Drill of the Month

Developed by Michael Lindsay

An Overview of Ventricular Assist

Devices
&
Pre Hospital Management
 Student Objectives
At the conclusion of this Drill Students will
be able to:
Define Heart Failure
Define Ventricular Assist Device (VAD) and their use in treating
Heart Failure
Identify types of Ventricular Assist Devices
Explain the difference between Pulsatile and Nonpulsatile flow
Identify hemodynamic differences in patients with a VAD
List VAD related complications
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.
 Heart Failure
* Heart failure is a condition where the heart
cannot pump enough blood throughout the
body.
* It develops over time as the pumping
action of the heart grows weaker.
* Most cases involve the left side where the
heart cannot pump enough oxygen-rich
blood to the rest of the body.
* With right sided failure, the heart cannot
effectively pump blood to the lungs where
the blood picks up oxygen.
 What is a VAD?
A single system device that is surgically attached
to the left ventricle of the heart and to the aorta
for left ventricular support

For Right Ventricular support, the device is

attached to the right atrium and to the
pulmonary artery
 Ventricular Assist Device (VAD)
A mechanical pump that is surgically attached to one
of the hearts ventricles to augment or replace native
ventricular function
Can be used for the left (L VAD), right (R VAD), or
both ventricles (Bi VAD)
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 can be pulsatile or nonpulsatile
 Why Do We Need VADs?
Heart disease is the leading cause of death in the
Western world
~5 million people in the US have congestive heart
failure (CHF)
250,000 are in the most advanced stage of CHF
~500,000 new cases each year
~50,000 deaths each year
only effective treatment for end stage CHF is heart
transplant
 Why Do We Need VADs?

But, in 2008:

7318 people were waiting for a heart

2210 received one

623 died waiting

~1200-1500 VAD implanted in 2008

 Indications for VAD
Bridge to transplant (BTT) Destination therapy (DT)
most common
permanent device,

allow rehab from severe instead of transplant

CHF while awaiting currently only in
donor transplant-ineligible
patients
Bridge to recovery (BTR) Bridge to candidacy
unload heart, allow (BTC)/
reverse remodeling Bridge to decision (BTD)
can be short- or long- when eligibility unclear

term at implant
not true indication but

true for many pts

 Types of VADs

Pulsatile
and

Non Pulsatile
 Pulsatile
Ventricle-like pumping sac device.
Blood enters via the inflow cannula and fills a flexible

pumping chamber.
Electric motor or pneumatic (air) pressure collapses the

chamber and forces blood into systemic circulation via the

outflow cannula.

Can be LVAD, RVAD, or BiVAD

First-generation devices (in use since early 1980s)

Patients will have a palpable pulse and a measurable blood

pressure. Both are generated from the VAD output flow.
 Pulsatile VAD Key Parameters
Pump Rate:
How fast the VAD is pumping (filling & emptying)

Can be set at a fixed rate or can automatically

adjust
Pulsatile VADs are loud and the rate can be

assessed by listening

Output:
The amount of blood ejected from the VAD

Measured is liters per minute

Is dependent upon preload, afterload, and pump

rate
 Non-Pulsatile
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

Are quite and cannot be heard outside of the patients 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.

The Mean Arterial Pressure is the key in monitoring hemodynamics.

Ideal range is 65-90 mmHg.
Non Pulsatile 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
Non Pulsatile 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 hearts cardiac

cycle
Varies by patient

Indicates volume status, right ventricle function, and

native heart contractility

Non Pulsatile VAD Key Parameters

The device parameters are displayed numerically on

the VAD console or Controller

Will vary with each individual patient and VAD device

 VAD Parameters
Parameters for pulsatile and non pulsatile
devices vary with each device model

Patientsand their care givers know the

expectable parameter ranges and goals for
their specific device

Contactthe VAD Coordinator at the implanting

medical center, they will be your best resource
when treating a VAD patient.
 Basic VAD Management
ALL VADs are:
Preload-dependent

