This video provides EMS professionals and first responders with practical education on mechanical circulatory support (MCS) and ventricular assist devices (VADs). A review of VAD components, patient assessment, common complications and alarms, emergency troubleshooting, and key considerations for the safe transport and care of patients with VADs.
Hi, my name is Mindy. I am the senior heart transplant LVAD coordinator and educator at Centerra Norfolk General Hospital, and today we are going to discuss, um, MCS VAD education for EMS and first responders. So today we are going to discuss what a VAD is, um, how do we determine a patient who needs a VAD, um, identifying system components and VAD parameters, um, understanding assessment and common complications, um, and assessment techniques, uh, identifying issues with alarms and how to troubleshoot those, and, uh, how to transport a patient safely if they do need to come to the hospital for further, uh, assistance. So mechanical circulatory support is basically an umbrella term that talks about heart pumps that move blood from the heart to the body and patients who have significantly diminished ventricular function. Um, there are several different devices out there. There are temporary devices, permanent devices, um, either supplemental or replacing the action of the heart altogether. Uh, but they do fall into two major categories, uh, pulsatile, pulse generating, or continuous flow non-pulsatile. And of course, managing someone with or without a pulse is completely different. So VAD stands for ventricular assist devices, which is what we're going to discuss today. The patients who leave the hospital go home with VADs, mainly left ventricular assist devices, and these are supplemental devices that just help to push the blood along, but they do not completely take over or replace the function of the native heart. There are not durable options for right-sided support or biventricular support where patients are able to actually go home and um live normal that are um widely used at this point. Um, but versus pulsatile versus non, um, total artificial heart is still out there. I think VCU does it. Uh, we do not uh manage or put in total artificial hearts at this point. Um, but just some things to know because we are in an area where people may come to visit and they, you may see one. Um, it is a pulse generating device, so these patients will have a pulse, um, and it replaces both of the ventricles with plastic ventricles, so it actually does replace, um, the function of the heart as opposed to our other devices we're gonna talk mainly about which supplement, um, things to know is because there are no actual native ventricles, you're not gonna get an EKG rhythm, so when you plug, um, the patient in for an EKG, it's gonna be a flat line, which is normal for that device. Um, but, uh, your pulsatile, um, pulse ox, auto blood pressure cuffs, and all of that will work for these patients because they are pulsatile. Um, but most commonly, we have our non-pulsatile continuous flow left ventricular assist devices, which are fixed speed devices that basically continue to push blood at a fixed speed through the patient's body, um, and they often lack a pulse with these devices, and again, it's the most common type. So how do we determine who needs a ad? So basically, uh, CMS considers or the um Medicare Medicaid governmental bodies um recognize durable LVAD and heart transplant as elective procedures, so they give us guidelines to follow in order to um have a patient qualify for these devices so they do have to be FDA approved devices for either. Term or short term use, um, so you have bridge to transplant. So is their end game transplant or a bridge to recovery? Do we think they may recover and we'll be able to take the device out, um, or is it neither of those and all we're doing is putting in a device for the length of that patient's life and that's all we're gonna do and that's called destination therapy. Um, but regardless of any of that, um, they have to have New York Heart Association Class 4 symptoms, which basically means that they are symptomatic at rest. They can't do their normal activities of daily living. Um, they have an ejection fraction on the left side of less than 25%, um, normal being 55 to 65%. Um, they're either dependent on inotropic support like your continuous Milrenow nabutamine drips, um, or if they're not, uh, they have a low cardiac index on optimal guideline direct medical therapy and failing to respond or not tolerating it anymore. Um, or they are on a temporary device and we are unable to wean them off of the temporary device, so we have to do a more permanent solution which would be a more durable device like these, um, so some things we do think about when we're evaluating patients for this therapy, um, is do they have a good history of compliance? Have they done well with following directions that we give them? Do they take their medications? Do they come to clinic and all of those things, um. Do they have caregiver and family support to help them get through the surgery and then long term to help with caring for the device and all the things that come along with that? Do they have reliable transportation to get to and from the hospital for the routine follow up? Do they have insurance to support? this therapy and even then can they afford