Left Ventricular Assist Device Management in the ICU

1Surgical Critical Care Services, MedStar Washington Hospital Center, Washington, DC. 2Advanced Heart Failure Program, MedStar Heart Institute, MedStar Washington Hospital Center, Washington, DC.
Critical care medicine (Impact Factor: 6.31). 11/2013; 42(1). DOI: 10.1097/01.ccm.0000435675.91305.76
Source: PubMed


To review left ventricular assist device physiology, initial postoperative management, common complications, trouble shooting and management of hypotension, and other common ICU problems.
Narrative review of relevant medical literature.
Left ventricular assist devices prolong the lives of patients with end-stage heart failure, and their use is increasing. Continuous-flow left ventricular assist devices have replaced first-generation pulsatile devices. These patients present unique management concerns. In the immediate postimplant period, care must be taken to support the unassisted right ventricle. Invasive monitors for blood pressure, pulmonary artery catheterization, and echocardiography are essential to optimize left ventricular assist device settings and cardiac performance. Anticoagulation is necessary to prevent devastating thrombotic and embolic complications, but bleeding is a major source of morbidity due to inherent bleeding diatheses and prescribed anticoagulants. Infection of the device can be life threatening, and all infections must be aggressively treated to avoid seeding the device. Patients are at risk of ventricular arrhythmias because of their underlying disease, as well as the placement and position of the inflow cannula. Aortic valve stenosis and insufficiency develop over time and can lead to thrombosis or heart failure. Cardiopulmonary resuscitation with chest compressions must be performed with care or not at all due to risk of dislodging the device.
Intensivists are increasingly likely to encounter patients requiring mechanical circulatory support with left ventricular assist devices at various points in the trajectory of their disease, from the immediate postimplant period to subsequent admissions for complications, and at end of life. A basic understanding of left ventricular assist device physiology is essential to the safe and effective care of these patients.

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    • "The surgeon opted for abdominal-only cardiopulmonary resuscitation (AO-CPR), fearing damage to inflow cannula with external cardiac compressions (ECCs). This theoretical risk is thought to be greater with larger preperitoneal devices, such as HeartMate II [2]. The 2009 European Association for Cardio-Thoracic Surgery guidelines on resuscitation following cardiac surgery [3] do not address this particular scenario, possibly because of a paucity of evidence at the time of guideline generation. "
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    ABSTRACT: A best evidence topic was written according to a structured protocol to determine whether there is evidence that cardiopulmonary resuscitation (CPR) by compressing the chest is safe and effective in patients with left ventricular assist devices (LVADs). Manufacturers warn of a possible risk of device dislodgement if the chest is compressed. AMED, EMBASE, MEDLINE, BNI and CINAHL were searched from inception to March 2014. Animal studies, case reports, case series, case-control studies, randomized controlled studies and systematic reviews were eligible for inclusion. Opinion articles with no reference to data were excluded. Of 45 unique results, 3 articles merited inclusion. A total of 10 patients with LVADs received chest compression during resuscitation. There was no report of device dislodgement as judged by postarrest flow rate, autopsy and resumption of effective circulation and/or neurological function. The longest duration of chest compression was 150 min. However, there are no comparisons of the efficacy of chest compressions relative to alternative means of external CPR, such as abdominal-only compressions. The absence of high-quality data precludes definitive recommendation of any particular form of CPR, in patients with LVADs. However, data identified suggest that chest compression is not as unsafe as previously thought. The efficacy of chest compressions in this patient population has not yet been investigated. Further research is required to address both the safety and efficacy of chest compressions in this population. Urgent presentation and publication of further evidence will inform future guidance.
    Interactive Cardiovascular and Thoracic Surgery 05/2014; 19(2). DOI:10.1093/icvts/ivu117 · 1.16 Impact Factor
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    ABSTRACT: The key determinants of organ perfusion are (a) generation of a blood pressure within the range that allows end-organs to maintain constant blood flow and (b) delivery of oxygen at values exceeding the current rate of consumption. Deliberate evaluation of these physiologic relationships throughout cardiac surgery and postoperatively can be used to define an individual's risk for organ dysfunction and to establish end points of resuscitation. A consistent focus on these parameters is relevant to all patient conditions regardless of whether the patient is in or out of the operating room, or whether receiving extracorporeal support. While the focus of this issue of SCVA is on cardiopulmonary bypass, optimizing oxygen delivery is relevant to all high-risk operative patients and their postoperative care. The reader will note that some of the monitoring modalities are more appropriate for use in the operating room than intensive care unit, and vice versa. Matching key patient problems to the different performance characteristics and anatomical constraints of each monitoring modality demands a focused yet flexible mindset.
    Seminars in Cardiothoracic and Vascular Anesthesia 05/2014; 18(2):117-136. DOI:10.1177/1089253214534781
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    ABSTRACT: Background: Cranial intraparenchymal hemorrhage represents a critical complication of mechanical circulatory support requiring constant antithrombotic treatment. Surgery of intraparenchymal hemorrhage under anticoagulation represents a challenge and imposes significant risks for patients. It was the aim to analyse surgical and clinical outcome of patients requiring surgical treatment due to intraparenchymal hemorrhage. Methods: Patients with mechanical circulatory support requiring surgical therapy due to space-occupying lobar supratentorial or infratentorial hemorrhage from January 1, 2009 to January 1, 2014 were included in our study. Baseline parameters are preoperative International Normalized Ratio (INR) values, postoperative anticoagulation regiment, bleeding size and localization. Co-primary outcome parameters were the extent of hematoma evacuation and the Modified Rankin Scale at discharge from hospital. Secondary outcome parameters included rate of recurrent hemorrhage, rate of revision surgery and in-hospital mortality. Results: Twelve patients (mean age 44 ± 18 years, nine supratentorial-/three infratentorial hemorrhages, 11 left ventricular assist devices, and one extracorporeal membrane oxygenation) were included. Surgical hematoma evacuation was performed in 11 patients, one patient received decompressive hemicraniectomy. Hematoma evacuation was complete in no patients, and partial in 11 patients. Initial INR was 2,7 ± 1,6. Rate of recurrent hemorrhage was 75 %. Revision surgery was performed in three patients achieving partial hematoma evacuation in two patients and complete evacuation in one patient. Modified Rankin Scale at discharge from hospital was six in nine patients (in-hospital mortality of 75 %), five in two patients and four in one patient. Conclusions: Surgical treatment of life threatening, space-occupying intraparenchymal hemorrhage under mechanical circulation support is of limited efficacy with high rates of recurrent hemorrhage and in-hospital mortality. We provide additional data that postponing anticoagulation is feasible and may lead to improved clinical outcome and survival.
    Acta Neurochirurgica 06/2014; 156(9). DOI:10.1007/s00701-014-2141-6 · 1.77 Impact Factor
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