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EMS Left Ventricular Assist Device Management
Introduction
The incidence of heart failure has been increasing in the United States and worldwide, with estimates of 6 million and more than 30 million, respectively. This increasing prevalence of heart failure could be due to improved survival in patients with prior episodes of heart failure, and the overall aging of the population. The mortality rate for patients with advanced (stage D) heart failure is as high as 80% in 1 year of diagnosis. The only non-pharmacologic therapies approved in the United States for such heart failure patients are heart transplants and left ventricular assist devices (LVAD). In the past, LVADs were used as a bridge to transplant (BTT) for patients who were eligible for heart transplants. However, in January 2010, after the FDA approved a first-line intermediate-to-chronic left ventricular assist device for destination therapy, the number of patients who received LVAD implants increased significantly. As the population of patients with LVAD increases, it becomes important to have a standardized or universal LVAD management training system for prehospital emergency medical services. The goal of this article is to review a systematic approach to the management of LVAD patients in the pre-hospital setting. [1],[2],[3],[4],[5]
Issues of Concern
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Issues of Concern
Ventricle assist devices are designed to supply cardiac output to perfuse vital organs for patients with a decreased left ventricular ejection fraction of less than 25%. This is achieved by removing preload from the ventricle and ejecting it into the proximal aorta. This can generate up to 8 to 10 L of blood flow to the system. The first generation of LVAD provided pulsatile blood flow to the systemic circulation, whereas second- and third-generation devices provided non-pulsatile and continuous blood flow. This continuous blood flow improves durability, decreases shear stress due to fewer moving parts, and allows for a smaller device with easier placement. The device is implanted in the thoracic cavity with the percutaneous driveline exposed over abdomen near the umbilicus. Patients with an LVAD usually carry a monitor, a controller, a spare controller, and 2 power sources with them at all times. They should also have an LVAD identification in the front pocket of an LVAD bag. It is important to identify all devices and transfer all pertinent equipment with the patient to the nearby hospital. [4],[6]
Clinical Significance
LVAD may be used in patients with a cardiogenic shock, a patient awaiting a heart transplant or following myocarditis. LVAD implantation is usually done by a cardiac surgeon but its care requires monitoring by an interprofessional team. LVADs are associated with numerous complications and 24/7 monitoring is mandatory.
References
Mancini D, Colombo PC. Left Ventricular Assist Devices: A Rapidly Evolving Alternative to Transplant. Journal of the American College of Cardiology. 2015 Jun 16:65(23):2542-55. doi: 10.1016/j.jacc.2015.04.039. Epub [PubMed PMID: 26065994]
Miller LW, Rogers JG. Evolution of Left Ventricular Assist Device Therapy for Advanced Heart Failure: A Review. JAMA cardiology. 2018 Jul 1:3(7):650-658. doi: 10.1001/jamacardio.2018.0522. Epub [PubMed PMID: 29710092]
Bowles CT, Hards R, Wrightson N, Lincoln P, Kore S, Marley L, Dalzell JR, Raj B, Baker TA, Goodwin D, Carroll P, Pateman J, Black JJM, Kattenhorn P, Faulkner M, Parameshwar J, Butcher C, Mason M, Rosenberg A, McGovern I, Weymann A, Gwinnutt C, Banner NR, Schueler S, Simon AR, Pitcher DW. Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices. Emergency medicine journal : EMJ. 2017 Dec:34(12):842-850. doi: 10.1136/emermed-2016-206172. Epub 2017 Nov 10 [PubMed PMID: 29127102]
Mechem CC. Prehospital assessment and management of patients with ventricular-assist devices. Prehospital emergency care. 2013 Apr-Jun:17(2):223-9. doi: 10.3109/10903127.2012.744786. Epub 2013 Jan 2 [PubMed PMID: 23281642]
Ryu B, Ishikawa T, Yamaguchi K, Matsuoka G, Eguchi S, Kawamata T. Long-term outcomes following thrombectomy for acute ischemic stroke in patients with a left ventricular assist device: a case series and literature review. Acta neurochirurgica. 2018 Sep:160(9):1729-1735. doi: 10.1007/s00701-018-3635-4. Epub 2018 Jul 31 [PubMed PMID: 30062437]
Level 2 (mid-level) evidenceAissaoui N, Jouan J, Gourjault M, Diebold B, Ortuno S, Hamdan A, Latremouille C, Pirracchio R, Morshuis M. Understanding Left Ventricular Assist Devices. Blood purification. 2018:46(4):292-300. doi: 10.1159/000491872. Epub 2018 Jul 26 [PubMed PMID: 30048974]
Level 3 (low-level) evidence