the copays that will come along with it? Um, they have to reside within 4 hours of any vat center, not necessarily us, but they have to be able to get somewhere in the event of an emergency and for obvious reasons they have to have power and phone services. So there are several contraindications to LVAD therapy. Medically, the most common reasons that a patient will not qualify is generally chronic kidney disease where we don't think we can get them through surgery without ending up on dialysis. Dialysis long term because that is a contraindication for LVAD therapy is for a patient who's on dialysis. Uh, another is, uh, chronic liver failure or cirrhosis. Um, we do have to be able to safely anticoagulate these patients, so they do have to have a somewhat functional liver. Um, relatives, big one is RV, um, Uh, dysfunction, we do have to adequately assess the right ventricle because this only supports the left. So if the right side doesn't work properly and get the blood where it needs to go, the LVAT is not gonna fix the problem. So those are the main contraindications that we run into the most, um, so why that and not transplant? So I would love to say every person who gets put on the list for a heart transplant will actually get one in a timely manner, but. Life doesn't work that way and hearts don't grow on trees, so we just have to um have alternatives for patients who can't wait or who won't qualify and this happens to be one of those um kind of alternative therapies. So how is the LVAD implanted? It is implanted with open heart surgery. Uh, the patient goes on the heart lung bypass machine. Uh, stops the heart, uh, puts, um, a hole in the base of the left ventricle for the inflow cannula where blood goes into the pump. Um, they then attach the pump to the base of the heart and then anastomos, um, a graft to the ascending aorta above the aortic valve where the blood pushes out through the outflow graft. So basically we're kind of bypassing the normal flow through the left ventricle by sucking the blood out and pushing it around the aortic valve. Kind of going around to the where it is helping to supplement. You do have to realize though blood still does go through that normal pathway as long as that aortic valve works, um, so it'll still push the blood out normally but also supplement by pushing it around, um, the actual circulation too, um, after they put the actual pump in the surgeon then tunnels the drive line or the wire, um, through the abdomen. Either on the right or left side, and then we plug that into all of our external equipment that you see here on the table. Um, so, where were we when it comes to technology with VADs and where are we now? So, we started uh back in the day in the 80s really with the pulsatile first gen pump, Heart mate um XVE. Very, um, very large pump had to sit in the abdominal cavity, um, because it would not fit in the chest, so it was, uh, very large and cumbersome. Uh, patients didn't generally get to leave the hospital much with these, so, um, they came out with a smaller device and decided because of the higher clot, um, issues they had with the pulsatile device they. That the technology continuous flow, so it ejects continuous blood out of it and therefore eliminating or lowering the risk for clot formation. So the second gen pumps were our heart rate too, uh, essentially it's like a glorified jet ski pump and I know, uh, EMS people are pretty good with and and fire are good with knowing about water pumps, and these are basically water pumps, so. Um, Heartmate 2 is an axial pump, uh, meaning blood just flows parallel with the rotor, uh, and then it, it pushes it kind of like a jet ski motor would push, um, water through its engine. That's the way this particular pump works. Um, then we went to our third generation pumps with Heartware HVAD and HeartMate 3. Uh, currently the HVAT is, is recalled. We cannot use it any longer, so, um, the patients who have HVAT here will either have to get transplanted, they'll pass away, or if they need to have a pump changed, it goes to a HeartM 3, which is currently the only device that we have out there FDA approved. Um, it's so that is our own, our kind of tried and true right now. So most of the patients moving forward at this point are gonna have HeartM 3s. Most of our patients do as well. Uh, HeartMate too, we do still have a few patients with it, so we'll talk about that. Um, this was FDA approved in 2008. It is an Abbott product. This is a little diagram that you'll see where each piece that I talk about where it it kind of goes. So we talked about the pump itself, uh, the inflow graph of cannula where the blood is pulled out of the heart is in the base of the left ventricle. It kind of points straight up at the aortic valve, and the outflow, um, that pushes the blood out is anastomosis on the ascending aorta. Drive line comes out through the belly, which is a wire, um, that communicates between the pump and the brain, which is the system controller. And the brain will run the pump as long as the circuit is complete with power, either your 14 volt lithium ion batteries or AC wall power. So this just shows you the pump itself. Uh, this pump flows 6 to 15,000 RPMs and can create 3 to 10 L per minute of flow. The uh parameters that you get off of the um system controller, these are kind of like extra vital signs that we