Medical Management of Patients With Continuous-Flow Left Ventricular Assist Devices

  • Adam D. DeVore
  • Robert J. Mentz
  • Chetan B. Patel
Heart Failure (W Tang, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Heart Failure

Opinion statement

The prevalence of patients living with advanced heart failure continues to rise. For a subset of these patients, continuous-flow left ventricular assist devices (LVADs) are a life-saving therapy. Given the efficacy and durability of contemporary LVAD devices, their use has increased exponentially in recent years. The medical management of patients with an LVAD is an area of expertise for advanced heart failure clinicians, but a general understanding of the initial approach to, and stabilization of, LVAD patients is an important skillset for many health care providers. The rapidly changing field of the medical management of LVAD patients is largely based on clinical experience and limited published data. In this manuscript, we integrate the available published data on the medical management of LVAD patients with the growing clinical experience.


Mechanical support Ventricular assist devices Advanced heart failure 

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart. 2007;93(9):1137–46.PubMedCrossRefGoogle Scholar
  2. 2.
    Go AS et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6–e245.PubMedCrossRefGoogle Scholar
  3. 3.
    Mancini D, Lietz K. Selection of cardiac transplantation candidates in 2010. Circulation. 2010;122(2):173–83.PubMedCrossRefGoogle Scholar
  4. 4.
    Costanzo MR, Mills RM, Wynne J. Characteristics of “Stage D” heart failure: insights from the Acute Decompensated Heart Failure National Registry Longitudinal Module (ADHERE LM). Am Heart J. 2008;155(2):339–47.PubMedCrossRefGoogle Scholar
  5. 5.
    INTERMACS Quarterly Statistical Report. Centers for Medicare & Medicaid Services. 2013 1st Quarter. 2013, The data collection and analysis center University of Alabama at Birmingham.Google Scholar
  6. 6.•
    Kirklin JK et al. Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant. 2013;32(2):141-56. The most recent report from INTERMACS, a registry of patients receiving mechanical circulatory support. These annual reports provide valuable information on type of mechanical support utilized, adverse events, and survival ratesPubMedCrossRefGoogle Scholar
  7. 7.
    Slaughter MS et al. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant. 2010;29(4 Suppl):S1–39.PubMedCrossRefGoogle Scholar
  8. 8.•
    Feldman D et al. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant. 2013;32(2):157-87. Recently published guidelines by the International Society of Heart and Lung Transplantation (ISHLT) for patients treated with mechanical circulatory support. These are the most comprehensive treatment guidelines published to datePubMedCrossRefGoogle Scholar
  9. 9.
    Patel C, Alexander K, Rogers J. Mechanical circulatory support for advanced heart failure. Curr Treat Options Cardiovasc Med. 2010;12(6):549–65.PubMedCrossRefGoogle Scholar
  10. 10.
    Khazanie P, Rogers JG. Patient selection for left ventricular assist devices. Congest Heart Fail. 2011;17(5):227–34.PubMedCrossRefGoogle Scholar
  11. 11.
    Radovancevic R et al. Plasma exchange before surgery for left ventricular assist device implantation. Artificial Organs. 2008;32(6):427–32.PubMedCrossRefGoogle Scholar
  12. 12.
    Matthews JC et al. The right ventricular failure risk score a pre-operative tool for assessing the risk of right ventricular failure in left ventricular assist device candidates. J Am Coll Cardiol. 2008;51(22):2163–72.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Kormos RL et al. Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg. 2010;139(5):1316–24.PubMedCrossRefGoogle Scholar
  14. 14.
    Fitzpatrick 3rd JR et al. Risk score derived from pre-operative data analysis predicts the need for biventricular mechanical circulatory support. J Heart Lung Transplant. 2008;27(12):1286–92.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Drakos SG et al. Risk factors predictive of right ventricular failure after left ventricular assist device implantation. Am J Cardiol. 2010;105(7):1030–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Grant ADM et al. Independent and incremental role of quantitative right ventricular evaluation for the prediction of right ventricular failure after left ventricular assist device implantation. J Am Coll Cardiol. 2012;60(6):521–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Fitzpatrick 3rd JR et al. Early planned institution of biventricular mechanical circulatory support results in improved outcomes compared with delayed conversion of a left ventricular assist device to a biventricular assist device. J Thorac Cardiovasc Surg. 2009;137(4):971–7.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Piacentino III V et al. Impact of tricuspid valve regurgitation in patients treated with implantable left ventricular assist devices. Ann Thorac Surg. 2011;91(5):1342–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Hillis LD et al. ACCF/AHA Guideline for coronary artery bypass graft surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;58(24):e123–210.PubMedCrossRefGoogle Scholar
  20. 20.
