Left ventricular assist device management in patients chronically
supported for advanced heart failure
Jennifer Cowgera, Matthew A. Romanob, John Stulakb, Francis D. Paganiband
Keith D. Aaronsona
In 1963, Dr Domingo Liotta at Baylor University College
of Medicine implanted the first left ventricular assist
device (LVAD) for the management of postcardiotomy
shock in a patient who had undergone double valve
surgery . After support on the Liotta-DeBakey LVAD
for 10 days at a flow of 1200ml/min, the patient recovered
myocardial function. This pivotal experience foresha-
dowed a new era of heart failure management employing
long-term mechanical circulatory support. With minimal
improvements made over the last 20 years in posttrans-
plant survival (50% at 10 years)  and the burdens and
complications of the required posttransplant medical
regimen, it is not unrealistic to envision a future where
mechanical circulatory support is deemed preferable to
transplant by many patients and physicians.
Although still in its infancy in 2011, mechanical circula-
tory support has already rapidly evolved. LVAD manu-
facturers have improved device size, fluid dynamics,
durability, and battery life. Patient selection, surgical
technique, and postoperative patient management con-
tinue to be refined, reducing the frequency of device
complications, patient morbidity and mortality. In the
destination therapy population, for whom 1-year survival
in the medical arm of the REMATCH trial was 25%,
survival of advanced heart failure destination therapy
patients supported with a HeartMate XVE LVAD was
the HeartMate II Destination Therapy trial, destination
therapy survival was further extended to 68% at 1 year
While the greatest hazard for mortality with LVAD
therapy will likely always be the early perioperative
period, the cumulative hazard for death on LVAD sup-
port has not plateaued in any major trial or registry
analysis to date. Thus, to ensure the best outcomes for
our patients on chronic LVAD support, frequent out-
patient follow-up and vigilant device, driveline, and heart
failure management are obligatory. This review will
discuss the important complications faced by patients
on chronic LVAD support and means of reducing the risk
for such complications.
Early postoperative management
The operative period imparts the greatest risk for death
following LVAD implantation. In the second annual
report of the Interagency Registry for Mechanical Cir-
culatory Support (INTERMACS), 3-month mortality for
aDivision of Cardiovascular Medicine andbSection of
Cardiac Surgery, University of Michigan Health System,
Ann Arbor, Michigan, USA
Correspondence to Jennifer Cowger, MD, MS,
University of Michigan Cardiovascular Center, 1500 E.
Medical Center Drive, SPC 5853, Ann Arbor,
MI 48109-5853, USA
Tel: +1 734 936 5265;
Current Opinion in Cardiology 2011,
Purpose of review
This review summarizes management strategies to reduce morbidity and mortality in
heart failure patients supported chronically with implantable left ventricular assist
As the population of patients supported with long-term LVADs has grown, patient
selection, operative technique, and patient management strategies have been refined,
leading to improved outcomes. This review summarizes recent findings on LVAD
candidate selection, and discusses outpatient strategies to optimize device
performance and heart failure management. It also reviews important device
complications that warrant close outpatient monitoring.
Managing patients on chronic LVAD support requires regular patient follow-up,
multidisciplinary care teams, and frequent laboratory and echocardiographic
surveillance to ensure optimal outcomes.
end-stage heart failure, left ventricular assist device, patient management
Curr Opin Cardiol 26:149–154
? 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
0268-4705 ? 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/HCO.0b013e3283438258
the 1283 patients undergoing primary LVAD implant
survival was lower in those with advanced age, preopera-
tive cardiogenic shock (requiring vasopressors or preo-
perative temporary mechanical support), evidence of
right ventricular dysfunction, and those for whom the
intended device strategy was not bridge to transplant
(i.e., destination therapy or bridge to candidacy) (Fig. 1b)
[5??]. In other studies, risks for death and morbidity in
the LVAD perioperative period include requirements
for preoperative ventilator support [6,7], high periopera-
tive transfusion requirements
[6,8?,9], and the development of renal failure following
LVAD implant [10?]. Thus, early LVAD survival relies
on careful patient selection and vigilant perioperative
Left ventricular assist device candidate selection
Patient selection is paramount for success after LVAD
support and this has been the subject of prior review
[11?,12]. The Lietz–Miller destination therapy risk score
was developed from 222 individuals undergoing Heart-
Mate XVE implant for destination therapy and may be
useful for distinguishing destination therapy candidates
at high risk for poor outcome on LVAD support . The
validity of this score in the bridge to transplant or ‘less ill’
population, as well as those on more contemporary
devices, warrants investigation.