have the patients pay attention to every day, so they should be checking for these settings and making sure they were at least somewhat comparable to what they were. The day before and they are instructed to call us if anything seems like it's not right with the with their current settings so the speed is really the only thing that we set for these patients, um, and basically that's how fast we want that rotor to spin inside of that pump, um, and typically we, uh, go 9 to 10,000 RPMs, but like I said we could go 6 to 15, um, and it will fluctuate by plus or minus 150 RPMs and that's completely normal. Um, your power is, is. Um, directly reflected by the speed, so the power is how many watts it takes to maintain the speed, so we monitor that carefully, um, because any, uh, increases and decreases in power could be from an obstruction or a blood clot inside the pump or something like that. So we do pay attention to rising, um, powers and if it ever gets into the double digits that means that there is a problem. So we do have them pay attention to that, um, the flow is a calculation. Uh, based on speed, power, and pressure gradient with heart rate too, um, the other pumps you factor in the patient's hematocrit to give a more, uh, accurate estimated flow, but since this is the older pump, it doesn't do that, um, so there is the chance of having minus minus minus and plus plus plus if it's fallen outside of the expected range, um, but typically you'll see flows range from 4 to 6 L per minute. PI or pulsativity index basically measures the amount of pulsativity seen over the pump in one second interval, and that typically is just showing us what the patient's underlying pulsativity is of their native heart, so that may be variable in itself based on what is going on with the patient. Um, the system controller again is the brains of the operation, so we're gonna take a little bit of time to look at that. Um, when you look at the system controller, you'll see a green circle at the top. That green circle basically is showing us that the pump is on and running. So as long as you see that green light, you know that your pump is actually running and functional. Um, other than that, you'll see a series of buttons and lights. Um, there are 3 buttons on the system controller. The first one is the battery. So when you press the battery button, it lights up the battery gauge symbol to show the patient how much battery power they have collectively between the two batteries. This particular Heart mate devices drain batteries together simultaneously, so it's gauging the two together with that battery gauge. Um, you also have a silence alarm button. It will silence your red and your, um, power related yellow alarms for 2 minutes. If you guys ever have an alarm or a patient calls for an alarm saying, hey, I had a bad alarm, and you get there and it has resolved. If you hit the silence alarm and display simultane. Sitaneously it will let you scroll through the last 6 alarms that patient has so you'll be able to go back and see exactly what that alarm was, um, and then you have your display button on this end which will then toggle through those, uh, parameters that we just talked about. When you click it once you'll see the speed you click it the second time it'll be the flow. 3rd time it'll be the pulsatility index. 4th time will be power. And the 5th time it'll let you know that um if the internal battery is charged or charging, um, and then it goes back to the blank screen and then you have a series of red and yellow here in the middle. Which, um, we'll get into in just a second here. Um, but anytime there is an alarm, there's always people on call, bad coordinators on call to help to troubleshoot and give any type of direction. Um, there is gonna be a display on the screen that tells you exactly what, um, the alarm is, and it will also, you wanna know, is the pump on and running. Those are very important things to know. Uh, also, if there's family trained family members around, they are actually very well versed in switching pieces of equipment also, so use those resources appropriately. When we go through the different alarms, um, the first, the yellow ones basically your connections here. So if you change batteries one at a time, you'll always get those yellow lines. And then the yellow diamond beside the battery gauge symbol is the 15 minute battery warning, which means that the set of batteries are wearing. Has about 15 minutes left, so moving to the reds, if they ignore this yellow diamond 15 minute warning, when they get to 5 minutes, the red battery will alarm, and that means that it's now only 5 minutes left. So it goes from a yellow to a red if they don't listen to the advisory, then converts to a hazard, um, if they disconnect both power sources at the same time. It will also create a red alarm with the red battery and it will show these two yellow ones flashing at the same time and that basically just means that they have no external power which it will tell you on the system control or display screen. Um, however, the pump does not stop because there's a backup battery in here that will run the pump for about 15 to 30 minutes without any external power. Um, there is a dry line disconnect, so the line that's coming from our patient, if that, uh, becomes disconnected, the pump has no way to run. So that, uh, does