A new clinical statement on the emergency management of patients with ventricular assist devices (VADs), made by a consensus consisting of members of the Heart Failure Society of America (HFSA), the Society for Academic Emergency Medicine (SAEM), and the International Society for Heart and Lung Transplantation (ISHLT), was recently published in The Journal of Heart and Lung Transplant. The full consensus statement includes information for clinicians on the basics of VADs and how to manage these patients and their equipment in emergency situations.

Preparation Recommendations for Emergency Management of Patients with VADs

The writing committee reminds clinicians to first perform a rapid assessment of the patient’s equipment to determine the make and model. Only then can clinicians identify appropriate treatment. In addition, the committee encourages hospitals to educate local providers regarding patients with VADs and to provide information to local clinicians about the resources to care for people with VADs, whether it is routine care or an emergency situation.

A focused history, targeted physical examination, and hemodynamics assessment should be undertaken by emergency providers when caring for patients with VADs. The statement suggests that all patients who experience emergencies that necessitate surgery should be considered high acuity, and if the patient has hemodynamic instability, hemodynamics should be stabilized at the nearest center and the patient should be subsequently transferred.

Medical Emergencies in Patients With VADs

According to the HFSA/SAEM/ISHLT committee, medical emergencies commonly reported in individuals with VADs include cardiac arrest, unstable arrhythmias, myocardial infarction, and unexplained hypotension. Situations that often require emergent transfer to a primary VAD center include cardiac tamponade, mechanical VAD failure, need for emergency noncardiac surgery, neurologic events, and pump thrombosis. Continuous blood pressure monitoring with an arterial line is essential when using anesthesia in patients with left VADs (LVADs) who are scheduled to undergo surgery for non-LVAD-related emergencies.

Emergencies Specific and Related to VADs

In a patient with an LVAD who presents with abdominal pain, physical examination and an assessment of medical history are recommended by the committee. If urgent/emergent surgery is needed for this patient, he or she should be treated by a multidisciplinary team familiar with VADs, the authors wrote.

Nonsurgical bleeding, which is frequently associated with morbidity in patients with continuous-flow LVADs, should be managed by first assessing hemodynamic stability alongside resuscitative measures, particularly in the case of gastrointestinal bleeding.

Strokes, including ischemic and hemorrhagic strokes, are the most devastating neurologic events that can occur in patients with VADs. In patients with hemorrhagic stroke, the committee recommends either discontinuing or reversing anticoagulation. Heart failure (HF) is another possible condition that occurs in people with continuous-flow LVADs. Inadequate left ventricular decompression as well as right ventricular failure are common contributors to HF in these patients. The consensus recommends diuretic therapy and positive inotropic support (eg, milrinone) in people with LVAD and subacute or chronic right HF.

In addition to these emergencies, the consensus statement covered VAD-specific emergencies, including pump thrombosis and pump stoppage or failure, and highlighted potential management options. Acute management of device stoppage, according to the authors, often “requires using an ungrounded cable or placing patients on batteries only, although this leads to a less stable long-term situation given the loss of redundancy should there be further damage to the percutaneous lead.”

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A limitation of the guideline was the paucity of information regarding pediatric patients living at home with VADs.

The authors concluded that “the presence of VAD emergencies and complications will take on even greater importance as VAD patients are projected to have longer waits for heart transplantation under the revised United Network of Organ Sharing heart allocation system.”

Disclosures: Several of the study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Givertz MM, DeFilippis EM, Colvin M, et al. HFSA/SAEM/ISHLT clinical expert consensus document on the emergency management of patients with ventricular assist devices. J Heart Lung Transplant. 2019;38(7):677-698.