Heartmate II Patients and CPR

Specialties Cardiac

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Specializes in Cardiac.

:redbeatheI would like to know, what do we do if our patient is a Heartmate Pt, and they are unconscious. We don't start CPR right, because it would do more damage.

Has anyone had to deal with these patients or been in this situation.?

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Specializes in Cardiac ICU.

A heartmate II patient should be treated like any other patient and on cardiac arrest cpr and acls should be initiated. It is possible that damage may be done to the vad, but the risk of not initiating acls the damage would be higher. On my unit, we have done cpr and acls on many heart mate II patients. Typically, there prognosis is poor post code secondary to their extensive heart damage. On some other vads, there is a cpr mode you must initiate prior to starting cpr, but with the heart mate II this is not necessary.

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Specializes in Emergency/Trauma/Critical Care Nursing.

I would have to disagree, pt's on LVAD, especially heartmate II or newer generations heartware, once the mechanical stops, unfortunately you're done. Mind you, the old generation LVAS XVE (a.k.a Heartmate I) had a manual pump in case it stops, but they are obsolete now. A real scenario is when a patient is "unconscious" and has (red heart alarm) you should first listen to the "humming" of the pump...then if it's present there are 5 main differentials...Hypovolemia, Arrhythmia, Right Ventricular Ischemia, Tamponade and Thrombosis. Thrombosis is a tricky one because you can feel the system controller heat up if you touch it due to the thrombos sitting in the propeller, and the only way you can save them is take them to the cath lab and use tpa...because in the meantime they will revert back to their old EF ie. 10%, that they had prior to LVAD placement.

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Specializes in Cardiac.
I would have to disagree, pt's on LVAD, especially heartmate II or newer generations heartware, once the mechanical stops, unfortunately you're done. quote]

but, if they are a full code, something must be done, right?

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Specializes in CTICU.
I would have to disagree, pt's on LVAD, especially heartmate II or newer generations heartware, once the mechanical stops, unfortunately you're done. Mind you, the old generation LVAS XVE (a.k.a Heartmate I) had a manual pump in case it stops, but they are obsolete now. A real scenario is when a patient is "unconscious" and has (red heart alarm) you should first listen to the "humming" of the pump...then if it's present there are 5 main differentials...Hypovolemia, Arrhythmia, Right Ventricular Ischemia, Tamponade and Thrombosis. Thrombosis is a tricky one because you can feel the system controller heat up if you touch it due to the thrombos sitting in the propeller, and the only way you can save them is take them to the cath lab and use tpa...because in the meantime they will revert back to their old EF ie. 10%, that they had prior to LVAD placement.

Christy, this makes no sense to me, and I work solely with VADs. If you had a pump thombus in the "propeller", how on earth would that make the system controller heat up? The pump is implanted in the abdomen and the controller is external.. I see no reason why or how this would possibly happen. In fact if there's a pump thrombus, it totally depends where exactly it is as to whether pump power would go up or down - in an axial flow pump if flow is restricted by a clot, less blood goes through the pump, so less pump work, so power goes down. If there's a small clot on the impeller, it may cause drag and increase pump work so that would make pump power go up. None of these scenarios would make the controller heat up.

As to the OP's question, if a VAD patient (particularly continuous flow VAD like HM-II) becomes unconscious, your first responsibility is to ABCs. Protect the airway, get O2 on, call a code, get a backboard, get the crash cart and/or sternotomy cart. The actions will depend a lot on how fresh postop they are - a fresh postop is more likely to be tamponading than someone 2 years down the track, who may be septic/hypotensive/having a stroke.

Remember people can become unconscious for neuro reasons and you may not be able to get a pulse, but try and get a doppler BP at the brachial artery to check for circulation. Check if the VAD is running - what does the monitor say, if they are on monitor? Do they have a flow? Are they having suction/PI events? Is the VAD alarming? What is alarming? Did the controller just fail and they are passed out, in which case you can just switch to the backup and get things running quickly? Do they have a bad cable (there is a current advisory on HMII patient-power module cable pins which are breaking). Is the pump running on auscultation of the pump pocket? If not, they may need to reopen the chest, clamp the outflow graft, and do internal compressions (again, depends how fresh postop they are).

Bottom line, dead is dead, so if they are unconscious, pump is off, you have no pulse or doppler pressure, by all means try chest compressions, because you can't be deader than dead. The inflow cannulae are not sharp edged like they used to be, so you may be lucky and not lacerate the heart. Just remember if the pump is ON and you have no doppler blood pressure, there's no point doing CPR/ECC unless you drop the pump speed - you're just trying to compress a heart that is empty from the VAD sucking all the blood out at high speed. You can drop to a minimum speed of 6000rpm but remember you won't have a flow displayed on the monitor once you go below 8000rpm.