stop the pump and treatment for that is to put it back together. Uh, and then you have two that they both tell you the same thing but mean very different things. Um, it'll say low flow call hospital contact. So low flow, you wanna make sure when you, if you do see that alarm, then the first thing you want to know is, is the pump on or is it not on. So this light, if it's, if it's on. Is a patient problem. The VAD's on and running per the light, so we know that it's not the VAD, it's the patient. So why might the patient have a low flow alarm? So low flow means that it's dropped below 2.5 L per minute. And is generally a preload or an afterload problem. So these are preload sensitive and afterload, um, uh, preload dependent afterload sensitive. So basically it'll either be volume depletion of some kind or it'll be a hypertensive issue. So blood pressure is probably the easiest way to find that out, um, if the pump is running because if it's high then that in itself is your reason for the low flow. So we would need to treat the blood pressure, i.e. the patient, to alleviate that alarm. Some other things that can cause these alarms um are less common is right heart failure because we're not getting enough blood flow to the left and then also um. Um, I'm trying to think what else, uh, arrhythmias, that's one. So if they have an arrhythmia like a ventricular arrhythmia or something like that, that will also lower the flow because it's pumping the heart's pumping very fast. It doesn't have enough time to fill to get the blood flowing through the pump enough. So those are some things to think about. So rhythm, blood pressure, volume status are big. Um, your other one that says low flow call hospital contact and your green light is off, it means that it is a pump issue because 0 is less than 2.5, so it's gonna trigger also a low flow alarm. So what happens if the green light is off? This is even more of an emergency because there will be a period of time that. If it's off for too long, we won't be able to restart it due to blood clots forming in the pump and we don't want to shower them everywhere. So there will come a point where we will stop trying to restart it if um if we can't get it restarted. So what do we do in the event a pump is stopped? OK? Um, first thing we do is check all our connections to make sure everything is tight. And connected as it should be. Generally we start with the patient's abdomen here and work our way down. So HeartM 3 has a little connection here that we would look for to make sure the drive line is intact. We would then come to this connection, make sure it's locked in place, and then follow our power leads to the battery and make sure they're all. Connected tightly if that is the case, everything is tight, then we change power so if we did have extra, um, we have extra batteries wall power we would just use an alternative power source and see if that helps um and if it doesn't, then we need to move to changing the system controller which is the brain. Um, so those are the steps that we would kind of go through to restart the pump. Uh, if it still doesn't restart, then you would have to assume that the pump inside the patient has stopped working and that is more of a, we're not gonna fix it here, they gotta go to the hospital. So what do we do if we do need to bring them to the hospital? Every patient has a black bag that looks like this that has all of their backup supplies and equipment in it, um, where they would have at least 2 extra charged batteries and then at least 2 extra clips, and their extra system controllers should be right here in the front, so everything that's on their person should be in this bag whenever they get transported. Um, if you do switch out a system controller and it does restart the pump, the next step is that the patient does need to come to us to get a replacement because now they're on the one that was in their bag and the one that was on them doesn't work, so they have zero backup. So they do need to come to us, uh, and get a new one. So for EMS, um, LVAD emergencies, there's always a primary on-call VAD coordinator and a backup VAD coordinator. So if you cannot reach the primary, you can also reach the backup, and they have designated numbers for that. How do we change batteries? OK, so when we have a battery in the clip, there is one button here which we would release and then we would find us a new charged battery, check here to make sure it's fully charged, and then we would reconnect it, lining up our red arrows, and you would just do it one at a time. Uh, again, you'll find some extras here if they're not in the backup bag at you're at their house. There's also a battery charger that holds 4 batteries also and will charge those. It takes about 4 hours to charge batteries, and they all get, um, 4 sets or 8 total batteries when they go home. So that's just some places to kind of look for the batteries if they're not right in front of you. So sys uh changing the system controller, um, I will kind of demo this, um, but what we do. Uh, and any, any controller change when you pull a controller out of the bag, it's gonna be off, OK, so any time that this is off there's no on off switch to turn it on. So how do we get it to turn on? We use power, OK, so the first thing we always do is power the device. So I always kind of put things together because