LVAD Emergencies: A Practical Guide for Junior Doctors(Left Ventricular Assist Device)

Introduction

Imagine standing in resus and a pale, breathless patient rolls in with no palpable pulse — but they’re awake and talking.Welcome to the world of LVAD patients.

LVADs (Left Ventricular Assist Devices) are mechanical pumps that support a failing left ventricle, either as a "bridge" to transplant or as "destination therapy" for those not suitable for transplant.Because LVADs completely change basic cardiovascular physiology, you must approach their emergency care differently.

Let’s break it down in a way that’s simple and unforgettable:

History Taking: What You Must Ask

LVAD patients are fragile. When they come to the ED, every minute matters. Focus your questions around these key areas:

Device details:

·     When was the LVAD inserted?

·     What type of device do they have? (HeartMate 3? HeartWare?)

·     Why was it inserted? (Ischemic cardiomyopathy? Dilated cardiomyopathy?)

·     Where is their LVAD centre? (They will usually have a "card" with emergency contacts.)

Symptoms of concern:

·     Any dizziness, syncope, or near-syncope? (Think pump failure.)

·     Any chest pain, palpitations, or dyspnoea? (Ischemia? Arrhythmia?)

·     Bleeding? (GI bleeding is very common due to anticoagulation and acquired von Willebrand disease.)

·     Fever, chills, or malaise? (Infection risk: driveline infections are common.)

·     Any history of recent shocks? (Implantable defibrillators are often combined with LVADs.)

·     Pump alarms? (Ask about any beeping, vibrations, or "low flow" warnings.)

Medications:

·     Are they on anticoagulation (warfarin/heparin)? (Almost always, yes.)

·     Any recent changes to medication?

Device Troubleshooting:

·     Any interventions attempted before arrival? (Battery changes, controller reset?)

Examination Findings: What to Look For

Rule #1: You might not feel a pulse!LVADs provide continuous flow → many patients have no palpable pulse and low or undetectable blood pressure using standard cuffs.Here’s what to focus on:

General Appearance:

·     Conscious level: Awake? Agitated? GCS?

·      Signs of shock: Mottled skin, cool peripheries, cyanosis.

Vital signs:

·     Blood Pressure:

o  Use a Doppler + manual cuff to find a mean arterial pressure (MAP) — aim for MAP 60–80 mmHg.

·     Oxygen saturation:

o  Might be unreliable due to non-pulsatile flow. Trust clinical signs more.

Heart and lungs:

·     Auscultate chest: LVAD hum should be heard — a whirring, mechanical sound. Absence of hum = BAD.

·     Signs of pulmonary oedema?

·     New murmurs? (Think aortic regurgitation or thrombus.)

Driveline inspection:

·     Look at the skin exit site:

o  Redness? Pus? Swelling? (Think driveline infection.)

other signs:

·     Signs of bleeding (pallor, melena, bruising).

·     Signs of right heart failure (raised JVP, hepatomegaly, peripheral oedema).

Investigations: What to Order Quickly

Bedside:

·     ECG:

o  Arrhythmias are common (VT, VF, AF).

·     Capillary blood glucose:

o  Hypoglycaemia can mimic or worsen shock.

·     Doppler BP measurement:

o   To assess MAP accurately.

Bloods:

·     FBC: Anaemia? Infection?

·     U&E: Renal function (important for fluid status).

·     Coagulation profile: Always anticoagulated → check INR!

·     CRP and blood cultures: If infection suspected.

·     Lactate: Marker of tissue hypoperfusion.

·     Group and save / crossmatch: Bleeding risk high.

Imaging:

·     Chest X-ray:

o  Position of device and signs of pulmonary oedema, infection.

·     Echocardiography (POCUS or formal):

o  RV function, LV collapse, pericardial effusion (tamponade risk).

Device Interrogation:

·     Needs LVAD specialist. If possible, call the LVAD team immediately!

Management Plan: Step by Step

Early Priorities:

·       CALL the patient’s LVAD centre team immediately.

·       Airway and Breathing: Oxygen if needed — titrate carefully.

·       Circulation:

o   Doppler MAP 60–80 mmHg is ideal.

o   Fluid boluses only if hypovolaemic and cautious: overloading → RV failure!

o   Start vasopressors (e.g., norepinephrine) if MAP <60 despite fluids.

Final Pearls for Junior Doctors

🌟 No pulse? — That's expected. Use Doppler.

🌟 LVAD patients are anticoagulated — Bleeding is common.

🌟 Always inspect the driveline — Infection is dangerous.

🌟 Always listen for the hum — No hum = device failure.

🌟 Never delay calling the LVAD team — They know the device inside out.