LVAD Implantation

[CCU BSN RN]

I work in a CICU at a level 1 trauma center.

We've been taking care of LVADs from the community for a few years, we have 4 or 5 patients where we are the only driveable LVAD center for them to come to.

The last few months, we've starting implanting LVADs, but there was no real further education or training, because we were basically told that we already had LVAD training and it's just a normal postop open heart but with an LVAD.

we've now done between 3 and 8 implants with varying degrees of success, but with all of us feeling 100% nervous and like we don't know what to look out for or what the heck we're doing.

So, those of you who work in institutions that have been around the block a few times...What do you wish you knew when you starting taking care of LVAD patients immediately postop from implantation? What alarms or complications seem to crop up more often and how do you prevent or manage/treat them? What kind of education were you provided with?

Thanks

[szyjarek]

Hi,

I work in clinic witch implants 10 lvad a year. We have background in mechanical circulatory support from years of use pulsatile pumps and intensive ecmo program. We din not have special trainig and preparation for lvad implantation. Of course company with produce pumps organized as many trainings and this was very useful.

I m vad coordinator and I take care of patient during his stay in hospital and after discharge. In hospital after implantation patient needs to by covered by intensive care team. In my opinion patient with pump is same like others after cardiac implantation but we need to remember how support system change his circulatory system. HeartWare and HeartMate 2/3 systems are sensitive for pre and afterload. So we must create field to proper function of pump but our priority is patient condition. We can expect low flow alarms as a effect of hypovolemic or high resistance. Important is function of right ventricle. It's function will have influence for support and function of LV. If we stabilize patient from circulatory point of view we need to care also of his anticoagulation therapy, driveline wound etc. We need to educate him in all aspects of system and self-care.

To improve his care and make our job easier we equipped them with INR control devices to measurement everyday effect of anticoagulants. We have also system for monitoring patient after discharge to home. They send as information about pump functions and parameters and also pressure , plus, weight, temperature and coagulation therapy. We created with group of our patient association with help exchange information about therapy and also as a effect of initiative of patient we created special information card.

Regards,

Jaroslaw Szymanski

[2210485]

Hate to be 'that guy' but is it cool to backtrack to an even more basic level:

From what I understand these devices are primarily bridges to transplant correct? I see these on extremely rare conditions... Mostly im only aware of them when they get in the way of pacemaker implantation. Dont even know who puts em in or what that process is like at all. On the invasive side i work cath, where patients are either gonna get an impella or if thats not the way we need to go then they just sort of.. Evaporate to some other part of the hospital and i never see them again.

Anyone familiar with patient selection criteria for these? What sort of folks tend to wind up with these? How long do they typically plan for them to stay in?

Are lvad implantations a significant operation? How does it vary in terms of the recovery process and demand on the nurses vs say.. Ecmo in the post op period.

Anyone whos game to give the down and dirty id appreciate it. I realize i could just probably google these things, but id imagine some of,you folks can answer the question with ease and in a more concise manner.

[diprifan]

I would be slightly concerned that you haven't had post-op LVAD training. There are some unique problems that can arise post-op, such as the ones Szyjarek mentioned, that are less so present in a patient with an LVAD in the community; I'm specifically thinking of tamponade and acute right sided failure... but it sounds like you recover open hearts, so those may be more obvious. Flow alarms are a big one.

2210485 - no, LVADs are for "destination therapy" in addition to bridging for transplant. Destination therapy is for a heart failure patient that has probably tried home inotropy without success and have been on a slow decline. The VAD buys them some time. I understand that you work in the cath lab and probably see your fair share of percutaneous VADs (impella and tandems) which are vastly different than what the OP is talking about. This type of mechanical support is placed under general anesthesia where the CT surgeon cracks the chest, cores out a part of the ventricle, and attaches it to a pump that is implanted into the chest and connected to a continuous power source and then hopefully closes the chest (probably over simplified it). The LVAD is permanent, and the patient goes home with it until they die or get a heart transplant. These patients usually have severe heart failure and already have a dual chamber pacer for resynchronization therapy (not sure why you mentioned pacers). The operation is a big one in terms of hemodynamics compromise and recovery. It usually takes a significant work up with cardiology and cardiothoracic surgery, but can be placed on an emergent basis. Most hospitals have teams that treat these patients both inpatient and outpatient. The patient recovers similarly to other open chest patients in terms of nursing care... which is why the OP was asking about specific training.

[2210485]

Thanks for your reply dirpifan!

As for mentioning pacers, i brought it up because one of our responsibilities here is pacemaker programming in the absence of the rep. We also handle outpatient programming for all the major brands.

This is the setting where i seem to run in to lvads the most.

They are noteworthy in this environment because the generate some sort of interference that impedes the ability of the programmer wand to obtain a connection with the device..

In other words, they are a pain to manage! You put the wand on and start trying to test or make adjustments but the wand loses its connection every few seconds and requires constant repositioning! Its kind of like trying to find that perfect spot in the room where you get a good cellphone connection...

They are very rare to see in the lab itsself.

All that said i am interested in the topic even if we dont work on the floor or in the operating room.. Simply because its kind of lame to have a gap in ones knowledge.

With that in mind tamponade might not be something i would see, because the lvad patients i have are those who have already been sent home with the device.. However id imagine there are some complications that could still arise with these patients down the line that i could potentially run in to.. Such as a flow alarm, or perhaps even something as straightforward as an infection.

[Frostin, BSN, RN]

The interference you're referring to is due to the electrical impulses generated by the electrical motor powering the VAD I these type of patients. The motor current routinely exceeds the preset thresholds for pulse generation in the the interrogation devices used to tweak ppms. The only way to bypass such a frustration is to have an L or RVAD controller available to MOMENTARILY pause said motor function and obtain your readings for later manipulation of the ppm's settings. HOWEVER, this is , in many cases in feasible secondary to the fact that many of these type of patients are completely VAD dependent and even momentary cessation of function results in either CNS depression (read : syncope and subjective complaints) or full-on cardiovascular collapse. Your best bet in the situation you described is to maintain your course of trying to find the "sweet spot" during ppm interrogations. If brief, and I do mean brief, interruption of VAD function is required to do the job, either a cardiologist or cv surgeon need be present and actually in the room during such an undertaking to cover your ... self

[2210485]

Yeah lol, not gonna be pausing any lvads.

At some point when i have more time ill probably wind up researching some more information from the manufacturers. Im sure they have a manual or a powerpoint or something to utilize. They probably have reps available to call to figure out the best resources to use

I dont see an excessive quantity of lvad patients.. Maybe 3 per week? But it would probably be a good idea to learn more about how the device works so i know what im up against at least.

Thankfully thus far i havent had one that was so difficult i had to call the electrophysiologist.. Just takes patience.

[Sunshine.nurse]

LVADs are very interesting.