there's a lot of wires here, so it could be kind of confusing. Um, we just changed batteries so we know that they're fresh. We will take and twist one of our batteries off. It doesn't matter which one, because remember we have to power the new one in order to turn it on. So we're gonna take it, do our half moon connections, push until that noise, well, push until we see the, the lights go on, and then we can twist because we know it's engaged now. And then we just twist it on. When you see your screen come on, it'll say charging or charging complete. Either way, it doesn't matter. Um, now we're ready to move our patients. So I always kind of flip them because when we do, um, disconnect, we wanna promptly connect it here. So you go into the unlock position here. So you expose the red button, push the red button and pull the line. Line up your arrows, click it in place, close the lock, and then flip it over. Flip it over to see did your green light pop on now? So it did. So the problem has been fixed. Pump is now running again. Um, now, we got to get this one to stop screaming. So we'll take the last battery. Silence that and then we will hook this one up, push and twist. So now we have successfully restarted our pump by changing the controller and then this is. Still looking at me and screaming if it wasn't silenced, so we're going to take this battery, hold the battery button down until this completely shuts off. The only time that it will allow you to put it into sleep mode is when there is no power and no patient attached. So if anything's still attached, it won't let you do it. So just keep that in mind. It's a little safety thing. So that's how to do your heart mate 2 and 3, power and controller exchanges. Um, again, if they do switch to the backup, they do have to come and get a replacement. And if you give us a heads up, we'll have it ready for them when they get there. Um, again, if they do switch to the backup, they do have to come and get a replacement. And if you give us a heads up, we'll have it ready for them when they get there. Um, the next device, um, that we're gonna, um, talk about is Heartware HVAD, and that is our other pump over here, and that is a Medtronic product. It was FDA approved in 2012, and I believe it came off as um taken off the market or recalled in 2021, I think, um. But it's, it's smaller, so it was actually a very good pump that fit into the chest cavity now, so it eliminated that pump being in the abdomen, um, and it's just a different brand, so it looks different, has a little bit of difference to it, but standardly it kind of works the same. It's still pulling the blood out of the left ventricle and pushing it above the aortic valve. So looking at the pump itself, it only has one moving part which is the rotor. It is held in place by an axis, um, and as you can see in that bottom diagram of the heart that the inflow cannula points straight up at that aortic valve which is that's properly positioned um heart pump. So looking at how the blood flows, centrifuge, this is a centrifugal pump as opposed to our axial type of heart mate 3. So what is the benefit of this? It it uses less speed, but it can also generate, um, the same amount of flow. So looking at, um, the system controller, it's a little different looking. Um, it has things coming out of both sides as opposed to one side with our Heart mate device. So your two power sources are gonna be the two closest to the screen up front. Your drive line will be in the back, and then there will be a capped port which we use for monitoring in the hospital. So what as far as alarms and buttons and such, um, there is a scroll button which will scroll if you, if we need it, we'll tell you to scroll and just push that down arrow and give us the information, um, and then the silence alarm button that will silence the red alarms. Your alarm indicator is what tells you the severity of the alarm. It'll either be solid yellow, flashing yellow, or flashing red. Different power consumption over here, uh, basically, heartware will drain one battery and then go to the other battery, so it doesn't drain them simultaneously as, uh, the Heartmate device devices do. Um, these use AC power will plug in place of one battery, so any time that they do go on to AC power or DC power, they still are required to wear one battery also. So this one basically has we're running off of side one with this battery and it's fully charged and then the one on side two is not in use. Um, if they plug into AC, the AC adapter will turn green, so that's also a thing. Um, your numbers will stay right on the front of the screen unless there's an alarm scenario. If you have an alarm, the first line on the display screen will tell you what the alarm is. Second thing will tell you exactly what to do for the alarm. If there are multiple alarms happening at the same time, you will see a downward. Pointing arrow which would indicate scrolling to see what the next so hitting that scroll button to see what the a subsequent alarm is so again I told you there was low, medium and high priority. Bad thing is is the high priority ones cannot be silenced. So if you do have a red alarm you have to fix the reason for it in order to make it stop being loud and obnoxious. um, so what are the different red alarms? OK. Um, these high priority alarms, um, the first one tells you