2. Objectives
• Define Ventricle Assist Device
• Identify hemodynamic differences in patients with a VAD
• List VAD related complication
• Demonstrate how to assess a patient with a VAD
• Describe how to treat VAD complications
• Identify VAD resources that can be utilized when caring
for these patients
3. What is a VAD?
• A left ventricular assist device (LVAD) is a pump that is
used for patients who have reached end-stage heart
failure or awaiting a heart transplant. The LVAD’s are
surgically implanted and are attached to the left ventricle
and aorta. The LVAD is a battery-operated, mechanical
pump, which then helps the left ventricle pump blood to
the rest of the body.
4. Ventricular Assist Device (VAD)
• A mechanical pump that is surgically attached to
one of the heart’s ventricles to augment or replace
native ventricular function
• Can be used for the left (LVAD), right (RVAD), or
both ventricles (BiVAD)
• Are powered by external power sources that connect
to the implanted pump via a percutaneous lead
(driveline) that exits the body on the right abdomen
• Pump output flow will be non-pulsatile
5. Indications for VAD
Bridge to transplant (BTT)
• Most common
• Allow rehab from severe
CHF while awaiting a
donor heart
“Destination” therapy (DT)
• Permanent device, instead
of transplant
• Currently only in
transplant-ineligible
patients
Bridge to recovery (BTR)
• Unload heart, allow
“reverse remodeling”
• Can be short term or
long term
Bridge to candidacy (BTC)/
Bridge to decision (BTD)
• When eligibility unclear
at implant
• Not true “indication” but
for many pts
6. VAD Setup
Continuous-flow devices
• Impeller (spinning turbine-like rotor blade) propels blood continuously
forward into systemic circulation.
• Axial flow: blood leaves impeller blades in the same direction as it enters
(think fan or boat motor propeller).
Most implanted devices are LVADs only
LVAD’s are quite and cannot be heard outside of the patient’s body.
Assess VAD status by auscultation over the apex of the LV. The VAD
should have a continuous, smooth humming sound.
The Patient may have a weak, irregular, or non-palpable pulse
The Patient may have a narrow pulse pressure and may not be
measurable with automated blood pressure monitors. This is due to
the continuous forward outflow from the VAD. Recommended use of
a Doppler and a manual B/P cuff to obtain B/P.
The Mean Arterial Pressure is the key in monitoring hemodynamics.
Ideal range is 65-90 mmHg.
7. VAD Key Parameters
Flow:
• Measured in liters per minute
• Correlates with pump speed (speed=flow,
↓speed=↓flow)
• Dependent on Preload and Afterload
Speed:
• How fast the impeller of the internal pump spins
• Measured in revolutions per minute (rpm)
• Flow speed is set and determined by VAD clinical
team and usually cannot be manipulated outside of
the hospital
8. VAD Key Parameters
Power:
• The amount of power the VAD consumes to
continually run at a set speed
• Sudden or gradual sustained increases in the power
can indicate thrombus inside the VAD
Pulsatility Index (PI):
• A measure of the pressure differential inside the
internal VAD pump during the native heart’s cardiac
cycle
• Varies by patient
• Indicates volume status, right ventricle function, and
native heart contractility
9. VAD Key Parameters
The device parameters are displayed
numerically on the VAD console or controller
Will vary with each individual patient a VAD
device
10. VAD Parameters
Parameters for VAD devices vary with each
device model
Patients and their care givers know the
expectable parameter ranges and goals for
their specific device
Contact the VAD Coordinator at the
implanting medical center, they will be your
best resource when treating a VAD patient.
15. Problems And Complications
Major VAD Complications
Bleeding
Thrombosis
Infection
•sepsis is leading cause of death in long-term
VAD support
RV dysfunction/failure
Suckdown (low preload causes a nonpulsatle
VAD to collapse the ventricle)
Device failure/malfunction (highly variable by
device type)
Hemolysis (the VAD destroys blood cells)
16. Problems And Complications
Other Common Issues
Arrhythmias
•A patient can be in a lethal arrhythmia and be
asymptomatic. Treat the patient not the monitor.
•Do not cardiovert/ defib. unless the patient is
unstable with the arrhythmia.
•Do not initiate chest compressions unless
instructed by a physician or VAD coordinator.
Chest compressions can disrupt the implanted
equipment causing bleeding and death
•Electrical shock from cardiovert/ defib. will not
damage any of the VAD equipment
17. Problems And Complications
Other Common Issues
Hypertension
•High afterload can limit VAD flow/ output
•Do not administer antihypertensive
medications or nitrates unless instructed
by a physician or VAD Coordinator
Hypotension/ loss of Preload
•All VADs are preload dependent. A loss or
reduction in preload will compromise
VAD function and limit flow/ output
18. Problems And Complications
Other Common Issues
Depression/ Adjustment Disorders
•Living with a VAD is difficult to
management for a lot of patients.
•A large percentage of patients experience
symptoms of depression
Portability/ Ergonomics
•The external VAD equipment is heavy and
cumbersome limiting a patient’s mobility
and greatly impacting their quality of life.