This should get you started thinking.. let me know if you have further questions.

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Specializes in CTICU.

Doh, somehow double posted.

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Broad question but I am just curious - how good is the outcomes of LVAD patients? Quality of life - post-op, length of stays post-op. What if a pt can't take Coumadin can they still receive a LVAD? I don't know much about this area and I am a new nursing student. After reading many articles the above questions come to mind. Any veteran nurses in a cardio unit that deals with LVADs willing to give me some information?

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Specializes in Intensive Care Unit.

I know of a few cases, one of which was successful and the other patient didnt make it. Both using the LVAD for a bridge to transplant. The patient who did though is loving life, always has to wear that over the shoulder bag to stay connected to it but it saved her life. When she loses power she needs to come to the hospital so she can charge it. If you ever get a chance to listen to one in a patient its really cool! Sounds nothing like a heart and its amazing bc it keeps them alive. I have never seen an RVAD idk how popular or successful those are.

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Specializes in OR, Nursing Professional Development.
I know of a few cases, one of which was successful and the other patient didnt make it. Both using the LVAD for a bridge to transplant. The patient who did though is loving life, always has to wear that over the shoulder bag to stay connected to it but it saved her life. When she loses power she needs to come to the hospital so she can charge it. If you ever get a chance to listen to one in a patient its really cool! Sounds nothing like a heart and its amazing bc it keeps them alive. I have never seen an RVAD idk how popular or successful those are.
RVADs are typically an emergent procedure, at least where I work. The HeartMate II is LVAD only, and we use a PVAD on patients for either RVAD, LVAD, or both. The pump is external and is run with a huge console. These folks will not be out and about with a shoulder bag.
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Specializes in Emergency/Trauma/Critical Care Nursing.

In my experience, the outcomes for LVAD patients vary.. for the pts who are not candidates for transplant & have the LVAD for end stage CHF can have a drastic improvement in their quality of life, or they can end up w/even more complications, depending on how compliant they are with meds, diet, etc. The majority of pts I've seen that are Lvad - bridge to transplant have a pretty decent quality of life and usually presented to the ED for elevated INRs or something else not related to the LVAD, & as long as they remained compliant & eligible for transplant, their outcomes were generally favorable.

We did have this one pt that had the heartmate II, not sure if he was a bridge to transplant or quality of life case, but a few years after it was placed he came to the ED after a power outage at home and they found that his Lvad had malfunctioned and hadn't been working for an unknown amount of time. The cardiologists were dumbfounded that he wasn't symptomatic, or even alive considering his pre-op EF was approx 10%. In the end they said that while he had the LVAD it "gave his heart a chance to rest" or something along those lines, & when the LVAD failed, his heart took over and was now functoning with an EF of 50-60%. They ended up removing the LVAD altogether and as far as I know the pt is still doing well. :)

Sent from my SPH-D700 using allnurses.com

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Specializes in CT-ICU.

I've heard of a few similar stories with LV improvement. I had a patient a few weeks ago that was on a stem cell trial in which they injected stem cells into the myocardial tissue of an LVAD pt. The premise was similar to your story, in that in a few years if the LV had recovered, they would explant the HM-II. If not, the pt would be listed for tx. Pretty interesting stuff.

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Specializes in CTICU.
Broad question but I am just curious - how good is the outcomes of LVAD patients? Quality of life - post-op, length of stays post-op. What if a pt can't take Coumadin can they still receive a LVAD? I don't know much about this area and I am a new nursing student. After reading many articles the above questions come to mind. Any veteran nurses in a cardio unit that deals with LVADs willing to give me some information?

Outcomes with VADs depends mostly on how sick the patient was before they got it. Overall heart transplant is still the gold standard, but current 1yr and 2yr survival rates for VAD are close to those of transplant (~70-90%). Being unable to take coumadin is usually a contraindication to VAD therapy, although there are some devices that require less anticoagulation than others. It depends on the reason they can't take coumadin.

Quality of life improvement again depends on how sick the patient was preop. Someone who had a sudden ischemic event like a huge MI and ended up on a transplant list with a VAD is not going to love it. Someone who's had end stage cardiomyopathy for years and been hospitalized multiple times, and who can't do anything much, will probably find they feel a ton better with good circulation and improved exercise tolerance. Most of the QOL surveys we do find that patients say they would do it again, even knowing what they know now.

Average national length of stay post VAD is around 30 days. Sometimes this is due to physical reasons and sometimes due to needing to train the patient and family on how to work the VAD equipment and what to do in case of emergency. More often nowadays we transfer patients to rehab to get stronger (and decrease hospital length of stay) while we train them.

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