LVAD Continuing Care: A Comprehensive Guide to Long-Term Support and Management

Abstract

Heart failure is a growing pandemic with a rising societal burden. Heart failure affects 3.6 million people in Europe and 5 million in the United States annually. The United States alone spends 30.7 billion annually managing heart failure, and that number is expected to eclipse 70 billion by 2030. Many people are not orthotopic heart transplant candidates, and many who are may not live long enough to receive a transplant. As a result, durable left ventricular assist devices (LVAD) have become both a bridging therapy and a destination therapy, necessitating a robust continuing care system. LVAD programs are expanding to fill this need. This chapter aims to cover the spectrum of LVAD continuing care from initial implantation to the outpatient clinic. This chapter will cover essential care practices for maintaining LVAD function, including driveline care, battery management, and alarm response/tracking. Troubleshooting the common issues and complications patients might experience, such as low flow alarms, bleeding, infection, and right heart failure. Emphasize the importance of the primary caregiver’s involvement and how to prepare them by providing resources for education, training, and ongoing support. Lastly, it will cover ethical concerns and the role of palliative care in the process.

1. Introduction

Heart failure (HF) is a global pandemic that has been increasing in prevalence. It affects 3.6 million people in Europe and 5 million in the United States (US) annually. Left ventricular assist devices (LVADs) were first introduced as a bridge to orthotopic heart transplant (OHT) and subsequently progressed into a viable long-term therapeutic option [1]. With prevalence now approaching 2% in the US and Canada and hospitalization rates as high as 3%, it comes as no surprise that $30.7 billion was spent annually in the US alone managing this critical diagnosis. Further, the cost is expected to exceed $70 billion by 2030 [2, 3].

Varying stages of HF come with progressively more severe disability for the patient and a progressively increasing need for more social support. End-stage heart failure leads to significantly higher morbidity with loss of autonomy and increasing societal costs [4]. OHT remains the gold standard for end-stage HF as it still boasts the most longevity when there is a favorable surgical outcome. Due to the limited availability of organs, many contraindications limit the eligible recipient pool greatly. Some of these include age greater than 70 years, severe pulmonary hypertension, severe lung disease, severe infection, viral infections with organ damage, a history of cancer, severe neurological deficits, psychiatric illness, current tobacco or recreational drug use, multisystem disease with poor long term survival, and many more [5]. For patients who are not ideal OHT candidates, LVAD remains an option, with a mean survival now surpassing 7.1 years [6]. For some patients, LVADs may serve as a bridge to transplantation, while for others it may be a final destination therapy. For those that are not LVAD candidates, those with severe right ventricular failure, restrictive or hypertrophic cardiomyopathy, left ventricular end-diastolic dimension <4.5 cm, or contraindications to anticoagulation, a palliative care referral is indicated [7].

2. Patient selection for LVAD therapy

The population of people living with advanced heart failure is growing along with the need for advanced therapies. From 2006 through 2017, there have been 25,000 durable LVADs implanted [8]. This boost in implantation was largely due to the advent of the superior continuous flow LVADs which tripled the volumes being recorded in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry [8]. Firstly, there are two major LVAD indications that are accepted by both payors and governing bodies in medicine alike, either as a bridge to heart transplant (BTT) or as a final destination therapy (DT) in the setting of refractory end-stage heart failure [8]. It is also worth noting a more recent and controversial indication that is not recognized by the FDA which is being called “bridge to candidacy (BTC).” In this patient population, the LVAD is implanted officially as a DT, however, the heart team is hoping later to improve the patient’s candidacy for a heart transplant. One example is an obese patient who would otherwise be a good OHT candidate where the LVAD is implanted with the hope of having the patient improve their BMI through weight management and/or bariatric surgery in order to become an eligible OHT candidate later. The least common implantation indication is as a bridge-to-recovery (BTR). While this remains a rare occurrence, only accounting for less than 3% of all LVAD recipients, there is recent retrospective data demonstrating that 40% of patients with a NICM and duration of HF less than or equal to 5 years at the time of implantation were alive and still not requiring MCS or OHT at 1-year post-LVAD explantation [9]. In the United States, the Centers for Medicaid and Medicare Services officially recognize the terms “short-term” and “long-term” in regard to the intention of LVAD implantation [8]. Patients who do qualify for an LVAD must undergo a qualification process to optimize their success post-surgery [10]. Risk stratification begins by classifying the patient with an INTERMACS profile. INTERMACS profiles range from 1 to 7, with 1 being the most severely decompensated cases of cardiogenic shock that require mechanical circulatory support (MCS) and 7 being the most compensated patients (Table 1). The advanced heart failure team will typically try to evaluate candidacy while the patient is still in INTERMACS profiles 3–4 where the post-surgical outcomes typically fare better than INTERMACS profiles 1 and 2.