blank display, no message, no message. So what does that mean? Um, this does not have a backup battery, so if you do disconnect both power sources, the pump will stop immediately. This has a completely different sound than all of your other red alarms, so. This is a no power. That's what a no power alarm would sound like. Very loud and obnoxious. Treatment is to plug power back in. The other ones are all going to tell you exactly what the problem is, um, and they sound different. So that's all the others And it does tell me that um it says that stop connect drive line so it told me exactly what it was and what to do about it, which is great um so there are two alarms on here that will prompt you to um change the system controller or tell you to do that. One says that stop change controller, and one says controller failed change controller. So one of the recalls that we previously had. Is that um if the pump is running they don't recommend stopping it because if it does if it's on and you stop it it may not restart um they gave us a non FDA approved controllers previously that we couldn't just give patients but if it happened we could use it to see if it would restart. Long term they have now put non-FDA approved and the old one together in one and now they say well it should be able to restart using both pathways that are incorporated into that so I wanna show you that um those different ones they look a little different so this one has a. Standard screen and then this has blue around it, so the ones that have the blue around it are the Type C uh controllers that have both startup algorithms. They still do not recommend changing the controller at this point unless it's absolutely necessary and the pump is already off. Otherwise they recommend bringing them to us so that we can do this in a controlled environment. At this point we wouldn't, we don't usually change these um heartware controllers even in the clinic which is right down the hall from the emergency room just because it's safer to have them in an acute care setting. So if you do have an alarm that tells you to change the controller, you wanna make sure that your pump is off before changing the controller, and if not they need to come to us to the emergency room and we'll change it there. But if the pump is off, it's not gonna hurt to try to get it to restart. How do we change? The system controller if we have to is we'll pull out our backup. It has this little red plug in it. This is called the silence alarm plug so there's only one available port on your controller and it's in the back over here. So you're gonna release this and you're going to put it in the back port. So now we have everything plugged off here and then I always kind of put this together so I know where I'm going with things. So the first thing we do again is power. So we'll take one battery and power. And I'm waiting for it to light up and show me that it's awake and then I pull the drive line there's these little um ridges you put your fingers pull straight out and then you put it. And then when you move that last battery, as long as the red plug is in, it will turn this one off, OK? So you always wanna put the plug in before you disconnect everything or it will continue to make that noise until it dies. So we don't wanna annoy you too much, so just use your red plug, um, but it's very similar to how we do the other device, um, and then if, um, if for some reason it doesn't restart the pump, um, changing the controller, then. Um, you're gonna kind of be in the same boat, um, if you will. Um, so what do our medium priority alarms look like? So these are all basically fault alarms, low flow, high watts. Um, why are these medium? Um, they're medium because we set low flow and high watt alarms based on our patients. So not everybody's alarms are gonna be set the same when it comes to the HVAD. What we look for is what their average flow is, and we set it to below what their average flow is, and the watt high watt gets set to above. What their average watt is so we can kind of catch it before it becomes an emergency. Um, these yellow alarms will not require a system controller change so again we don't want to stop that running pump. Um, low priority are all power related basically, um, and also will not require any, um, controller exchanges. Um, the different, uh, power sources they have again there's a AC, DC, and battery option. These backup bags should again have the same items your backup system controller and at least 2 extra fully charged batteries. If you can't, if they're not in the bag, there's also a battery charger that will charge the batteries 4 at a time. It takes about 4 hours to charge there too. So batteries last 4 to 6 hours each, so between the two you should get 8 to 12 hours of power with one set. They also get 4 sets or 8 total batteries when they go home. Heartmate 3. So currently the only one that we're putting in is Heartmate 3. So we'll talk about why it's different, um, so basically if you look at the last two we discussed this kind of looks like they took it and put it together and made a new one. So that's kind of how it went down. That's exactly what it is, so. What did they do to make Heart mate 3 better and different from the other pumps? Um, so inside the rotor there is no, um, axis holding it in place. It is a, um, levitated magnetic rotor that