Strategies to reduce right ventricular failure, bleeding,
and infection risks are the focus of perioperative LVAD
and patient management. The authors refer readers to a
Figure 1 Survival and hazard for death and survival by device strategy
369 121518 21 24
Months after device implant
Survival after primary LVAD
Device strategy at implant
0369 12 1518 21 24
Months after device implant
: June 2006 – March 2009
Primary LVAD: n = 1092, deaths = 191
Intermacs: June 2006 – March 2009
Primary LVAD: n = 1092
DT = 100, deaths = 39
BTC = 458, deaths = 92
BTT = 496, deaths = 54
Event: Death (censored at transplant or recovery)
Event: Death (censored at transplant or explant recovery)
P < 0.0001
implant in 1092 patients enrolled into INTERMACS are shown. All patients underwent implant of Food and Drug Administration-approved LVADs. At
the bottom, the cumulative hazard for mortality (censoring for transplant or recovery) is also shown. (b) Survival by device strategy following LVAD
implant in INTERMACS. Kaplan–Meier estimates of survival according to intended device strategy [bridge to transplant (BTT), destination therapy
(DT), bridge to candidacy (BTC)] is shown for patients undergoing LVAD implant in INTERMACS. Reproduced with permission from [5??].
prior review on pre and early postoperative LVAD man-
agementstrategiestoreduce rightventricular failurerisks
[14?]. In addition to a vigilant intraoperative hemostatic
technique , preemptive preoperative assessment of
bleeding and right ventricular failure risk is important
[8?,15]. When possible, glycoprotein (GP)2b3a inhibitors
and vitamin K antagonists should be discontinued well in
advance of surgery and international normalized ratios
(INRs) should be normalized. Measures to reduce hepa-
tic congestion (diuresis, inotropes, right ventricular after-
load reduction) and improve nutritional status should be
undertaken.AtthetimeofLVAD initiation, optimization
of speeds/flows should be done with transesophageal
echocardiogram guidance to minimize septal shift and,
thereby, right ventricular wall stress. Early postoperative
inotrope administration with close monitoring of cardio-
pulmonary hemodynamics is often beneficial for right
ventricular support and to assist with management of
mobilized intraoperative fluids.
Reducing complications: management of the
outpatient on long-term left ventricular assist
include infection, stroke, device thrombosis, gastrointes-
tinal bleeding, and recurrent heart failure symptomatol-
ogy with or without multisystem organ failure [16??].
The University of Michigan (UofM) LVAD program’s
until they are 6 months postoperative to allow laboratory,
driveline line and volume status monitoring, LVAD
speed optimization, and frequent patient and caregiver
(re)education. After this point, return visits are extended
to 2–3-month intervals unless complications arise.
Heart failure management after left ventricular assist
Heart failure management after LVAD implant should
include the application of standard American College
of Cardiology/American Heart Association (ACC/AHA)-
recommended evidence-based medications for heart
failure – angiotension inhibitors and receptor blockers
(ARB), beta-blockers, and aldosterone antagonists .
In addition to offering a few patients the chance for
myocardial recovery while on LVAD support, these
medications work with the LVAD to reduce the acti-
vation of the renin–angiotensin–aldosterone system
(RAAS) and sympathetic nervous system (SNS). The
RAAS and SNS not only play critical roles in adverse
myocardial remodeling that may impact long-term left
ventricular and right ventricular performance; they also
drive fluid retention and increase systemic afterload.
Hydralazine and nitrate combination therapy can be
added to the medical regimen of patients who are on
maximal tolerated doses of the above medications,
particularly in the setting of elevated pulmonary vascular
resistance or systemic hypertension.
Finally, studies have shown that ventricular arrhythmias
occur at increased frequency following LVAD implant,
especially in the early postoperative period when normal
repolarization is disrupted by myocardial edema and
inflammation [18,19?,20]. In a prospective study of 61
patients with an implantable converter defibrillator
(ICD) in place, 34% of patients supported for a mean
of 365 days had an appropriate device intervention for a
ventricular arrhythmia [19?]. Thus, ICD prophylaxis
should be strongly considered in patients undergoing
LVAD support; it is standard practice at our center.
all LVAD models and manufacturers is beyond the scope
of this paper. In general, care strategies aim to set device
load while simultaneously avoiding perturbation of right
centrifugal pumps) are very afterload sensitive and tight
blood pressure control (goal mean arterial pressure 60–
90mmHg) should be achieved to facilitate optimal device
flows and reduce device power consumption.
