LVADS IN THE
EMERGENCY DEPARTMENT
ZAK CERMINARA PHARMD
UW MEDICINE RESIDENT
SEPTEMBER 4, 2014
CONTENT
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Background
Pharmacotherapy
Infections
GI Bleeds
Arrhythmias/Codes
Miscellaneous
PATIENT PRESENTATION
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MJM 64 y/o male
ICM s/p LVAD 6/2014
Hx of 2 recent admits for GI bleeds
Presented to the ED on 8/21 with solid, black stools
since 1200 that day with mild fatigue
PMH
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Coronary artery disease
Hx of complete heart block
HeartMate II LVAD in place
Chronic anticoagulation
Hx of acute renal failure
Acute blood loss anemia
Protein calorie malnutrition
Situational depression
Insomnia
HISTORIES
• Allergies:
• NKDA
• Family History:
• Father: CVA
• Brothers: DM
• Social History:
• EtOH: Occasional
• Tobacco: Smoked for 40-45y, quit
• IVDU: Denies
HOME MEDICATION LIST
Indication
Medication
Heart History
ASA 81 mg PO Daily
Metoprolol Succinate 25 mg PO BID
Pravastatin 20 mg PO daily
Warfarin 1.5 mg PO Qmonday
Warfarin 2 mg PO QTuWThFSaSu
GERD/GI Bleed Hx
Pantoprazole 40 mg PO daily
Pain
APAP 650 mg PO Q6H PRN
Oxycodone 5 mg PO Q6H PRN
Constipation
Docusate 200 mg PO daily PRN
Supplements
Multivitamin PO daily
Vitamin D 1000 IU PO daily
Magnesium Oxide 400 mg PO BID
VITALS
• Admission to ED
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Weight: 86.5 kg
Height: 6’ 1”
BMI: 25.2
BP=MAP: 61
Temp: 36.7
RR: 20
LABS: CBC
8/21
WBC
RBC
Hgb
Hct
MCV
Plt
5.82
2.39
7.2
22
94
279
LABS: BMP
Na
8/21
K
140 4.2
Cl
CO2
111 24
Anion
Gap
SCr
BUN
Ca
Corrected
Ca
5
1.12
24
8.2
9.32
LABS: LFTS
8/21
AST
ALT
Alk Phos
Bili
Albumin
25
25
56
0.7
2.6
LABS: COAGULATION
8/21
PT
INR
aPTT
27.4
2.6
37
BACKGROUND
Heart failure (HF) is increasing in prevalence
5.7 million currently have diagnosis
670,000 are newly diagnosed yearly
1 year mortality rate is 20%
Less than 15% survive 8-12 years
Pharmacotherapy can be used to manage HF in
the earlier stages
• Transplant is the preferred therapy for end-stage HF
• Left ventricular assist devices (LVADs) have become
increasingly more popular
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Circulation. 2012 Jan 3;125(1):e2-e220.
BACKGROUND CONT.
• LVADs decrease symptoms by decreasing the work
of the heart
• LVADs:
• Reverse HF
• Bridge to transplant
• Destination therapy
Circulation. 2012 Jan 3;125(1):e2-e220.
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
PHARMACOTHERAPY
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Angiotensin-converting enzyme inhibitors (ACEIs)
Angiotensin II receptor blockers (ARBs)
Aldosterone Antagonists
Digoxin
Beta blockers
Diuretics
Hydralazine (+/- nitrates)
Warfarin
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
INFECTIONS
INFECTIONS
• Infection rates have been shown to be 25-80%
• VAD-related infections should be treated
aggressively
• Common VAD-related infections
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Driveline
Pocket
Mediastinitis
Pump endocarditis
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
J Heart Lung Transplant. 2011 Apr;30(4):375-84.
INFECTIONS CONT.
• Goal of therapy is to keep infection confined to
prevent progression
• Device related infections do not prevent transplant
• Non-VAD related infections require aggressive
treatment
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
INFECTIONS CONT.
• Retrospective study by Nienaber et al.