has no bearings to hold it in place, so less risk for clot, um. Also, it has larger blood flow pathways that was meant to try to um decrease shear stress. So one of the things we've noticed with our continuous flow devices, we have a lot of GI bleed issues because our GI tract does not like to not have pulsatility. So arterial venous malformations or AVMs form and bleed into the GI tract. So this was meant to uh reduce that. Um, we still do have a major issue with GI bleeding, so I can't say that it fixed it or improved it, but it, they did try to fix that. Um, it also has intrinsic pulsatility, so when you listen to a chest of a patient with a heart rate 3, this is the only one that sounds like it's revving up and down, and that's normal because basically it's flushing all the cells out every other second by ramping itself up and down. Um, looking at just how the blood flow goes through it, it kind of works similarly to the HVAD and how the blood flows through it, except for the, the lack of access. So blood clots tend to form around the axis and get stuck around it so that when you do take the pump out for a thrombus and you replace it, when you pull it out, it looks like a very long worm. So that's where blood clots end up is wrapping around the rotor. This has less likelihood of that to happen. Um, there's also an extra connection on the drive line, so. This little connector here, basically the reason they did that is so if a patient breaks a wire outside of their body, we can replace this part of the cable without admission or any of that. We can do it right in the clinic. Um, parameters are basically the same as they were for Heartmate 2, except the speed is a little bit less with our, um, Heartmate 3, because of the type of pump it is. So typically we're 4700 to 6200 RPM. Um, power flow, PI, same, it'll still low flow if it gets below 2.5 L per minute. Um, alarms, all of that are exactly the same as they were for Heartmate 2. batteries are identical as they were for Heartmate 2. They just last longer because of the lower speeds. Um, so these will go up to 17 hours per set, um, and then how to troubleshoot a stopped pump is exactly the same as for Heartmate 2, so connections, power, and then control are in that order. Um, how do we assess blood pressure in a patient who has an LVAD? Um, typically, you are not going to have a pulse, so you're only, you're not going to be able to use a regular cuff. It won't pick it up because of the narrow pulse pressure. It comes up with an error message. So, it does require a manual cuff and a Doppler. So, we provide our patients with manual cuffs, Dopplers, jelly, all of that. Um, I cannot promise that they keep it in the backup bag, but if you are in their home, you should be able to locate it with, um, the family's assistance. Um, there is a video to kind of see the technique for this, but essentially what we're doing is we're putting the cuff. We're gonna feel, we're gonna feel for a pulse because sometimes they do have a pulse if their pulse utility is. Higher and then in that instance you actually may be able to use your other assessment tools like the cuff, auto cuff and the um pulse ox, but if you do not feel a pulse, you're gonna have to use a Doppler and a manual cuff, place it here or here, you're gonna go over with the Doppler, either the radial or brachial artery, pump the cuff until that sound disappears. Release the first sound you hear is their map or mean arterial pressure. Um, generally we like it to be between 65 and 90. If you think about it like that, that's across the board. Um, once it gets above 90, the flow will start to drop because we talked about the afterload problem. So they're afterload sensitive. Higher maps will cause low flow. So potential complications for LVAD patients. We talked about bleeding, GI bleeding being a big one. another, um, bleeding problem we sometimes will have more is nosebleeds. It's also mucosal tissue, same kind of factor happens. Um, thrombus, we know that it can happen. They're all on anticoagulation. Um, at this point, everyone is on warfarin or Coumadin. Um, we usually target an INR goal of 2 to 3. Um, Heart mate 3 does not require, uh, our patients to be on aspirin at all, um, but our other pumps do. Usually, these patients for, um, heartwear will be on 325 mg of aspirin. Heart mate 2 patients, 81 mg of aspirin. Um, so if they are on one of those other devices, they may be on, um, antiplatelet therapy also. Um, infection because of the line coming out of the belly, um, that does, um, create a problem for infection. We do train the families on sterile dressing changes. They get the kits delivered straight to the house, but long story short, this material here on the drive line is meant to protect tissue growth. So when we put the device. And we suture the drive line down for about 8 weeks post um implant in order to allow that tissue growth to happen. Infection generally starts after the sutures are out and they're out doing things and that line tugs and disrupts that tissue from the side of the drive line and then creates a pathway for bacteria to then get down into that drive line site. Um, so I will tell you drive line infections are can be very fatal because this is a foreign object. Bacteria biofilms on foreign objects and therefore are very impossible to eradicate completely, so they will most likely