INTERMACS
1	Life-threatening cardiogenic shock despite inotropic support
2	Declining functional status despite inotropic support
3	Stable on inotropic support
4	Symptoms at rest (NYHA Class IV)
5	Symptoms with activity (NYHA Class III)
6	Symptoms within minutes of activity
7	Living comfortably (NYHA Class II)

Table 1.

INTERMACS profile descriptions.

LVAD candidacy evaluation should include a heart failure specialist, cardiac surgeons, anesthesiology, palliative care, psychology, and social work [11]. Additionally, multiple risk factors including the patient’s age, renal function, liver function, hyponatremia, pulmonary disease, glucose tolerance, dysrhythmias, functional capacity, and history of recurrent admissions are all assessed [12]. All patients being evaluated for a durable LVAD should have early consultation with a palliative care specialist to establish each individual patient’s goals of care by improving symptom management, setting realistic expectations, and clearly defining end-of-life care preferences. Progressive renal dysfunction is associated with a poorer prognosis, so it is generally recommended to implant the LVAD before developing severe cardiorenal syndrome or to place a temporary MCS device and monitor for improvement. For pulmonary assessment, it is recommended that the patient have a baseline chest X-ray and undergo invasive hemodynamic assessment. Routine ABGs are not required and there is limited data to validate the benefit of routine pulmonary function testing, but both may be useful if occult disease, such as COPD, is suspected [13]. CT or MRI to evaluate the chest anatomy in patients with a prior history of cardiac surgery is a reasonable choice pre-implantation for surgical planning. All patients should have a comprehensive neurological physical exam and any significant findings, including dementia and severe neuromuscular disease warrant a neurological consultation as these patients may not be able to manage their equipment. A CT head or an MRI may be considered if there is a prior history of stroke to establish a baseline. All patients should also have peripheral vascular disease screening by carotid and vertebral Doppler examinations. All patients should have their PT, aPTT, and INR checked and if an abnormality is found then it needs to be investigated as thrombophilia could thrombose the LVAD. Patients with a history of cancer in long-term remission may be candidates for DT LVAD. Patients with active malignancy, but a life expectancy greater than 2 years may also be considered for DT LVAD therapy in consultation with an oncologist. DT LVAD is not recommended in patients with an active malignancy and a life expectancy of less than 2 years. All patients should be screened for diabetes and those with known diabetes should have their glycemic control optimized prior to surgery. Women of reproductive age should be screened for pregnancy as durable LVADs are contraindicated during active pregnancy. Endoscopy and colonoscopy are reasonable in patients with a history of gastrointestinal bleeding or premalignant polyps.

Right heart failure (RHF) can be a common post-LVAD implantation complication, therefore the right ventricle must be thoroughly evaluated by a multifaceted approach that incorporates physical exam findings, invasive hemodynamics, echocardiography, and other advanced imaging modalities [14]. The gold standard of RV function and structural assessment is the cardiac MRI. Unfortunately, the utilization of MR may be limited in this population by device incompatibility. Right heart strain and 3D echocardiography have improved the ability to identify right heart failure on echocardiography and may be considered. While there is no ideal individual risk assessment tool for right heart failure, there are several predictive models that may be considered: Michigan RCF, Penn RVAD, Heartmate II bridge-to-transplantation RVF analysis, Utah RVF, Pittsburgh decision tree, EuroMACS, and other similar ones have been noted in the literature [14].

