Ventricular assist devices

Overview

A ventricular assist device (VAD) is a medical device designed to facilitate the circulation of blood from a heart chamber (ventricle) to the rest of the body.

Various types of VADs exist:

• Left ventricular assist device (LVAD): This is the most prevalent type, aiding the left side of the heart in pumping oxygen-rich blood from the heart to the body.
• Right ventricular assist device (RVAD): It is responsible for pumping oxygen-poor blood from the right side of the heart to the lungs.
• Biventricular assist device: This device supports both sides of the heart.
• Pediatric VADs: These are smaller devices equipped with smaller cannulas and pumps. They can be tailored to accommodate individuals ranging from newborns to young adults.

Reasons for undergoing the procedure

A Ventricular Assist Device (VAD) may be necessary for individuals with advanced heart failure who are either awaiting a heart transplant or need ongoing assistance to ensure sufficient blood circulation in their bodies.

Ventricular assist devices offer various benefits:

• Bridge to recovery: Provides cardiac support during the period when the heart is recovering from weakness, serving as a temporary measure.
• Bridge to transplant: Designed for individuals eligible for a heart transplant, the VAD offers essential support while waiting for a suitable donor heart.
• Destination therapy: Intended for those ineligible for a heart transplant, this option provides permanent cardiac support, enhancing longevity and improving overall quality of life.

Risks

Possible complications linked to the surgical placement of a ventricular assist device (VAD) and the long-term utilization of the device comprise:

• Infection.
• Hemorrhage.
• Arrhythmias.
• Malfunction of the device.
• Formation of blood clots.
• Cerebrovascular accident.
• Right-sided heart failure.

Before the procedure

When someone has severe heart failure, not everyone qualifies for a ventricular assist device (VAD). After being diagnosed with advanced heart failure, individuals undergo thorough medical and psychological evaluations. These evaluations check the current function of the heart and other organs and screen for various health issues such as breast cancer, prostate problems, and infectious diseases. The evaluation includes:

• Electrocardiogram (EKG)
• Echocardiogram
• Computed Tomography (CT) scan
• Exercise testing
• Both left and right cardiac catheterizations

Besides medical assessments, there are discussions about what it’s like to live with a VAD, and patients receive detailed education on the day-to-day tasks involved in caring for the device. The healthcare team also helps patients identify nearby loved ones or a support system that can offer assistance when needed.

During the procedure

During VAD implant surgery, the following steps occur:

• General anesthesia is administered to induce sleep and momentarily impair feeling. Patients won’t remember the process. Breathing is supported by a ventilator during the procedure and in the early postoperative period in the intensive care unit (ICU).
• The surgeon opens the sac (pericardium) surrounding the heart by making an incision in the middle of the chest through the sternum.
• The surgeons put the patient on a cardiopulmonary bypass machine after administering heparin to maintain blood flow throughout the body and stop blood from passing through the heart while the procedure is being performed.
• The VAD driveline is then tunneled through the abdominal wall.
• The VAD is then inserted by the surgeon into the proper locations within the heart. Although there are many different configurations available, the inflow cannula of an LVAD normally connects to the apex of the left ventricle, and the outflow graft connects to the aorta.
• After the VAD is implanted, the surgeon speeds up its operation to support the patient’s circulatory needs while weaning them off the bypass machine.
• The surgeon uses a medication called protamine to reverse the heparin and encourage blood clotting once the VAD’s function is stable. After that, the surgeon reattaches the sternum using metal wires. After applying a sterile dressing, they use absorbable sutures to seal the more superficial layers.

After the procedure

Following implant surgery, you will spend a minimum of a few days in the intensive care unit (ICU). Once your health improves and you no longer require ICU-level care, you will be transferred to the cardiac step-down unit for the remainder of your hospital stay. During your postoperative stay, healthcare professionals will closely monitor your organ functions, including your heart, kidneys, brain, lungs, and liver. You will also collaborate with physical and occupational therapists and other specialists to learn how to manage your life with the new device. Your providers will prescribe a blood-thinning medication called warfarin sodium to prevent blood clots from forming inside the VAD.

A nurse or VAD coordinator provides instruction on maintaining your ventricular assist device, covering the following aspects:

• Properly cleaning the equipment and driveline.
• Regularly monitoring the incisions, including the driveline exit site, to ensure they remain healthy and are healing properly.
• Learning how to replace the batteries and addressing any troubleshooting needs for various alarms that may arise from the device.
• Being informed about who to reach out to if you have any questions or concerns.

Outcome

Living with a VAD (Ventricular Assist Device) comes with certain limitations and responsibilities:

Limitations:

• Power source: You’ll need a power source, either batteries or a wall socket, to keep the device running.
• Medication: Taking blood thinners is necessary, and you’ll require regular lab tests to monitor their effectiveness.
• Water avoidance: Avoid activities that may get the device wet, like swimming or taking baths. You can learn how to safely shower with it.
• No contact sports: Steer clear of contact activities to prevent excessive bleeding in case of injury.

Responsibilities:

• Medication management: Besides blood thinners, you may need other cardiovascular medications for blood pressure control and rhythm management.
• Healthy lifestyle: Quit smoking, maintain a nutritious diet, and engage in regular physical activity for overall well-being.
• Rehabilitation: Participate in cardiac rehabilitation to regain strength and confidence after VAD implantation.
• Device maintenance: Properly care for your VAD, and your medical team will provide guidance and support.

After discharge, routine follow-up visits are essential. Initially frequent, these visits become less frequent as you progress. During these visits:

• Blood pressure monitoring: Regularly check and manage your blood pressure, as it can be a concern.
• Medication review: Ensure your medications, especially anticoagulants, are correctly dosed.
• Device data check: Assess VAD data for alarms or issues with device function.
• Device adjustments: If needed, make adjustments to VAD settings.
• Lifestyle progress: Discuss your progress with lifestyle changes and receive helpful tips.

Contact your healthcare provider if you experience:

• Coughing up blood
• Fever or chills
• Chest pain
• Dark-colored urine
• Joint pain
• Redness, tenderness, or unusual warmth near incisions or the driveline exit.

Regular communication with your healthcare team ensures your VAD’s optimal function and your well-being.