EKG-independent

Afterload-sensitive

Anticoagulated

Prone to:

infection
bleeding
thrombosis/stroke
mechanical malfunction
Key differences depend on pulsatile vs. non-

pulsatile device
VADs commonly seen in the
community
 Thoratec VAD (pVAD/iVAD)
Pneumatic, external(pVAD) or internal (iVAD), pulsatile
pump(s)
right-, left-, or bi-ventricular support
(RVAD/LVAD/BiVAD)
up to ~7.2 lpm flow
Short- to medium-term use (up to ~1-2 years)
bridge to recovery
bridge to transplant
hospital discharge possible

iVAD
pVAD
Thoratec pVAD
 HeartMate XVE LVAS
Internally implanted, electric pulsatile pump
left heart support only
up to 10 lpm flow
Medium- to long-term therapy (months to years)
bridge to transplant
destination therapy (only FDA-approved DT device)
 HeartMate II LVAS
Internally implanted, axial-flow (non-pulsatile) device
left heart support only
speed: 8000-15000 rpm
flow: ~3-8 lpm
Medium- to long-term therapy (months to years)
bridge to transplant (FDA-approved)
destination therapy (investigational)
 Jarvik 2000 LVAD
Axial-flow (non-pulsatile)
pump
electric, intra-ventricular
left heart support only
Speed: 8000-12000 rpm
flow: ~3-5 lpm
Medium- to long-term therapy
(months to years)
bridge to transplant
(investigational)
Jarvik 2000 LVAD
VAD Issues
 Problems/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)

 Problems/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
 Problems/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
 Problems/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 patients mobility and greatly impacting their
quality of life.
 Problems/Complications

Bleeding & Thrombosis

Careful control of anticoagulation is
imperative
Patients are often on both anticoagulants and
platelet inhibitors
Device thrombosis
rare in pulsatile devices
typically revealed by increased power and signs and
symptoms of hemolysis
 Problems/Complications
Bleeding & Thrombosis Tx
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
 Problems/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

 Problems/Complications
PreventingInfection
* Always observe clean/ sterile
technique when able

* Make sure driveline exit site is

covered with a clean, dry gauze
dressing
 Problems/Complications

Suckdown
LV collapse due to
hypovolemia/hypotension or VAD
overdrive
nonpulsatile devices only
indicators: hypotension, PVCs/VT, low
VAD flows.
 Problems/Complications

Treating Suckdown
Initiate a peripheral IV and slowly give
volume to increase preload
If able and instructed by the VAD
Coordinator, reduce the speed of the
VAD
Assess for signs and symptoms of
bleeding and sepsis
 Problems/Complications
Device Failure
This is a true emergency requiring immediate
transport to the implanting VAD center
Most common in pulsatile devices
Patients & caregivers are trained to identify
signs and symptoms of device failure
May require the VAD to be replaced
 Problems/Complications

Hemolysis

Blood cells are destroyed as they travel

through the VAD

More common in non pulsatile devices

 Problems/Complications
Treating Hemolysis
Initiate a peripheral IV and slowly give
volume
If able and instructed by the VAD
Coordinator, reduce the speed of the VAD
If thrombus is suspected to be causing
hemolysis, administer lytics and
anticoagulants as able/ ordered
 Alarms
All VAD devices typically have two
distingue alarms to indicate a problem and
its severity
Advisory Alarms
Critical/ Hazardous Alarms
 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.
 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
 Field Management
All VADs are dependant 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.
 Field Management
Nitratescan 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
 Field Management
Initiate
IV therapy with all VAD patients if
possible
Use aseptic technique due to the patients
increased risks of infection
 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
 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
Make sure to keep all cables tangle and kink free
 Preplanning
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
 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
 Remember
Ask for the contact number for the managing
centers 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
 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
 For additional resources materials
and information please visit:
www.thoratec.com
www.jarvikheart.com
www.umm.edu/heart/index.htm
Thank You!