    Borgi J et al. Significance of postoperative acute renal failure after continuous-flow left ventricular assist device implantation. Ann Thorac Surg. 2013;95(1):163–9.PubMedCrossRefGoogle Scholar
  21. 21.
    HeartWare Ventricular Assist System Instructions for Use (USA).
  22. 22.
    HeartMate II LVAS Operating Manual, Featuring GoGear System Components (105747.A).
  23. 23.
    Slaughter MS et al. Post-operative heparin may not be required for transitioning patients with a HeartMate II left ventricular assist system to long-term warfarin therapy. J Heart Lung Transplant. 2010;29(6):616–24.PubMedCrossRefGoogle Scholar
  24. 24.
    Mentz RJ et al. Dysphagia in the setting of left ventricular assist device hemolysis. ASAIO J. 2013;59(3):322–3.PubMedCrossRefGoogle Scholar
  25. 25.
    Zierer A et al. Late-onset driveline infections: the Achilles’ heel of prolonged left ventricular assist device support. Ann Thorac Surg. 2007;84(2):515–20.PubMedCrossRefGoogle Scholar
  26. 26.
    Wever-Pinzon O et al. Pulsatility and the risk of nonsurgical bleeding in patients supported with the continuous-flow left ventricular assist device HeartMate II. Circ Heart Fail. 2013;6(3):517–26.PubMedCrossRefGoogle Scholar
  27. 27.
    Cowger J et al. The development of aortic insufficiency in left ventricular assist device-supported patients. Circ Heart Fail. 2010;3(6):668–74.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Pak S-W et al. Prevalence of de novo aortic insufficiency during long-term support with left ventricular assist devices. J Heart Lung Transplant. 2010;29(10):1172–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Aggarwal A et al. The development of aortic insufficiency in continuous-flow left ventricular assist device–supported patients. Ann Thorac Surg. 2013;95(2):493–8.PubMedCrossRefGoogle Scholar
  30. 30.•
    Uriel N et al. Development of a novel echocardiography ramp test for speed optimization and diagnosis of device thrombosis in continuous-flow left ventricular assist devices: the Columbia ramp study. J Am Coll Cardiol. 2012;60(18):1764-75. The first rigorous study of an echocardiographic-based protocol to determine optimal LVAD speed settings and to evaluate for device thrombosisPubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Miller LW et al. Use of a continuous-flow device in patients awaiting heart transplantation. New Engl J Med. 2007;357(9):885–96.PubMedCrossRefGoogle Scholar
  32. 32.•
    Aaronson KD et al. Use of an intrapericardial, continuous-flow, centrifugal pump in patients awaiting heart transplantation. Circulation. 2012;125(25):3191-200. Results from ADVANCE, a multicenter trial of the HeartWare HVAD in patients receiving an LVAD as a bridge to transplantation. The control arm for the study was a similar group of patients in INTERMACS. The results of this study led to the FDA approval of the HeartWare HVAD for this indication.PubMedCrossRefGoogle Scholar
  33. 33.
    Ziv O et al. Effects of left ventricular assist device therapy on ventricular arrhythmias. J Am Coll Cardiol. 2005;45(9):1428–34.PubMedCrossRefGoogle Scholar
  34. 34.
    Brenyo A et al. Risk of mortality for ventricular arrhythmia in ambulatory LVAD patients. J Cardiovasc Electrophysiol. 2012;23(5):515–20.PubMedCrossRefGoogle Scholar
  35. 35.
    Bedi M et al. Ventricular arrhythmias during left ventricular assist device support. Am J Cardiol. 2007;99(8):1151–3.PubMedCrossRefGoogle Scholar
  36. 36.
    Cantillon DJ et al. Improved survival among ventricular assist device recipients with a concomitant implantable cardioverter-defibrillator. Heart Rhythm. 2010;7(4):466–71.PubMedCrossRefGoogle Scholar
  37. 37.
    Andersen M et al. Incidence of ventricular arrhythmias in patients on long-term support with a continuous-flow assist device (HeartMate II). J Heart Lung Transplant. 2009;28(7):733–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Ambardekar AV et al. Implantable cardioverter-defibrillator shocks in patients with a left ventricular assist device. J Heart Lung Transplant. 2010;29(7):771–6.PubMedCrossRefGoogle Scholar
  39. 39.
    Kühne M et al. Simultaneous use of implantable cardioverter-defibrillators and left ventricular assist devices in patients with severe heart failure. Am J Cardiol. 2010;105(3):378–82.PubMedCrossRefGoogle Scholar
  40. 40.
    Oswald H et al. Implantable defibrillator therapy for ventricular tachyarrhythmia in left ventricular assist device patients. Eur J Heart Fail. 2010;12(6):593–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Refaat MM et al. Survival benefit of implantable cardioverter-defibrillators in left ventricular assist device-supported heart failure patients. J Card Fail. 2012;18(2):140–5.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Garan AR et al. Ventricular arrhythmias and implantable cardioverter-defibrillator therapy in patients with continuous-flow left ventricular assist devices. Need for primary prevention? J Am Coll Cardiol. 2013;61(25):2542–50.PubMedCrossRefGoogle Scholar
  43. 43.
