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left ventricular assist device (LVAD)

Mechanical left ventricular assist device. Indications: - NYHA class 4 heart failure a) *prior to cardiac transplantation b) recovery from cardiogenic shock c) LVAD is primary therapy* d) *in connection with combination drug therapy# - bridge to cardiac transplantation Contraindications: - mortality very high in patients with ESRD [10] - moderate mitral regurgitation is not a contraindication - LV diastolic dysfunction is not a contraindication - increased left atrial pressure is not a contraindication - blood pressure of > 160/110 mmHg is not a contraindication (GRS12) [15] * cardiac transplantation relatively contraindicated in patients > 72 years of age [15] (GRS12) thus not an option Procedure: - continuous flow device superior to pulsatile flow device [3] - intrapericardial centrifugal flow device non inferior to axial flow device [9] - centrifugal-flow device superior to an axial-flow device [11] Complications: 1) infection 2) bleeding, hemolysis, anemia - may present with overt bleeding, fatigue, or exertional dyspnea [4,18] - obtain blood hemoglobin for dyspnea (first test) [4,18] - echocardiography after anemia has been resolved [4] 3) device malfunction 4) stroke 5) device thrombosis [5] - magnetically levitated centrifugal-flow HeartMate 3 significantly reduced rates of thrombotic pump malfunction [8] 6) ventricular thrombus 7) acquired von-Willebrand's disease (vWD) [4] 8) heart failure 9) arrhythmias, stroke * * 52% 1 year survival vs 25% with medical management # combination drug therapy 1) start lisinopril, losartan, spironolactone, carvedilol 2) monitor for hyperkalemia 3) after achieving maximal regression of LV dilatation, add clenbuterol & replace carvedilol with bisoprolol Management: - anticoagulation with warfarin to prevent ventricular thrombus [6]

Related

cardiac transplantation; heart transplant heart failure (HF) New York Heart Association classification of heart failure

General

enhanced external counterpulsation (EECP); percutaneous ventricular assist device surgical tissue replacement cardiac assist device; ventricular assist device

References

  1. Journal Watch 21(24):197, 2001 Rose EA et al for the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Study Group. Long-term mechanical left ventricular assistance for end-stage heart failure. NEJM 345:1435, 2001 PMID: 11794191
  2. Birks EJ et al Left ventricular assist device and drug therapy for the reversal of heart failure. N Engl J Med 2006 355:1873 - Renlund DG & Kfoury AG When the failing, end-stage heart is not end-stage. N Engl J Med 2006, 355:1922
  3. Slaughter MS et al. for the HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009 Dec 3;361(23):2241-51. Epub 2009 Nov 17. PMID: 19920051 http://dx.doi.org/10.1056/NEJMoa0909938 - Fang JC. Rise of the machines - Left ventricular assist devices as permanent therapy for advanced heart failure. N Engl J Med 2009 Nov 17 PMID: 19920052 http://dx.doi.org/10.1056/NEJMe0910394
  4. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  5. Starling RC et al. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med 2014 Jan 2; 370:33 PMID: 24283197
  6. Brock AS et al A Not-So-Obscure Cause of Gastrointestinal Bleeding N Engl J Med 2015; 372:556-561. February 5, 2015 PMID: 25651250 http://www.nejm.org/doi/full/10.1056/NEJMcps1302223
  7. Garbade J, Barten MJ, Bittner HB, Mohr FW. Heart transplantation and left ventricular assist device therapy: two comparable options in end-stage heart failure? Clin Cardiol. 2013 Jul;36(7):378-82 PMID: 23595910
  8. Mehra MR et al. A fully magnetically levitated circulatory pump for advanced heart failure. N Engl J Med 2016 Nov 16 PMID: 27959709 http://www.nejm.org/doi/10.1056/NEJMoa1610426
  9. Rogers JG et al. Intrapericardial left ventricular assist device for advanced heart failure. N Engl J Med 2017 Feb 2; 376:451. PMID: 28146651 Free Article http://www.nejm.org/doi/10.1056/NEJMoa1602954 - Hetzer R, Delmo Walter EM. Mechanical circulatory support devices - in progress. N Engl J Med 2017 Feb 2; 376:487 PMID: 28146667 http://www.nejm.org/doi/10.1056/NEJMe1613755
  10. Bansal N, Hailpern SM, Katz R et al. Outcomes associated with left ventricular assist devices among recipients with and without end-stage renal disease. JAMA Intern Med 2017 Dec 18; PMID: 29255896 - Thomas SS et al. The Renal Challenge With Left Ventricular Assist Device Therapy-When Enough Is Enough. JAMA Intern Med. 2017 Dec 18. PMID: 29255894
  11. Mehra MR, Goldstein DJ, Uriel N et al. Two-year outcomes with a magnetically levitated cardiac pump in heart failure. N Engl J Med 2018; 378:1386-1395. April 12, 2018. ePub Mar 11 PMID: 29526139 http://www.nejm.org/doi/10.1056/NEJMoa1800866
  12. Robertson J, Long B, Koyfman A. The emergency management of ventricular assist devices. Am J Emerg Med. 2016 Jul;34(7):1294-301. Review. PMID: 27162114
  13. Stokes MB, Bergin P, McGiffin D. Role of long-term mechanical circulatory support in patients with advanced heart failure. Intern Med J. 2016 May;46(5):530-40. Review. PMID: 26010730
  14. Stokes MB, Saxena P, Mariani JA et al Left Ventricular Assist Device (LVAD) as a Bridge to Recovery for Tachycardia-Mediated Cardiomyopathy. J Card Surg. 2015 Nov;30(11):871-3. dEpub 2015 Sep 8. PMID: 26350745
  15. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 12th edition (GRS12) Colburn JL, Wescott AM, Potter JF (eds) American Geriatrics Society, 2025
  16. Hamad EA, Byku M, Larson SB, Billia F. LVAD therapy as a catalyst to heart failure remission and myocardial recovery. Clin Cardiol. 2023 Oct;46(10):1154-1162. PMID: 37526373 PMCID: PMC10577530 Free PMC article. Review. https://pmc.ncbi.nlm.nih.gov/articles/PMC10577530/
  17. Kanwar MK, McIlvennan CK, Lohmueller LC et al Defining Optimal Outcomes in Patients with Left Ventricular Assist Devices. ASAIO J. 2021 Apr 1;67(4):397-404. PMID: 32701625
  18. Mehra MR, Goldstein DJ, Cleveland JC, et al. Five-year outcomes in patients with fully magnetically levitated vs axial-flow left ventricular assist devices in the MOMENTUM 3 randomized trial. JAMA. 2022;328:1233-1242. PMID: 36074476