Cardiopulmonary stress testing (CPET) can be useful with peak oxygen consumption levels ≤12 mL/kg/min on beta-blocker therapy or ≤ 14 mL/kg/min off of beta-blocker therapy warranting further evaluation for advanced therapies [15]. Additionally, the patient’s home should be evaluated for safety (lack of clutter, grounded electrical outlets, reliable telephone access, and emergency medical service access). The patient’s psychosocial status should be assessed to evaluate the patient’s capabilities and decision-making capacity as well as to mitigate any barriers to the patient being able to care for them self and manage the device. Psychosocial assessment aids in the success of post-LVAD morbidity and mortality. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a tool that can be used to determine post-implantation healthcare needs and behaviors. It analyzes a patient’s preparedness, social support system, psychosocial stability, and lifestyle effects [16]. Any patient with a significant psychiatric disorder should be evaluated by a psychiatrist. Patients with a history of tobacco and marijuana use should receive counseling on the importance of cessation. Implanting centers vary on their respective policies in regard to marijuana use given the changing legal climate. Patients with a history of alcohol or other substance abuse must be abstinent for a period of time determined by the implanting centers. Active users of alcohol or other substance abuse should not receive an LVAD. The presence of a caregiver and their ability to participate in equipment and driveline management should be evaluated. Lack of a caregiver or a significant burden on the caregiver they cannot handle is a relative contraindication to implantation. While still poorly understood, frailty is associated with poorer outcomes and it is reasonable to use an objective frailty assessment tool such as the Fried Frailty Phenotype, The Deficit Index, or Handgrip strength test [8]. CT Imaging has been used to measure muscle mass as a surrogate as well [17].

Further, all reversible causes of heart failure should be thoroughly investigated including, but not limited to: treatable coronary disease, arrhythmogenic cardiomyopathy, valvular heart disease, cardiotoxic agents, and infiltrative disorders. The patient’s guideline-directed medical therapy should be at maximally tolerated doses and device therapy with cardiac resynchronization therapy (CRT) should be optimized. OHT candidacy should be evaluated. LVAD therapy in advanced heart failure can lead to a significant improvement in quality of life. Follow-up is extensive and complex, requiring a thorough pre-implantation evaluation. Appropriate follow-up requires physicians, nurse practitioners, physical and occupational therapists, as well as social workers [18].

3. LVAD functioning and care

An LVAD is a device that supplants the workload of the left ventricle by pumping blood from the heart to the body. The first generation of LVADs were pulsatile pumps with unidirectional valves that were later transitioned to continuous flow systems due to improved rates of adverse events [19, 20]. Continuous flow LVADs are further divided into axial pumps (propelling blood forward) and centrifugal pumps (moving blood away from pump). Centrifugal-flow LVADs are superior with respect to survival after 2.5 years, gastrointestinal bleeding, and pump thrombosis [21, 22]. The MOMENTUM 3 trial summarized that the newer device system of HeartMate 3 was superior to the previous devices with respect to disabling strokes and the need to replace malfunctioning devices [23].

LVAD implantation requires cardiopulmonary bypass during which the centrifugal pump system is connected to a conduit in the ascending aorta. The pump is connected to an external control unit by a cable called the driveline. The driveline is connected to the pump and tunneled through the abdominal subcutaneous tissue and then to an external controller. The control unit includes batteries and a display of pump parameters [24, 25]. Given the gravity of this intervention, preoperative risk assessment is extensive. It requires optimizations of comorbid conditions and physical fitness. Patients with right ventricular or renal dysfunction may be evaluated in the ICU with invasive hemodynamic monitoring to optimize volume status and end-organ perfusion prior to surgery. The need for renal replacement therapy or mechanical support before LVAD placement is an indicator of higher mortality [11].

4. Post-operative care and monitoring

Immediate post-operative or perioperative care occurs in cardiac or cardiothoracic intensive care units. Optimizing volume status is extremely important in the initial phase as the right ventricle learns to manage the new preload it is exposed to. The LVAD speed is adjusted to optimize the patient’s hemodynamics. Typically, the speed is changed with echocardiographic guidance to ensure adequate left ventricular unloading without overloading the right ventricle [25]. The aortic valve should open periodically and minimal mitral regurgitation should be evident.

When titrating the speed, visualization of the interventricular septum is required as the septum should be maintained midline to avoid right ventricular bowing, tricuspid regurgitation, and right ventricular failure. Typical speeds for the HeartMate III are 3000–9000 revolutions per minute (RPM), 6000–15,000 RPM for the HeartMate II, and 2400–3200 RPM for the HeartWare Ventricular Device [26, 27].

Due to mechanisms that are poorly understood, a significant proportion of LVAD patients develop RHF following implantation. Furthermore, RHF plays a pivotal role in the high mortality rates observed among LVAD patients who die from heart failure and multi-organ failure. As a result, in order to optimally manage patients in the postoperative period following surgical LVAD implantation, it is important to understand the pathophysiology of RHF, specifically as it presents in LVAD patients.

