1. An interesting case…
Karen Neoh

2. Case History 68 year old man with ischaemic cardiomyopathy
Left ventricular assist device (LVAD) inserted July 2012
Recurrent GI bleeds exacerbated by anti coagulation
Admitted to Royal Freeman (Newcastle) with 2nd pump thrombus
Admitted to hospice Friday, I was on call Saturday/Sunday

3. Overview Left ventricular assist device (LVAD) Case history
Ethical issues
Practical issues

4. LVAD
Left ventricular assist devices are implanted in patients with severe heart failure
May be temporary, while patient awaits a heart transplant
Can be a lifesaving procedure in themselves, some patients are not fit enough to go on to have transplant or die before

5. LVAD
Mechanical pump which contracts and circulates blood around the body, essentially taking over the job of the left ventricle
LVAD is surgically implanted just below the heart. Attached to the left ventricle and aorta.
Blood flows from the ventricles into the pump which passively fills. When the sensors indicate it is full, the blood is ejected out of the device
A tube (the driveline) passes from the device through the skin and connects the pump to the external controller and power source
2. Left Ventricular Assist Device (LVAD) for Heart Failure accessed online 21/4/14

6. http://www.nhlbi.nih.gov/health/health-topics/topics/vad/ (4)

7. Facts Approximately 100 people in the UK currently living with an LVAD
Number of heart transplants performed in the UK in 2011/12 138
Approximately 80 people have an LVAD implanted each year in the UK
3. British heart foundation: Focus on: Left ventricular assist devices. accessed online 21/4/14

8. Potential complications
Early complications
Late complications
Perioperative haemorrhage
Right ventricular failure (worsened by improvement in left ventricle).
Bulkier pulsatile devices inserted into the abdomen can lead to gastrointestinal (GI) obstruction, fistula and adhesions
Infection
Thromboembolism
Haemolysis
Device failure
Bleeding complications due to anti coagulation
All patients with LVADs need a level of anticoagulation, usually with warfarin (INR target 2-3) as well as anti-platelet therapy.

9. 2013 admission to Royal Freeman
August 2013 had a pump thrombus which was treated with IV heparin and antiplatelet therapy
This dissolved the thrombus but during this stay he experienced a GI bleed
CT scan of his abdomen was normal
The GI bleed had ceased when his anticoagulation had been reduced once the thrombus had cleared

10. History prior to transfer
Admitted to cardiology centre after patient noted high watt value
Diagnosed with second pump thrombus
Commended IV heparin and increased doses of antiplatelet therapy.
Developed haematemesis and malaena – has happened before
Given blood transfusions and due to on-going bleeding issues it was not possible to fully anticoagulate him
Invasive attempt via cardiac catheter was made to remove the thrombus but this was also unsuccessful

11. Why transfer to the hospice?
After discussion with the patient and his family (and the hospice) it was decided to transfer the patient to a hospice closer to home as his prognosis was felt to be very poor
The cardiology team expected that over time the wattage would rise and the pump would eventually fail (less than a week)
Patient reliant on the device for his cardiac output, will die when the pump started to reach it’s maximum power

12. Medications on admission
Tinzaparin units then warfarin
Aspirin 150mg bd
Bisoprolol 1.25mg od
Frusemide 40mg od
Lisinopril 2.5mg od
Omeprazole 40mg bd
Paracetemaol
Prasugrel 10mgod

13. Admitted 21/2/14 for terminal care
The LVAD nurse, who had known him for 18 months, came to our centre to deliver training on the device
Symptoms dyspnoea, poor appetite, poor sleep
Nose bleeds
Haematuria

14. Issues
Level of knowledge and objective indication that the patient had of his own deterioration.
Patient fully aware of the implications of rising watt value
Told expected death in less than a week
The hospice had to monitor the device readings in order to assess the patient and allow preparation to be made by the patient, staff and family for any events
Maximum value the pump could work to was 25 watts. We were informed by the cardiologists that once the value started to get up towards 25; time ahead would be very short

15. Day 2 watt 11.1
The staff became aware of the negative impact that checking the watt value might have on the patient
He/We watching the value rise!
Reviewed the initial procedure we had in place which was checking the device several times a day
It is possible to check the value without the patient seeing the reading
Patients’ family also wished to know the value and he stated he did not mind knowing the readings

16. Practical issues for staff
The device has an alarm which sounds when there is a power or technical failure or if the pump stops
The pump can stop due to a mechanical failure or if a patient dies. We were told this alarm is similar to a fire alarm as it needs to alert people quickly and effectively
Team discussed turning the alarm of pre-emptively (while leaving the pump on) but it was decided that as we would not know if there was a power failure we should leave the alarm on.
Alarm would require turning off after/around death to maintain patient dignity

17. Turning the device off. In the event that the patient became unconscious would we then turn the pump off to allow his death?

18. Day 3 watt 13
Day 9 watt 5.4
Spontaneously the watt value began to decrease and returned to a value of around 3. It is unknown why this happened but it is assumed that the thrombus cleared (we did not refer for any investigations as there would have been no change in management).

19. The patient continues on warfarin (tinzaparin if INR <2)
On-going GI bleeding with haematemesis and maelena
Ongoing blood transfusions
Difficult to discharge patient due to uncertainty of the future
Possible long prognosis
The patient wrote an advance directive, documenting circumstances in which he would want the device turning off and who was to assess him prior to this (2 doctors).

20. Advance directive More challenging than usual advance directive
Turn off device if irreversible cause of
Unconscious
Confused
Can we be 100% certain?
Or dying
Turning device off would definitely hasten death (has had turned off before and became peri arrest) so this needs to be in advance directive ‘even if shortens life’

21. Hospice admission Long admission
Medical problems e.g. chest infection and GI bleeding
Supportive with blood transfusions
Mostly well symptom controlled
Family very anxious about discharge

22. Conclusion LVAD can be life saving
Ethical and practical issues for staff, patient and family.
? Some similarities can be drawn between LVAD and renal dialysis

23. Update Deteriorated this week
Ongoing GI bleed, hb 60, LFT’s/renal function also worse
Chris....?

24. References
1. Birks, EJ. Left ventricular assist devices Heart 2010;96:63-71
2. Left Ventricular Assist Device (LVAD) for Heart Failure accessed online 21/4/14
3. British heart foundation: Focus on: Left ventricular assist devices. accessed online 21/4/14
4. National heart, lung and blood institute. accessed online 3/5/14