1. Ventricular Assist Device Complications Suzanne Wallace MSN, ACNP-C Northwestern Memorial Hospital Bluhm Cardiovascular Institute September 19, 2009

2. Early Complications (In hospital) Bleeding Bleeding Tamponade Tamponade Arrhythmias Arrhythmias Suction Events Suction Events ARF ARF

3. Late Complications Infection Infection RV Failure RV Failure Pump malfunction Pump malfunction Thromboembolism Thromboembolism Hemolysis Hemolysis HTN HTN CVA – hemorrhagic vs. embolic CVA – hemorrhagic vs. embolic GI bleeding/AVMs GI bleeding/AVMs

4. Bleeding/Tamponade Monitor CT output, no anticoag until hemostasis achieved (approx 24hours), monitor Hct – Monitor CT output, no anticoag until hemostasis achieved (approx 24hours), monitor Hct – Other potential sources late: GI, epistaxis, gums etc Other potential sources late: GI, epistaxis, gums etc Tamponade – typical in hospital first 24-48hrs – may be delayed (ie – w/supratherapeutic INR) Tamponade – typical in hospital first 24-48hrs – may be delayed (ie – w/supratherapeutic INR) S/S: Hypotension/low MAPs, High CVP, Low Flows, arrhythmias, abrupt cessation of mediastinal CT outtput S/S: Hypotension/low MAPs, High CVP, Low Flows, arrhythmias, abrupt cessation of mediastinal CT outtput Tx: emergent OR, exploration, volume resuscitation Tx: emergent OR, exploration, volume resuscitation

5. Arrhythmias VT or VF VT or VF S/S: S/S: dizzy, low flows, low PI, low SV, fatigue, palpitations dizzy, low flows, low PI, low SV, fatigue, palpitations Etiology: Etiology: consider suction event, hemodynamic, lytes consider suction event, hemodynamic, lytes Tx: Tx: Volume resuscitation, anti-arrhythmics (Amio), electrolyte repletion (K > 4, Mg > 2), cardioversion/defib Volume resuscitation, anti-arrhythmics (Amio), electrolyte repletion (K > 4, Mg > 2), cardioversion/defib

6. Suction Events S/S: S/S: dizziness, low flows, low CVP (may be high with RV dysfunction), arrhythmias(VT), dampened waveforms dizziness, low flows, low CVP (may be high with RV dysfunction), arrhythmias(VT), dampened waveforms Etiology: Etiology: hypovolemia, rpm increases, cannula position, RV dysfunction hypovolemia, rpm increases, cannula position, RV dysfunction Tx: Tx: Volume resuscitation, decrease rpms temporarily, treat arrhythmias Volume resuscitation, decrease rpms temporarily, treat arrhythmias

7. Infection S/S and exam: S/S and exam: Leukocytosis, fever, erythema, drainage, tenderness around driveline site, positve cultures, hyperdynamic flows, hypotension Leukocytosis, fever, erythema, drainage, tenderness around driveline site, positve cultures, hyperdynamic flows, hypotension Etiology: (multifactorial) Etiology: (multifactorial) Poor dressing technique, improper immobilization of driveline, immunosuppression (ANC < 1000), diabetes, low albumin/poor nutritional status Poor dressing technique, improper immobilization of driveline, immunosuppression (ANC < 1000), diabetes, low albumin/poor nutritional status Tx: Tx: Antibiotics (po/IV depending on severity), Possible OR for exploration, fluid resuscitation, dressing changes/Vacs etc. Antibiotics (po/IV depending on severity), Possible OR for exploration, fluid resuscitation, dressing changes/Vacs etc.

8. RV Failure S/S: S/S: High CVP, hypotensive, low flows High CVP, hypotensive, low flows Dx: Dx: exam, confirm with echo exam, confirm with echo Etiology: Etiology: HTN, volume overload, multiple transfusions HTN, volume overload, multiple transfusions Tx: Tx: Inotropes (Milrinone, Dobut) Diuresis, Adequate ventilation, NO/Vasodilators (Nitrates), RVAD support if severe Inotropes (Milrinone, Dobut) Diuresis, Adequate ventilation, NO/Vasodilators (Nitrates), RVAD support if severe