19. Problems And Complications
Bleeding & Thrombosis
Careful control of anticoagulation is
imperative
•Patients are often on both anticoagulants
and platelet inhibitors
•Device thrombosis
Typically revealed by increased power
and signs and symptoms of hemolysis
20. Problems And Complications
Bleeding & Thrombosis Treatment
• Assess for signs and symptoms of
bleeding
• Neuro Assessment to rule out CVA
• Initiate IV therapy and administer
fluid slowly to maintain preload
• Device Thrombus is treated with low
dose lytics and/ or increasing
anticoagulation therapy
21. Problems And Complications
Infection
• The leading cause of mortality in VAD
patients
• Higher incidence in pulsatile VADs
• The driveline provides direct access into
the body and into the blood stream
• Often recurrent and difficult to treat
22. Problems And Complications
Suckdown
LV collapse due to
hypovolemia/hypotension or VAD
overdrive
Indicators: hypotension, PVCs/VT,
low VAD flows.
23. Problems And Complications
Treating Suckdown
• Initiate a peripheral IV and slowly
give volume to increase preload
• Assess for signs and symptoms of
bleeding and sepsis
24. Problems And Complications
Device Failure
This is a true emergency requiring immediate
transport to the implanting VAD center
Patients & caregivers are trained to
identify signs and symptoms of device
failure
May require the VAD to be replaced
26. Problems And Complications
Treating Hemolysis
• Initiate a peripheral IV and slowly
give volume
• If thrombus is suspected to be
causing hemolysis, administer lytics
and anticoagulants as able/ ordered
27. Alarms
All VAD devices typically have two
distingue alarms to indicate a problem
and it’s severity
• Advisory Alarms
• Critical/ Hazardous Alarms
28. Alarms
Advisory Alarms are intermittent beeping sounds
that have a corresponding YELLOW light that
illuminates on the system controller
• Not critical but the device requires attention
• Likely due to low battery, cable disconnected,
or device not functioning properly.
29. Alarms
Hazardous or Critical alarms are a loud,
continuous, shrill sound that have a
corresponding RED light that illuminates on
the system controller
• Indicating the device needs immediate
attention
• Often because the pump has stopped or a
problem is detected with the system
controller
• Most likely intervention required is to
change out the system controller
30. Field Management
All VADs are dependent on adequate preload in
order to maintain proper functioning
Volume resuscitation in an unstable VAD
patient is the first line of therapy before
vasopressors but be cautious with fluid as to not
over load the right ventricle in L VADs only.
31. Field Management
Nitrates can be detrimental to a VAD patient
because of the reduction in preload
• Results in decreased pump efficiency
• Consult with medical control before
administering nitrates per protocol
32. Field Management
Initiate IV therapy with all VAD patients if
possible
• Use aseptic technique due to the
patient’s increased risks of infection
33. Field Management
VAD patients are susceptible to other injuries
unrelated to the VAD
Contact the VAD Coordinator, they are your
most valuable resource when encountering
these patients
Consult with medical control about transport
34. Patient Transport
This is emergency, resource and protocol driven decision
making
VAD patients require unique care that not all medical
centers are equipped to handle. Transport to the
implanting center when able or the closest VAD center
Make sure when transporting to bring all VAD related
equipment
Secure VAD batteries and the controller to prevent
dropping or damage. If batteries need to be changed
during transport, change one at a time system will alarm
during battery change but this is normal and will stop.
Make sure to keep all cables tangle and kink free
35. Pre-Planning For Transport
Medical Control
• Inquire ahead of time the level of knowledge/
comfort with your medical directors regarding the
management of VAD patient
Know Transport Options
• Air vs. Ground
• Know your tertiary facilities and their ability to
management VAD patients
36. Things To Remember
EMS can walk into just about any situation
Depending on the individuals- the family may not be
able to handle the emergency
Listen to the family members that can handle the
emergency and “assist” them with whatever they need
The only resources/ tools you can truly rely on are the
ones you bring to the call
Follow-up and educate yourself to new technologies
that keep entering into the industry
37. Things To Remember
Ask for the contact number for the managing
center’s VAD Coordinator as soon as you arrive, this
should be on the person or close by. This is the
coordinator they work very closely with and will be
your best resource
Family, friends, co-workers- listen to them for
direction, they should be educated/ trained to assist
with most VAD related complications
911 activation may not be for a VAD related
emergency
38. Things To Remember
Emergency bag containing back-up VAD supplies
needs to stay with the patient at all times. Should
contain extra batteries and the spare system
controller
Ask the family for any trouble shooting guidelines
that maybe available. This often includes various
alarms and interventions
Remember that the family/ friends are not
emergency responders or maybe too upset to assist
you
If a VAD patient calls 911 it will not be for
something simple like a battery change. VAD related
emergencies are serious life threatening events
39. Additional resources materials and
information please visit:
www.thoratec.com
www.jarvikheart.com
www.umm.edu/heart/index.htm
