.

A BIVAD might be used if both ventricles don't work well enough to meet the body's needs. Another treatment option for this condition is a total artificial heart.

The LVAD device was FDA approved in the US in 2010 for 3 situations.

1. "Bridge to Transplant" for those patients awaiting a heart transplant

2. To "rest" a damaged left ventricle after a surgical procedure, or major heart attack.

3. "Destination Therapy" for those who have severe end stage heart failure, but are not candidates for a heart transplant

Mechanical deviceSurgically implantedImproves cardiac outputMost common type LVADShands is our closest VAD center

They use the Heartmate 2 most commonly

An LVAD has four components that are both internal and external

1.The pump2.The driveline3.The controller4.The batteries

The pump is internal It is connected to your left ventricle that pulls blood into the pump which then sends the blood to the acending aorta which sends the blood to your body with your heart having to do minimal work.

The Pump

The Driveline

The driveline is internal and external. It is a percutaneous lead that connects the pump to the controller. It contains necessary power and electronic cables. It exits through the skin, on either the right or left side of the abdomen.

THE CONTROLLER  Is EXTERNAL and it operates the pump and has

lights, messages, and/or alarms if the power is low or if it is not functioning properly. It can be worn around the waist or over the shoulder. Look at the color of the tag on the controller so you can refer to the EMS guide on how to treat your pt with that specific VAD.

Options for PowerBatteries AC power sources  The batteries are charged using

a device specific battery charger. The controller and/or batteries will show you how much power the batteries have left and alert you when they need to be changed. When the patient is outside of their home they need to have extra fully charged batteries with them. Depending on their specific VAD device, the batteries may be in a pack along with the controller or carried in a holster over their shoulders.

 When the patient sleeping or about to sleep, they need to connect the VAD to the device-specific electrical power source to eliminate the chance of battery power loss while sleeping. The electrical power source should include a backup battery (possibly internal) in case there is a power outage. The device may also come with a DC adaptor, which will allow them to power their VAD in a car.

In short If you have a pt with an LVAD make sure you•Bring their extra batteries•Be sure you have their AC power cord

LVADS can be pulsatile

or continuous

flow

Continuous flow LVADs you will not feel a pulse and may not be able to obtain a b/p

When assessing a pt with an LVAD start with your normal assessment

intervene as necessary

Initial assessment

• Airway assessment

• Attach cardiac monitor and

pulse ox

PULSE OX MAY NOT DETECT AN O2 SAT

To assess specifically for the VAD

1. Auscultate heart sounds to determine if the device is functioning. If it is a continuous flow device you should hear a “whirling sound”

2. Assess the device for any alarms3. Find the color tag on the controller so you can

identify the specific device in the ems guide for LVAD devices

4. Intervene appropriately based on the type of alarm, color tag and what the EMS guide says for that VAD

5. Initiate IV of NS or LR 6. Assess v/s if possible7. Optimal way to assess v/s is us the mean b/p with a

doppler if no doppler is available and you are able to obtain one with the NIBP then us the MEAN of that.

8. You may or might not be able to detect a b/p which can be normal. Pulse also may or may not be palpable.

Best indicator with LVAD pts is:

Their LOC and the skin color and condition.

Cardiac Arrest LVAD PTIf your pt is unconscious, unresponsive to stimuli and pulseless listen to the pts chest. If you hear the whirling sound of the LVAD, DO NOT PREFORM CPR. If you cannot hear the device then CPR should be performed per cardiac arrest protocol.

Yes you can do a 12 lead and defibrillate as you would given the situation

Treat all STEMI and chest pain complaints as you would using the Chest Pain Protocol but be mindful that pt may be on viagra to reduce chances of right heart failure (male or female).

Transport to closest VAD center if possible, otherwise to the closest hospital if pt is hemodynamically unstable or to the hospital of choice if pt is stable.

If you suspect the pt is dehydrated bolus 250cc of NS with a max of 500cc until pt is improving . Be sure to continuously check lung sounds and watch for signs of CHF. If pt starts to have signs of CHF discontinue fluid bolus. Pt will have a low or no b/p reading DO NOT treat the b/p. Treat the PT not the monitor.

LVAD pt should have all medications that a non LVAD pt with heart failure would have including blood thinners to help prevent the development of clots.

When taking care of a pt always remember:

ALL VAD pt and their families/caretakers have been well educated on the VAD and the care along with it. If you have any questions ask the pt or the family. If it is an emergent situation or the pt is unable to answer questions bring a family member with you.

Special Considerations1. Be careful not to twist, cut or bend the

driveline coming out of the abdomen (this is the lifeline and if it disconnects they will die).

2. Most common complications are bleeding and thromboemboli

3. Do not get tunnel vision, LVAD pts will call for reasons unrelated to their LVAD

4. It is possible for pt to be in VF or VT and be awake, alert and talking

Treat dysrhythmias in accordance with the appropriate dysrhythmia protocol