    Ambardekar AV et al. Effect of left ventricular assist device placement on preexisting implantable cardioverter-defibrillator leads. J Card Fail. 2010;16(4):327–31.PubMedCrossRefGoogle Scholar
  44. 44.•
    Gordon RJ et al. Prospective, multicenter study of ventricular assist device infections. Circulation. 2013;127(6):691-702. Results from the Ventricular Assist Device Infection Study Group. This was a comprehensive, multicenter study of infections in patients with LVADsPubMedCrossRefGoogle Scholar
  45. 45.
    O’Shea G, Teuteberg JJ, Severyn DA. Monitoring patients with continuous-flow ventricular assist devices outside of the intensive care unit: novel challenges to bedside nursing. Prog Transplant. 2013;23(1):39–46.PubMedCrossRefGoogle Scholar
  46. 46.
    Yancy CW et al. ACCF/AHA Guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013.Google Scholar
  47. 47.
    Shah P et al. Lactate dehydrogenase is superior to serum free hemoglobin as a marker of pump thrombosis in left ventricular assist devices. J Heart Lung Transplant. 2013;32(4 Supplement):S37.CrossRefGoogle Scholar
  48. 48.
    Goldstein DJ et al. Young patients with nonischemic cardiomyopathy have higher likelihood of left ventricular recovery during left ventricular assist device support. J Card Fail. 2012;18(5):392–5.PubMedCrossRefGoogle Scholar
  49. 49.
    Birks EJ et al. Left Ventricular Assist Device and Drug Therapy for the Reversal of Heart Failure. New Engl J Med. 2006;355(18):1873–84.PubMedCrossRefGoogle Scholar
  50. 50.
    Birks EJ et al. Reversal of severe heart failure with a continuous-flow left ventricular assist device and pharmacological therapy: a prospective study. Circulation. 2011;123(4):381–90.PubMedCrossRefGoogle Scholar
  51. 51.
    Dandel M et al. Heart failure reversal by ventricular unloading in patients with chronic cardiomyopathy: criteria for weaning from ventricular assist devices. Eur Heart J. 2011;32(9):1148–60.PubMedCrossRefGoogle Scholar
  52. 52.
    Estep JD et al. The role of echocardiography and other imaging modalities in patients with left ventricular assist devices. JACC Cardiovasc Imaging. 2010;3(10):1049–64.PubMedCrossRefGoogle Scholar
  53. 53.
    Rasalingam R et al. Transthoracic echocardiographic assessment of continuous-flow left ventricular assist devices. J Am Soc Echocardiogr. 2011;24(2):135–48.PubMedCrossRefGoogle Scholar
  54. 54.
    Estep JD et al. Imaging for ventricular function and myocardial recovery on nonpulsatile ventricular assist devices. Circulation. 2012;125(18):2265–77.PubMedCrossRefGoogle Scholar
  55. 55.
    Jessup ML et al. 5 Risk for bleeding after MCSD implant: an analysis of 2358 patients in INTERMACS. J Heart Lung Transplant. 2011;30(4):S9.CrossRefGoogle Scholar
  56. 56.
    Bonde P et al. 4 National trends in readmission(REA) rates following left ventricular assist device (LVAD) therapy. J Heart Lung Transplant. 2011;30(4):S9.CrossRefGoogle Scholar
  57. 57.
    Suarez J et al. Mechanisms of bleeding and approach to patients with axial-flow left ventricular assist devices. Circ Heart Fail. 2011;4(6):779–84.PubMedCrossRefGoogle Scholar
  58. 58.
    Lewis BS et al. Does hormonal therapy have any benefit for bleeding angiodysplasia? J Clin Gastroenterol. 1992;15(2):99–103.PubMedCrossRefGoogle Scholar
  59. 59.
    Junquera F et al. A multicenter, randomized, clinical trial of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. Gastroenterology. 2001;121(5):1073–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Junquera F et al. Long-term efficacy of octreotide in the prevention of recurrent bleeding from gastrointestinal angiodysplasia. Am J Gastroenterol. 2007;102(2):254–60.PubMedCrossRefGoogle Scholar
  61. 61.
    Dray X et al. Treatment of gastrointestinal angiodysplasia and unmet needs. Dig Liver Dis. 2011;43(7):515–22.PubMedCrossRefGoogle Scholar
  62. 62.
    Uriel N et al. Acquired von Willebrand syndrome after continuous-flow mechanical device support contributes to a high prevalence of bleeding during long-term support and at the time of transplantation. J Am Coll Cardiol. 2010;56(15):1207–13.PubMedCrossRefGoogle Scholar
  63. 63.
