Immediately contact hospital or patient's LVAD coordinator to help coordinate care
Check controller to ensure power light is on
Ensure humming sound of pump is auscultated over chest/abdomen
If pump not working, replace with patient's backup controller
Check all connections to power source, driveline, and controller are intact
Disconnect all connections after checking, and reconnect immediately
Inspect driveline for damages/defects
Assess battery, replace with backup battery
Patient should be positioned flat on stretcher before replacing battery
OR connect to hospital's power base unit or patient's power base unit if available
IF NONE OF ABOVE, contact VAD coordinator to find local LVAD patient in vicinity willing to transport extra batteries to ED
Take note that if battery is critically low, many<unk> s will automatically lower speed, which can cause syncope or lightheadedness
Hemodynamic, supportive care
Many LVAD patients fluid restrict too much due to their history, and LVADs are preload dependent
IVF crystalloid fluid bolus when indicated (low-flow indicator alarm)
MAP goal 70-90 mmHg
LVAD patients afterload sensitive
Address high BP emergently if thought to contribute to increased work of pump, which leads to thrombus and stroke
Beware of suction event complication, which requires IVF bolus and allowing the controller to sense this, slow pump speed and slowly bring up to fixed speed to allow for adequate<unk>  filling
Take special care to not twist, bend, cut, or otherwise damage the driveline
First generation LVADs had pulsatile flow
Subsequent designs use continuous flow - patient will not have a palpable pulse
Patient will be on anticoagulation and antiplatelet therapy secondary to high risk of pump thrombus, CVA, and other thromboembolic events
VADs are ECG independant, unlike ICD (many patients with a VAD will also have an ICD in place)
ICD discharges are common, and frequently inappropriate (possibly secondary to LVAD interference)
Ensure that patient or family bring in any additional batteries and charging elements as these will not be available in most hospital settings
Thrombosis, tPA in emergencies
Breadth of literature supporting is overall small
When patient not responding to continuous anticoagulation (heparin, argatroban drip)
AND when going directly to LVAD exchange or catheter-directed thrombolysis are not possibilities
Consider tPA if not contraindicated for survival and avoidance of needing LVAD exhange
5 mg IV bolus tPA
3 mg/hr infusion in NS for 10 hours
1 mg/hr for up to 48 hours, never exceeding 100 mg max total dosage
In single center study cited above, there was:
70% that had hemolysis resolve and no need for LVAD exchange at 30 days
95% survival at 30 days
10% hemorrhagic stroke with no difference between tPA and control group
Alternative dosing, while plus/minus continuing heparin drip
Initial dosing of 10 mg IV bolus
Followed by 1 mg/min for 20 min
Then 1 mg/hr for 24 hours
Monitor LDH levels and discontinue heparin drip when LDH acceptably lowered
Ensure humming sound of pump is auscultated over chest/abdomen
If pump not working, replace with patient's backup controller
Check all connections to power source, driveline, and controller are intact
Disconnect all connections after checking, and reconnect immediately
Inspect driveline for damages/defects
Patient should be positioned flat on stretcher before replacing battery
OR connect to hospital's power base unit or patient's power base unit if available
IF NONE OF ABOVE, contact VAD coordinator to find local LVAD patient in vicinity willing to transport extra batteries to ED
Take note that if battery is critically low, many<unk> s will automatically lower speed, which can cause syncope or lightheadedness
Many LVAD patients fluid restrict too much due to their history, and LVADs are preload dependent
IVF crystalloid fluid bolus when indicated (low-flow indicator alarm)
MAP goal 70-90 mmHg
Address high BP emergently if thought to contribute to increased work of pump, which leads to thrombus and stroke
Beware of suction event complication, which requires IVF bolus and allowing the controller to sense this, slow pump speed and slowly bring up to fixed speed to allow for adequate<unk>  filling
Subsequent designs use continuous flow - patient will not have a palpable pulse
ICD discharges are common, and frequently inappropriate (possibly secondary to LVAD interference)
Breadth of literature supporting is overall small
When patient not responding to continuous anticoagulation (heparin, argatroban drip)
AND when going directly to LVAD exchange or catheter-directed thrombolysis are not possibilities
Consider tPA if not contraindicated for survival and avoidance of needing LVAD exhange
5 mg IV bolus tPA
3 mg/hr infusion in NS for 10 hours
1 mg/hr for up to 48 hours, never exceeding 100 mg max total dosage
In single center study cited above, there was:
70% that had hemolysis resolve and no need for LVAD exchange at 30 days
95% survival at 30 days
10% hemorrhagic stroke with no difference between tPA and control group
Alternative dosing, while plus/minus continuing heparin drip
Initial dosing of 10 mg IV bolus
Followed by 1 mg/min for 20 min
Then 1 mg/hr for 24 hours
Monitor LDH levels and discontinue heparin drip when LDH acceptably lowered
5 mg IV bolus tPA
3 mg/hr infusion in NS for 10 hours
1 mg/hr for up to 48 hours, never exceeding 100 mg max total dosage
In single center study cited above, there was:
70% that had hemolysis resolve and no need for LVAD exchange at 30 days
95% survival at 30 days
10% hemorrhagic stroke with no difference between tPA and control group
70% that had hemolysis resolve and no need for LVAD exchange at 30 days
95% survival at 30 days
10% hemorrhagic stroke with no difference between tPA and control group
Initial dosing of 10 mg IV bolus
Followed by 1 mg/min for 20 min
Then 1 mg/hr for 24 hours
Monitor LDH levels and discontinue heparin drip when LDH acceptably lowered
Unconscious, apneic, no evidence of LVAD function (auscultate for mechanical noise)
Immediately evaluate LVAD components and attach to reliable power source
Some first-generation LVADs have external hand pumps that can be used to provide circulation
Begin CPR if patient is unresponsive with MAP less than 50mmHg, end tidal carbon dioxide level less than 20mmHg, or LVAD cannot be restarted.
Unstable patients with shockable dysrhythmias should be cardioverted.
Optimal placement of pads is in the anterior-posterior fashion & not over the drive line.
Patient can be intubated, given IV fluids and ACLS drugs, etc
New Paradigm shift with since AHA officially endorsed the use of chest compressions in 6/2017.
Some studies available indicate that CPR may not be as harmful as previously thought, or that abdominal compressions are an alternative but further investigation needed
Some first-generation LVADs have external hand pumps that can be used to provide circulation
Unstable patients with shockable dysrhythmias should be cardioverted.
Optimal placement of pads is in the anterior-posterior fashion & not over the drive line.
Patient can be intubated, given IV fluids and ACLS drugs, etc
Optimal placement of pads is in the anterior-posterior fashion & not over the drive line.
Some studies available indicate that CPR may not be as harmful as previously thought, or that abdominal compressions are an alternative but further investigation needed
Left ventricular assist device complications
Bleeding - most common reason for ED visit, most common in first month after implant 
Heart transplant complications
GI bleeding is the most common source 
Aortic endograft complications
Mechanisms:
Cardiac ablation complications
Acquired Von Willebrand Disease 