Echocardiography is a critical tool to guide LVAD speed/
flow optimization. Device settings should allow for
decompression of the left ventricle (LV), leading to a
reduction in left ventricular volumes and/or dimensions
from preimplant measures. With appropriate LVAD
flows/speeds, left ventricular afterload is reduced and,
consequently, mitral regurgitation should be insignifi-
cant. The apical four chamber view is useful for visual-
ization of the interventricular septum and the left ven-
tricular inflow cannula. Leftward displacement of the
septum induced by high LVAD inflows should be
avoided due to the impact on right ventricular wall stress
and potential for device-induced suction events. Doppler
interrogation of the inflow cannula should be without
turbulence. Elevated inflow velocities may suggest
Finally, there is growing evidence that aortic insuffi-
ciency tends to progress with the duration of LVAD
support, potentially due to LVAD-induced shear-stress
damage to the aortic root and the root side of the aortic
valve [21?,22?]. While the clinical impact of aortic insuf-
ficiency on LVAD outcomes is not yet known, it could
lead to ineffective LVAD output through blood recircu-
lation. Thus, aortic insufficiency should be monitored in
patients on LVAD support and device speeds may need
to be adjusted accordingly if clinical heart failure is noted
with aortic insufficiency progression. There is data to
suggestthatafullyopeningaorticvalvemay haveless ofa
Left ventricular assist device management Cowger et al. 151
propensity for developing regurgitation [21?]. However,
it is unclear at this time whether optimizing device
speeds to ensure regular valve opening will prevent
ing valve will reduce the likelihood of leaflet fusion, and
maintenance of normal aortic valve operation is likely
important for those in whom myocardial recovery is
anticipated. The risk of development of aortic root
thrombosis is also lessened in the setting of intermittent
aortic valve opening.
Until a fully implantable technology is available, infec-
tion will remain the biggest obstacle to the success of
truly long-term LVAD support. The hazard for sepsis is
highest in the early postoperative period but never
reaches zero, and infection is associated with a marked
reduction in LVAD survival [16??,23,24?,25]. In the
REMATCH trial, freedom from sepsis at 1 year in Heart-
Mate XVE-supported patients was 58%, and 1-year sur-
vival in those with sepsis was 38% compared with 60% in
those without. Device-related infections without septi-
cemia are also prevalent and offer little better prognosis.
In the 465 patients supported with pulsatile pumps in an
INTERMACS (2006–2008) analysis, the infection rate at
12 months was 1.99 events per patient [24?]. In the
HeartMate II Destination Therapy trial, LVAD-related
infections (pump, pump pocket, driveline) occurred at
rates of 0.48 and 0.90 events/patient-year for HeartMate
II and HeartMate XVE devices, respectively [4??]. Case
series have demonstrated that 60–70% of patients with a
driveline infection require further surgical intervention,
and 20–35% progress to pump infections requiring either
driveline infection include duration of LVAD support
, known driveline trauma , and larger body mass
index [27,28]. While studies have suggested that Heart-
Mate XVE devices are associated with higher risk for
driveline infection compared with the HeartMate II
[4??,28], a recent report suggests that patient character-
istics and implant era may confound the interpretation
of these prior nonadjusted analyses [29?]. Further, the
association between driveline infections and pump
pocket infections is anticipated to be much less frequent
with the HeartWare HVAD device, as this intrapericar-
dially positioned device does not have an abdominal
To reduce infectious complications, patient education on
driveline care and infection warning signs is important.
Education should encompass aseptic driveline cleansing
techniques (which can rarely be performed by the patient
alone) and appropriate driveline fixation using an
abdominal binder and Velcro driveline ‘lead locks’.
Our patients are instructed to wear their binder 24h a
day due to the risk for driveline disruption during sleep.
Patients should be educated on avoiding activities that
may lead to driveline displacement or bandage soiling.
Antimicrobial prophylaxis administered in the periopera-
tive period is targeted at culprit Gram-positive organisms
(Staphylococcus species) as well as certain Gram-negative
(Pseudomonas, Serratia) and fungal (Candida) pathogens.
The duration of postoperative antimicrobial therapy and
specific regimens administered are heterogeneous across
LVAD institutions. Most will continue oral therapy until
full driveline incorporation, which occurs between 3 and
6 months postoperative. At UofM, we use dual therapy
(doxycycline and a fluoroquinolone) until the driveline is
incorporated and then continue therapy with a single
agent thereafter. For some destination therapy patients
felt to be at high risk for infection, dual therapy may be
continued indefinitely, but there is no evidence-based
data to support either practice.