    Gordon SM et al. Nosocomial bloodstream infections in patients with implantable left ventricular assist devices. Ann Thorac Surg. 2001;72(3):725–30.PubMedCrossRefGoogle Scholar
  64. 64.
    Simon D et al. Left ventricular assist device-related infection: treatment and outcome. Clin Infect Dis. 2005;40(8):1108–15.PubMedCrossRefGoogle Scholar
  65. 65.
    Topkara VK et al. Infectious complications in patients with left ventricular assist device: etiology and outcomes in the continuous-flow era. Ann Thorac Surg. 2010;90(4):1270–7.PubMedCrossRefGoogle Scholar
  66. 66.
    Hannan MM et al. Working formulation for the standardization of definitions of infections in patients using ventricular assist devices. J Heart Lung Transplant. 2011;30(4):375–84.PubMedCrossRefGoogle Scholar
  67. 67.
    Vollkron M et al. Suction events during left ventricular support and ventricular arrhythmias. J Heart Lung Transplant. 2007;26(8):819–25.PubMedCrossRefGoogle Scholar
  68. 68.
    Cantillon DJ et al. Electrophysiologic characteristics and catheter ablation of ventricular tachyarrhythmias among patients with heart failure on ventricular assist device support. Heart Rhythm. 2012;9(6):859–64.PubMedCrossRefGoogle Scholar
  69. 69.
    Dandamudi G et al. Endocardial catheter ablation of ventricular tachycardia in patients with ventricular assist devices. Heart Rhythm. 2007;4(9):1165–9.PubMedCrossRefGoogle Scholar
  70. 70.
    Maisel WH, Stevenson LW. Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol. 2003;91(6, Supplement 1):2–8.CrossRefGoogle Scholar
  71. 71.
    Maury P et al. First experience of percutaneous radio-frequency ablation for atrial flutter and atrial fibrillation in a patient with HeartMate II left ventricular assist device. J Intervent Card Electrophysiol. 2010;29(1):63–7.CrossRefGoogle Scholar
  72. 72.
    Slaughter MS et al. Advanced heart failure treated with continuous-flow left ventricular assist device. New Engl J Med. 2009;361(23):2241–51.PubMedCrossRefGoogle Scholar
  73. 73.
    Rajagopal K et al. Natural history and clinical effect of aortic valve regurgitation after left ventricular assist device implantation. J Thorac Cardiovasc Surg. 2013;145(5):1373–9.PubMedCrossRefGoogle Scholar
  74. 74.
    Wang TS et al. Valvular heart disease in patients supported with left ventricular assist devices. Circ Heart Fail. 2013.Google Scholar
  75. 75.
    Grohmann J et al. Trans-catheter closure of the native aortic valve with an Amplatzer® Occluder to treat progressive aortic regurgitation after implantation of a left-ventricular assist device. Eur J Cardio Thorac Surg. 2011;39(6):e181–3.CrossRefGoogle Scholar
  76. 76.
    Freed BH et al. Percutaneous transcatheter closure of the native aortic valve to treat de novo aortic insufficiency after implantation of a left ventricular assist device. JACC Cardiovasc Interv. 2012;5(3):358–9.PubMedCrossRefGoogle Scholar
  77. 77.
    Russo MJ et al. Percutaneous transcatheter closure of the aortic valve to treat cardiogenic shock in a left ventricular assist device patient with severe aortic insufficiency. Ann Thorac Surg. 2012;94(3):985–8.PubMedCrossRefGoogle Scholar
  78. 78.
    Parikh KS et al. Percutaneous transcatheter aortic valve closure successfully treats left ventricular assist device–associated aortic insufficiency and improves cardiac hemodynamics. JACC: Cardiovascular Interventions. 2013;6(1):84–9.PubMedGoogle Scholar
  79. 79.
    Santini F et al. First successful management of aortic valve insufficiency associated with heartmate ii left ventricular assist device support by transfemoral corevalve implantation: the Columbus’s egg? JACC: Cardiovascular Interventions. 2012;5(1):114–5.PubMedGoogle Scholar
  80. 80.
    D’Ancona G et al. TAVI for pure aortic valve insufficiency in a patient with a left ventricular assist device. Ann Thorac Surg. 2012;93(4):e89–91.PubMedCrossRefGoogle Scholar
  81. 81.
    Holman WL et al. Durability of left ventricular assist devices: interagency registry for mechanically assisted circulatory support (INTERMACS) 2006 to 2011. J Thorac Cardiovasc Surg. 2013;146(2):437–441.e1.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Adam D. DeVore
    • 1
  • Robert J. Mentz
    • 1
  • Chetan B. Patel
    • 1
  1. 1.Division of CardiologyDuke University Medical CenterDurhamUSA

Personalised recommendations