Each patient’s physiology is monitored on the LVAD monitor via the power, flow, and pulsatility index (PI). Power is the amount of work the LVAD performs to maintain a set speed and typically ranges between 2.5 and 8.5 watts. The flow displayed is an estimation with normal values between 2 and 4 L/min. Changes in power and flow outside of the normal range raise concern for pump thrombosis or hypovolemia (Table 2). PI represents the strength of left ventricular unloading and is calculated as flow magnitude over 15 seconds with 1–10 being the expected range [25].

Flow	High	High CO	Distributive shock; Infection Adrenal insufficiency Vasodilating medications	Volume resuscitation; Treat underlying etiology
		Low CO	Aortic insufficiency (AI)	Valve repair
	Low	High CVP	Tamponade; Pneumothorax; RV failure; LV failure; Inflow or outflow obstruction Pump failure	Treat underlying etiology
		Low CVP	Hypovolemic shock; Hemorrhage Gastrointestinal losses	Point-of-care ultrasound for hemothorax, hemoperitoneum, retroperitoneal hemorrhage Symptomatic control of nausea and vomiting

Table 2.

Unexpected LVAD flows algorithm.

CO = cardiac output, CVP = central venous pressure.

Shock in LVAD patients has a slightly different algorithm than in patients without LVADs since the LVAD controller is able to give live time reports. In events where the patient’s MAP is less than 60 mmHg, the LVAD flow rate and power should be noted. Simultaneously, cardiac output should be calculated if hemodynamic monitoring is available and bedside echocardiography should be performed [26].

Having a high power with a low flow rate is a strong indicator of possible pump thrombosis. Treatment with thrombolysis, device exchange, or anticoagulation should be considered and implemented immediately. High flow indicator warrants evaluation of cardiac output. In a high flow state with high cardiac output, fluid resuscitation should be started and distributive shock due to infective, vasodilation, or adrenal insufficiency should be considered [26]. If the flow rate is high and the cardiac output is low, then aortic insufficiency (AI) should be evaluated urgently. Decreasing the pump speed would decrease the AI while increasing left ventricular volume. Increasing speed would improve end-organ perfusion while accelerating progression of AI. LVAD outflow cannula diastolic acceleration and systolic-to-diastolic peak velocity ratio correlates well with the true AI severity [28].

The optimal management of cardiac arrest in LVAD patients remains an area of ongoing debate, but a few general principles may be applied in this scenario. Physical exam should be performed promptly to verify the presence or absence of both an audible LVAD ‘Hum,’ as well as the presence or absence of an arterial pulse by doppler. In the absence of an audible hum or absence of a pulse by doppler examination, ACLS protocol should be initiated immediately with establishment of an airway by intubation. As chest compressions are a relative contraindication, abdominal compressions have been attempted, but there is limited data to support the efficacy of this method. Postoperative cardiac arrest should be brought back to the operating room without delay [29].

Right ventricular function is thoroughly evaluated prior to LVAD placement (see additional details in ‘Patient Selection for LVAD’ section above). Postoperative RHF plays a pivotal role in the high mortality rates observed among LVAD patients who die from heart failure and multi-organ failure. As a result, in order to optimally manage patients in the post-operative period following surgical LVAD implantation, it is important to understand the pathology of right heart failure [14].

Favorable hemodynamic changes take place after LVAD implantation, including reductions in left ventricular (LV) and pulmonary artery (PA) pressures. With immediate reduction in LV filling pressures and more long-term remodeling of a long-standing pulmonary hypertension, pulmonary artery resistance goes down, leading to eventual improvement in RV afterload and systolic function. With improved cardiac output, comes increased preload for the RV to accommodate. Chronic right heart failure may result from chronic RV pressure and volume overload. This can occur in the setting of uncontrolled hypertension (excess afterload), excessive LVAD speed, hypervolemia, or any combination of these factors. Tricuspid regurgitation may also be exacerbated by leftward septal shift upon LV decompression which can cause tethering of the tricuspid valve leaflets. RV failure can be precipitated with hypoxemia and increased central venous pressure [14]. This should be evaluated with regular echocardiograms and cautious volume optimization with LVAD speed adjustments, diuresis, or ultrafiltration. Pulmonary hypertension should be treated with phosphodiesterase-5 inhibitors or inhaled nitric oxide [30].