Balancing bleeding risk with thrombosis and thrombotic
Anticoagulation and antiplatelet therapy are required for
most LVADs due to the potential for in-situ device
thrombus formation and cardioembolic complications.
For the HeartMate II device, rates of device thrombosis
in the major trials were very low (0.02–0.03 events/
patient-year), with rates of ischemic stroke ranging from
XVE arm of the HeartMate II Destination Therapy trial
had a device thrombosis, and ischemic stroke rates were
0.10 events/patient-year [4??]. In the outpatient setting,
close monitoring of INRs, serum lactic acid dehydrogen-
ase, serum free hemoglobin, bilirubin, and hematocrit
levels is important.
INTERMACS defines clinically significant hemolysis as
a serum free hemoglobin more than 40mg/dl more than
72h after device implant with other clinical signs .
Whether other thresholds or other markers of hemolysis
are more sensitive/specific for predicting adverse events
The low thrombotic event rates discussed above come
at increased risks for bleeding complications, even in
patients on HeartMate XVE support for whom warfarin is
not required. In addition to pharmacologic-induced
bleeding diathesis, LVAD support has been shown to
impact hemostasis. Acquired von Willebrand syndrome
with a reduction in von Willebrand factor (vWF) high
molecular weight multimers has been well characterized
and tends to onset early (as soon as 24h) after LVAD
support, resolving upon device explant [32??,33??,34].
Other LVAD-induced changes in the coagulation system
include a reduction in factors XI and XII and an increase
in markers of fibrinolysis . In the major trials,
bleeding requiring blood product transfusion occurred
in 42–81% of patients and bleeding requiring surgery
occurred in15–30%ofLVAD patients [3,4??,30].Hemor-
rhagic stroke rates range from 0.05 to 0.11 events/patient-
year [3,4??,30]. Of growing concern are complications
from gastrointestinal bleeding. Similarly to Heyde’s
syndrome in aortic stenosis, patients on LVAD support
can develop gastrointestinal arteriovenous malformations
with high propensity for bleeding due to acquired vWF
deficiency. Cohort studies show a cumulative incidence
of gastrointestinal bleeding ranging from 32% (mean
patient follow-up 371 days) to 40% (follow-up unknown)
with a mean time to first bleed of 112 and 87 days,
respectively [32??,36?]. Angiodysplastic bleeds can occur
anywhere in the gastrointestinal tract, tend to be recur-
rent, and carry associated burdens of blood transfusion
and allosensitization risk. Compared with pulsatile flow
devices, the risk for angiodysplasia development appears
to be higher in patients supported with continuous flow
LVADs, but further studies are underway [36?,37].
Unfortunately, there is no known intervention to prevent
or reduce gastrointestinal bleeding risk.
Patient and family education
Because patient device management is integral to LVAD
success, one of the most important components of out-
patient management is education. In addition to the
extensive inpatient education provided after LVAD
implant, re-education in the outpatient arena is key.
(1) device alarms;
(2) proper battery management: changing batteries, car-
rying back up batteries, purchasing an electric gen-
erator for emergency use;
(3) aseptic driveline care and occlusive bandaging;
(4) drivelinefixation: proper positioning and sizing ofthe
abdominal binder, proper fixation of leads to avoid
fracture, high-risk activities that may increase drive-
line infection risk;
(5) controller fixation;
(6) signs and symptoms of gastrointestinal bleeding.
LVAD therapy offers patients with advanced heart failure
improved survival and quality of life. To ensure that
greatest benefits are gained from LVAD support for the
longest duration necessary, careful heart failure, driveline,
and device management are key. A multidisciplinary
approach to patient care that includes cardiac surgeons,
social work are vital to the success of an LVAD program
should include patient and caregiver education with fre-
quent attempts at re-education. Due to the complexity of
LVAD management and the present ‘novelty’ of the
ders who specialize in LVAD care is essential for patients
and outside practitioners.
Disclosures for Drs Aaronson and Pagani – Both doctors have
relationships with HeartWare (unpaid) and Terumo as members of
Clinical Steering Committees. Dr Aaronson’s interactions with Heart-
Ware and Thoratec are regulated by Conflict Management Plans on file
with the University of Michigan’s Conflict of Interest Board. The other
doctors have nothing to disclose.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 173).
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