be on antibiotics for life. Um, aortic insufficiency is a big one. So what happens if the aortic valve is insufficient? Or pushing the blood above the aortic valve. So, if it's insufficient, the blood goes back through the aortic valve instead of pushing forward, back into the pump, then back up, then back through the pump. So, it never pushes forward and perfuses the patient. So, they don't feel good. It doesn't fix anything. Um, right ventricular failure, another big one. We're not supporting the right. If the right side doesn't work, we're only helping the left side. So, blood has to get from the right to the left. If it can't do that, then they're still going to have heart failure and we're not going to fix it. Um, pump malfunction failure, we kind of talked about that. If we change out all of the external pieces of equipment and the pump still won't restart, then it's an internal problem and that's gonna have to be a surgical fix there by replacing the pump. Um, arrhythmia, they do still have them. Um, they can be in VTAC VFib and still walking and talking to you, so just be mindful that arrhythmias still happen. Some of them have internal defibrillators, some don't, um, but you will still be able to get an EKG and see what that rhythm is in the event of, um, that being a, a thought. Um, and anti-arrhythmics we use the same ones that you normally would use in anyone else, um, and they can also be cardioverted and all of that too without affecting the device. Um, hypovolemia we kind of talked about how volume dependent it is, so if they're dehydrated or bleeding, it will cause low flow again. Um, CPR, uh, that changed last year in 2025. Um, right now they want you to treat them like any other patient. If they are not perfusing or not perfusing perfusing enough, you're to start your BLS ACLS protocol, um, so no longer like, hey, try to fix the vat or any of that, just go straight for compressions and CPR and doing your ACLS BLS. If there are a second rescuer to arrive, they can try to turn the pump back on if it's off, but you are to treat the patient first. Um, so this is about who to call when. So how do we know when to call the physician or provider versus the um bad coordinator? So if it's a green light on patient problem like low flow pump on. Um, any type of blood pressure concerns, bleeding, they fell, they broke something, all of that goes to the provider. There's always a physician on call, and that would need to go to them if it is an equipment issue, pump's not running or you're getting an alarm that is not a patient specific alarm, that would be the VAD coordinator. So if you need help troubleshooting the equipment, VAD coordinator, patient, physician. Um, just to kind of recap, um, these patients tend to be pulseless, so we're gonna need to use mental status, skin color, skin temp, capillary refill to assess for perfusion. Um, pulse oxes, auto cuffs, they generally don't pick up because of the lack of pulse. Um, auto cuffs again still probably won't help if they're not pulsatile because there's no pulse pressure to pick anything up. Um, so the preferred method for obtaining a blood pressure on an LVAD continuous flow LVAD is with, um, a Doppler manual cuff or an arterial line, um, just remembering preload and afterload, um, as reasons for low flow. Um, they're all anticoagulated with warfarin plus or minus aspirin depending on the device. Generally we target an INR goal of 2 to 3, um, and we always have the availability to be reached in the event of either a patient problem or an equipment problem, um, assessing the device, so we wanna, we need to know for one if it's an equipment problem, is the pump on or is it not on. Um, that's gonna help tremendously when troubleshooting and also what information is that controller giving you those numbers we talked about, the parameters, we need to know exactly what it's telling us to do to fix the alarm. Um, ensure that all the connections are tight, change power, and then change the controller in that order if the pump is off, um, and then we, when you do transport a patient, so if you go into the home and they're on the wall power in bed. You have to convert them to batteries in order to take them to the hospital, so you'll look for the batteries and connect them to batteries before taking them. Um, if we do change batteries, if they're already on them and they need to be changed, we do it one at a time. We never want to stop the pump. However, if the pump has been off for a prolonged period of time, consult with the on-call AHF cardiologist prior to trying to restart the pump because like we said, clots will form and we don't want to throw clots everywhere, so they'll make the call and say don't restart it, just get them here. Um, EKG, cardioversion, defibrillation, um, none of that will affect the pump. External pacing can be performed too. Um, ACLS meds work the same as anybody else. Um, compressions important to only do manual compressions. No Lucas device, no auto devices. It has to be manual compressions that is recommended by both of the manufacturers of the companies. Um, MRI's are the only tests they can't have. It's contraindicated. Um, and then, um, any other testing is completely acceptable, and then you're bringing them to Norfolk General for all LVAT emergencies. And that's all.
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