Left Ventricular Assist Device Management in the ICU

Article · November 2013with136 Reads
DOI: 10.1097/01.ccm.0000435675.91305.76 · Source: PubMed
Abstract
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.
    • with fewer complications than their predecessors, which has improved the quality of life for BTT and DT pa- tients [6][7][8]. Continuous-flow LVADs available today produce two types of blood flow: centrifugal or axial [9] . In a centrifugal pump, blood is captured between rotating blades, which spin and, basically, throw the blood tangentially out from the blade tips (an induced force).
    [Show abstract] [Hide abstract] ABSTRACT: Mechanical circulatory assist devices are now commonly used in the treatment of severe heart failure as bridges to cardiac transplant, as destination therapy for patients who are not transplant candidates, and as bridges to recovery and "decision-making". These devices, which can be used to support the left or right ventricles or both, restore circulation to the tissues, thereby improving organ function. Left ventricular assist devices (LVADs) are the most common support devices. To care for patients with these devices, health care providers in emergency departments (EDs) and intensive care units (ICUs) need to understand the physiology of the devices, the vocabulary of mechanical support, the types of complications patients may have, diagnostic techniques, and decision-making regarding treatment. Patients with LVADs who come to the ED or are admitted to the ICU usually have nonspecific clinical symptoms, most commonly shortness of breath, hypotension, anemia, chest pain, syncope, hemoptysis, gastrointestinal bleeding, jaundice, fever, oliguria and hematuria, altered mental status, headache, seizure, and back pain. Other patients are seen for cardiac arrest, psychiatric issues, sequelae of noncardiac surgery, and trauma. Although most patients have LVADs, some may have biventricular support devices or total artificial hearts. Involving a team of cardiac surgeons, perfusion experts, and heart-failure physicians, as well as ED and ICU physicians and nurses, is critical for managing treatment for these patients and for successful outcomes. This review is designed for critical care providers who may be the first to see these patients in the ED or ICU.
    Full-text · Article · Dec 2016
    • Overall, providers should transition anticoagulation appropriately, withhold it entirely if there are concerns for hemorrhage, and be prepared for transfusion when indicated. Patients awaiting transplantation should receive leukoreduced and irradiated blood products, though indications for transfusion are unchanged from patients without devices [35].
    [Show abstract] [Hide abstract] ABSTRACT: The use of ventricular assist devices has expanded significantly since their approval by the Food and Drug Administration in the United States in 1994. In addition to this, the prevalence of heart failure continues to increase. We aim to provide an overview of perioperative considerations and management of these patients for non-cardiac surgery. We performed a Medline search for the words “ventricular assist device,” “Heartmate” and “HeartWare” to gain an overview of the literature surrounding these devices, and chose studies with relevance to the stated aims of this review. Patients with ventricular assist devices are presenting more frequently for surgery not related to their cardiac pathology. As the mechanically supported population grows, general anesthesiologists will be faced with managing these patients, possibly outside of the tertiary care setting. The unique challenges of this patient population can best be addressed by a thorough understanding of ventricular assist device physiology and a multidisciplinary approach to care.
    Full-text · Article · Dec 2015
    • These findings must be corroborated by further independent cohort studies. MiR-423-5p might be also investigated in more severe forms of AHF including cardiogenic shock where biomarkers are needed to help predicting failure of medical therapy and the need of ventricular device as bridge to therapy [32].Table 3 and inFig 2. (XLSX)
    [Show abstract] [Hide abstract] ABSTRACT: Background: The biomarker value of circulating microRNAs (miRNAs) has been extensively addressed in patients with acute coronary syndrome. However, prognostic performances of miRNAs in patients with acute heart failure (AHF) has received less attention. Methods: A test cohort of 294 patients with acute dyspnea (236 AHF and 58 non-AHF) and 44 patients with stable chronic heart failure (CHF), and an independent validation cohort of 711 AHF patients, were used. Admission levels of miR-1/-21/-23/-126/-423-5p were assessed in plasma samples. Results: In the test cohort, admission levels of miR-1 were lower in AHF and stable CHF patients compared to non-AHF patients (p = 0.0016). Levels of miR-126 and miR-423-5p were lower in AHF and in non-AHF patients compared to stable CHF patients (both p<0.001). Interestingly, admission levels of miR-423-5p were lower in patients who were re-admitted to the hospital in the year following the index hospitalization compared to patients who were not (p = 0.0001). Adjusted odds ratio [95% confidence interval] for one-year readmission was 0.70 [0.53-0.93] for miR-423-5p (p = 0.01). In the validation cohort, admission levels of miR-423-5p predicted 1-year mortality with an adjusted odds ratio [95% confidence interval] of 0.54 [0.36-0.82], p = 0.004. Patients within the lowest quartile of miR-423-5p were at high risk of long-term mortality (p = 0.02). Conclusions: In AHF patients, low circulating levels of miR-423-5p at presentation are associated with a poor long-term outcome. This study supports the value of miR-423-5p as a prognostic biomarker of AHF.
    Full-text · Article · Nov 2015
    • 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.
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · May 2014
  • [Show abstract] [Hide abstract] 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.
    Article · May 2014
  • [Show abstract] [Hide abstract] 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.
    Article · Jun 2014
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July 2014 · Critical Care Medicine · Impact Factor: 6.31
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March 2013 · Seminars in Thoracic and Cardiovascular Surgery
The use of long-term left ventricular assist devices (LVADs) has revolutionized the treatment of end-stage heart failure. The most significant advance in this field has been the longer durability of devices secondary to a simpler pump design with fewer or no mechanical bearings and valves. Continuous-flow LVADs have recently been shown to provide safe and effective circulatory support and have... [Show full abstract]
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September 2013 · The Annals of thoracic surgery · Impact Factor: 3.85
Because no series has specifically analyzed the impact of preoperative atrial fibrillation (AF) on patients already at higher risk of thromboembolism after implantation of a left ventricular assist device (LVAD), we review our experience with these patients. Between July 2003 and September 2011, 389 patients (308 male) underwent implantation of a continuous flow LVAD at University of Michigan... [Show full abstract]
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Patients in acute and chronic heart failure have the options of several mechanical circulatory support devices to assist them as ventricular assist devices. These devices may be used temporarily in acute decompensation or as part of a long-term strategy in chronic disease. Strategic goals of resolution/diminution of heart failure, bridge to transplant, or as a permanent “destination” therapy... [Show full abstract]
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