• They identified 101 episodes of LVAD infections in 78 of
247 patients (32%)
• Most common infection: Drive line infections (47%)
• Followed by VAD and non-VAD related BSIs (24% and
22%)
• Pathogens:
• Gram-positive cocci, staphylococci (45%)
• Gram-negative bacilli, nosocomial (27%)
• Chronic suppressive antimicrobial therapy: 42%
• Intraoperative debridement: 14%
• VAD removal: 3 patients
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
BLEEDING
BLEEDING
• Bleeding is the most common adverse event
associated with VAD therapy
• Common bleeding issues:
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Epistaxis
Gastrointestinal bleeding
Vaginal bleeding
Cuts or other trauma
Complications after outpatient procedures
• Bleeding may be related to:
• Systemic anticoagulation
• Operation
• Acquired von Willebrand disease
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
POSTOPERATIVE BLEEDING
• Immediate postoperative bleeding may be related
to:
• Adhesions
• Cannulation sites
• Coagulopathy
• In many causes can be controlled using:
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Blood products
Hemostatic agents (aminocaproic acid)
Desmopressin acetate
Protamine sulfate
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
VON WILLEBRAND SYNDROME
• In a study of 26 patients with LVADs
• All subjects developed von Willebrand syndrome
• It was reversible on explant
• A different prospective study examined the
characteristics of von Willebrand syndrome related
to LVADs
• All patients developed von Willebrand syndrome
• The cause is unknown
• It may be due to the stress of the continuous flow VAD
leading to proteolysis of the multimers
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
HEMOLYTIC ANEMIA
• Hemolysis occurs when RBCs lyse as they pass
through the VAD
• Related to platelet activation
• Patients may develop symptoms:
• Fatigue
• Dark tea-colored urine
• Icterus
• Management includes:
• Close monitoring
• Possible addition of dipyridamole
• May occur at a rate of 1.2% to 3%
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
ARRHYTHMIAS/CODING
ARRHYTHMIAS
• Arrhythmias occur in approximately 27% to 38% of
VAD patients
• Treatment options include:
• Fluid boluses
• Antiarrhythmic agents (amiodarone, beta-blockers +/mexilitene)
• Normalization of serum electrolyte
• Weaning pressors
• Direct current cardioversion/Defibrillation
• Always continue preoperative antiarrhythmics after
LVAD implantation
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
Crit Care Med. 2014 Jan;42(1):158-68.
CODING
• When terminal rhythms occur with power outputs
indicating flow through the device use only:
• Electrical cardioversion/defibrillation
• Epinephrine
• Atropine
• When power output is low, compressions may be
necessary
• The major risk with chest compressions is dislodgement
of:
• The device
• The outflow cannula
• This is mainly of concern with the larger devices
• Alternative is abdominal compressions, given 1–2 inches
left of midline
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
Resuscitation. 2014;85(5):702-4. doi: 10.1016.
ABDOMINAL COMPRESSIONS
• One case study of performed abdominal
resuscitation in an LVAD patient successfully
• Abdominal compressions can maintain a coronary
perfusion pressure of 15 mm Hg
• At ROSC, care should be taken to support the
ischemic RV
J Cardiothorac Surg 2011; 6:91.
MISCELLANEOUS
MISCELLANEOUS
• Neurologic
• Turbulent flow leads to thrombus formation and stroke
• Newer pumps decrease this risk
• RV Failure
• An imbalance can develop between the ventricles
• Incidence ranges from 11.8% to 14.8%
• Can lead to pulmonary hypertension
• Multiple Organ Failure
• Device Malfunction
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
BACK TO MJM
• Medications given in the ED:
• Pantoprazole 80 mg bolus
• Pantoprazole 8 mg/hr drip
• Medications in the ICU:
• Pantoprazole 8 mg/hr drip for total 24 hrs
• Pantoprazole 40 mg PO BID through 8/27
• All home medications
• Warfarin was held
REFERENCES
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Roger VL, Go AS, Lloyd-Jones DM et al. Heart disease and stroke statistics 2012
update: a report from the American Heart Association. Circulation. 2012 Jan
3;125(1):e2-e220.
Pistono M, Corrà U, Gnemmi M et al. How to face emergencies in heart failure
patients with ventricular assist device. Int J Cardiol. 2013 Oct 15;168(6):5143-8.
Nienaber JJ, Kusne S, Riaz T et al. Clinical manifestations and management of left
ventricular assist device-associated infections. Mayo Cardiovascular Infections
Study Group. Clin Infect Dis. 2013;57(10):1438-48. Hannan MM, Husain S, Mattner F
et al. Working formulation for the standardization of definitions of infections in
patients using ventricular assist devices. International Society for Heart and Lung
Transplantation. J Heart Lung Transplant. 2011;30(4):375-84.
Pratt AK, Shah NS, and Boyce SW. Left Ventricular Assist Device Management in
the ICU. Crit Care Med. 2014 Jan;42(1):158-68.
Rottenberg EM, Heard J, Hamlin R et al. Abdominal only CPR during cardiac
arrest for a patient with an LVAD during resternotomy: A case report. J
Cardiothorac Surg 2011; 6:91.
Shinara Z, Bellezzoa J, Stahovich M et al. Chest compressions may be safe in
arresting patients with left ventricular assist devices (LVADs). Resuscitation.
2014;85(5):702-4. doi: 10.1016.