Morning Report: 5/14/2012

Today’s Morning Report was originally presented by Dr. Tan on 5/7/2012:

Left Ventricular Assist Device (LVAD)

• Indications:
  • New York Heart Association class 4 heart failure
  • Ejection fraction <25%
  • VO2 max less than 15 among other criteria
• How does it work:
  • Bypasses left ventricle function.
  • External pump unit outside body with intake channel (blood is drained from the apex of the left ventricle) and output channel (blood is ejected into the aorta).

• Note: BiVAD bypasses both ventricles.
• When would they come to the ED?
  • Infections
    • Driveline infections
    • Overwhelming sepsis is unlikely but these infections can be difficult to treat once the patient is colonized

• Bleeding – major problem with LVADs
  • Anti-coagulation typically recommended for the majority of patients with LVAD
  • Even if not, can develop acquired Von Willebrand disease (similar to patients on dialysis or with aortic stenosis) and angiodysplasias
  • If the patient stops their Coumadin, are they going to have a thromboembolic event? UNLIKELY
• The patient is in extremis, altered or not breathing. You check and there is no pulse. Is the patient coding?
  • Listen to the heart to make sure the pump is working (“like a muffled blender”).
  • If the pump is not working, the patient is coding!  You need to get the pump working…FAST
    • Check all the wiring; controller, batteries, cables.
    • Check for power!
  • If it is working, there are several things you need to do.
    • You need to get a MAP using Doppler.
    • You need to get a monitor/EKG to look for evidence of RV problems (eg arrhythmias, STEMI)
    • Cardiac echo via bedside ultrasound
• Things that can go wrong
  • Pulmonary hypertension
    • Decreases amount of blood that reaches the LVAD
    • Exacerbated by acidosis and hypoxia. Consider intubation and bicarb
    • Echo helpful – if you see a large right ventricle and a small left ventricle, think about pulmonary hypertension
  • Thrombosis of the pump – consider heparin
  • Consider inotropes in these patients
    • Right heart failure –> consider milrinone or dobutamine
    • Sepsis –> levophed
  • Also think about PE

Thanks Dr. Tan, please leave any comments below!

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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