9. Pump Malfunction Mechanical malfunction – continuous/loud or red alarms on all VADs are BAD!! Mechanical malfunction – continuous/loud or red alarms on all VADs are BAD!! Assess pt – 911 if indicated – Call Vad Pager Assess pt – 911 if indicated – Call Vad Pager Etiology: mechanical, thromboembolic events (high pump power) Etiology: mechanical, thromboembolic events (high pump power) Change system controller if indicated Change system controller if indicated Note: if pump stopped > 5minutes(continuous flow) do not attempt to restart – support pt hemodynamically – will get TPA/thrombolytics – prior to restarting pump/going to OR (Directed by VAD implanting Center) Note: if pump stopped > 5minutes(continuous flow) do not attempt to restart – support pt hemodynamically – will get TPA/thrombolytics – prior to restarting pump/going to OR (Directed by VAD implanting Center)

10. Thromboembolism Monitor for increasing pump power, look for thrombus (IVAD) Monitor for increasing pump power, look for thrombus (IVAD) Maintain adequate speeds to maximize pump flow Maintain adequate speeds to maximize pump flow Proper Anticoagulation – Goal INR 1.7-2.5 for most devices Proper Anticoagulation – Goal INR 1.7-2.5 for most devices Notify Vad coordinator – analyze waveforms Notify Vad coordinator – analyze waveforms Severe – pumps can stop – need urgent OR Severe – pumps can stop – need urgent OR

11. Hemolysis More common on pulsatile VADs More common on pulsatile VADs S/S: S/S: Elevated LDH, Plasma Free Hgb, low H/H Elevated LDH, Plasma Free Hgb, low H/H Dark urine Dark urine Etiology: Etiology: Inflow/outflow occlusions, Pulsatile VADs – valves, Liver dysfunction, Multiple transfusions Inflow/outflow occlusions, Pulsatile VADs – valves, Liver dysfunction, Multiple transfusions Tx: Tx: Pulsatile vads: decreasing rate, vaccuum Pulsatile vads: decreasing rate, vaccuum Continuous Flow VADs: temporarily reduce pump speed, Continuous Flow VADs: temporarily reduce pump speed, Transfuse Transfuse

12. Hypertension S/S: S/S: MAPs > 80, SBP > 120-140; Low Flows, High PIs, Possible Headache MAPs > 80, SBP > 120-140; Low Flows, High PIs, Possible Headache Etiology: Etiology: Chronic HTN, Volume overload, Pain/Anxiety Chronic HTN, Volume overload, Pain/Anxiety Tx: Tx: Antihypertensives: BBlocker ( if No RV- dysfunction), Ace-I (if Crt stable), Hydralazaine, Norvasc Antihypertensives: BBlocker ( if No RV- dysfunction), Ace-I (if Crt stable), Hydralazaine, Norvasc Treat Pain/Anxiety Treat Pain/Anxiety Diuresis Diuresis

13. Stroke S/S: S/S: HA, slurred speech, visual changes, unilateral weakness, numbness or paresthesias HA, slurred speech, visual changes, unilateral weakness, numbness or paresthesias Etiology: Etiology: hemorrhagic vs. thromboembolic – check INR, MAP/BP hemorrhagic vs. thromboembolic – check INR, MAP/BP Tx: Tx: Medical Emergency: 911 – then Vad coordinator Medical Emergency: 911 – then Vad coordinator Tx underlying cause – antihypertensives, give thrombolytics if indicated – (Head CT/Neuro consult) etc.. Tx underlying cause – antihypertensives, give thrombolytics if indicated – (Head CT/Neuro consult) etc..

14. GI bleeding/AVMs S/S: S/S: Abdominal pain, low H/H, blood in stool or emesis Abdominal pain, low H/H, blood in stool or emesis Dx: Dx: Colonoscopy, IR, guiac stool Colonoscopy, IR, guiac stool Etiology: Etiology: Continuous flow/high pump speed?, supratherapeutic INR, antiplatelet, HIT pts Continuous flow/high pump speed?, supratherapeutic INR, antiplatelet, HIT pts Tx: Tx: Decrease coumadin dosing, antiplatelet agents, transfuse if indicated, Decrease coumadin dosing, antiplatelet agents, transfuse if indicated, Tx

15. Summary Multiple complications possible Multiple complications possible Astute assessment skills Astute assessment skills Early intervention Early intervention Notify Vad coordinator ASAP when complications Arise Notify Vad coordinator ASAP when complications Arise