The emergency management of ventricular assist devices.

BACKGROUND: Heart failure is a common condition in the United States. When medical therapy fails, ventricular device (LVAD) therapy may be required. With increasing use of LVADs, emergency physicians should understand how to manage problems that may arise with these devices.

OBJECTIVE: The objective of this review is to familiarize physicians with LVAD components and LVAD physiology, and discuss the evaluation and management of LVAD complications.

DISCUSSION: The LVAD contains numerous components, but the most important include the pump, inflow and outflow cannulas, and driveline. Initial assessment of perfusion is vital, as hemodynamic instability may be due to decreased preload, increased afterload, mechanical failure, dysrhythmias, infection, or bleeding. Assessment of hemodynamic status is required, and utilization of Doppler for measurement of mean arterial pressure is warranted. This review provides recommendations for the evaluation and management of the LVAD patient in heart failure, the unstable patient with decreased preload, the unstable patient with increased afterload, thrombosis of the LVAD, mechanical failure, dysrhythmias and cardiac arrest, infections and sepsis, right ventricular failure, aortic insufficiency, and bleeding. Patients with LVAD require consultation with the LVAD coordinator and cardiothoracic surgeon. By understanding these aspects, physicians can provide optimal management for these complicated patients.

CONCLUSION: With an increasing number of LVADs, emergency physicians should expect to see patients with complications directly or indirectly related to LVADs. This review provides physicians with an extensive review of LVAD physiology and the evaluation and management of potential complications related to the device.