Ramp testing is a formalized protocol that can be utilized to optimize speed and detect device thrombosis. Prior to ramp testing, ensure that the patient is therapeutically anticoagulated with an INR > 1.8 or PTT > 60 seconds. Opening arterial pressure via doppler should be >65 mmHg at baseline. The parasternal long axis view is the primary view used throughout the study. This is due to its optimal position in assessing the LVEDD and LVESD along with the frequency of opening of the aortic valve, any degree of AI or MR, and heart rate. Continuous-flow LVAD parameters are also monitored throughout the study including power, PI, and flow at each stage. Specific speed adjustments for the HMII, and HVAD are given as follows: testing speed range is 8000–12,000 rpm (HMII) and 2200–3200 rpm (HVAD). Start the test by decreasing the speed to 8000 rpm (HMII) and 2300 rpm (HVAD). Give it 2 minutes of washout time, and then evaluate for all the parameters listed above. Perform stepwise increases in speed at intervals of 400 rpm (HMII) and 100 rpm (HVAD) until the upper limit of speed is attained. This will be indicated by LVEDD <3 cm, a suction event or premature ventricular contraction (PVC) beats will occur. PVCs can indicate contact between the LVAD inflow cannula and the interventricular septum (IVS). As stated above, clinically the speed is adjusted to a midline interventricular septum, intermittent opening of the aortic valve as to prevent AI, and minimal MR. Other parameters such as high CVP, low RV stroke work index, elevated pulmonary vascular resistance (PVR), low pulmonary artery pulsatility index (PAPi), high CVP: PCWP ratio, and an elevated diastolic pulmonary gradient have been associated with RHF. The management of RHF can be a multimodal approach to therapy, but generally includes pulmonary artery catheter-guided therapy, aggressive volume optimization using diuretics or even renal replacement therapy when necessary, inotropes, pulmonary vasodilators, heart rate and/or rhythm control, and lastly mechanical RV support in the most severe cases [31].

Options for mechanical RV support include the Impella RP, Protek Duo, peripheral VA ECMO, Paracorporeal CentriMag RV assist device, and durable biventricular assist devices. The timing of when a mechanical RV support device is required varies among centers. One may find that certain centers even preemptively place RV mechanical support in high-risk patients. Others will only offer it once optimal medical therapy has failed. The choice of device also varies depending on the center’s practice and experience levels [14].

Anticoagulation in the immediate postoperative period should entail the initiation of intravenous unfractionated heparin within 48 hours of implantation with goal aPTT titrated based on the particular LVAD manufacturer. For example, for the HMII, an aPTT of 40–45 seconds in the first 48 hours, followed by a titration up to an aPTT of 50–60 seconds by 96 hours. For HM III, start heparin 12–24 hours post-implantation with a goal aPTT of 45–50 seconds in the first 24 hours, 50–60 seconds in the subsequent 24 hours, and 55–65 seconds in the subsequent 24 hours. For the Heartware device, begin low-dose heparin at 10 units/kg/h on postoperative day one to target an aPTT of 40–50 seconds and gradually increase to a goal aPTT of 50–60 seconds. Close monitoring of chest tube drainage is key, and a goal aPTT should be adjusted with the quantity of chest drainage in consideration. Heparin is used as a bridge to anticoagulation with Warfarin (vitamin K antagonist therapy). Once a goal INR has been attained with warfarin therapy, heparin can be discontinued. For the HMII, start warfarin within 48 hours of implantation with a goal INR of 2–2.5 by postoperative day 5–7. For the HM III, start warfarin on postoperative day 3–5 once there is no evidence of bleeding and all chest tubes have been removed. A goal INR should be maintained between 2.0–3.0. For the Heartware device, Warfarin should be started within 4 days of implantation with a goal INR 2.0–3.0 [31].

Pump thrombosis is a dire complication and studies have shown increasing fibrous tissues on the LVAD surface due to thrombin generation [32]. As such, anticoagulation is initiated with low-dose heparin and aspirin on post operative day 1 with an aPTT goal 40–60 seconds which is later increased to 60–80 seconds. If no evidence of bleeding, warfarin is initiated after the removal of surgical chest tubes with a goal INR of 2.0–3.0 [33]. Post operative bleeding is an additional complication and management must be cautious as pump thrombosis can have fatal effects. Desmopressin and antifibrinolytics are used, however vitamin K or reversal of anticoagulation should not be considered lightly [34].

Ventricular arrhythmia is another factor that may worsen after LVAD implantation impacting mortality in the first 3 months. It is unclear whether arrhythmias are a sign of hemodynamic compromise rather than the primary cause of mortality [35]. ICD implantation is considered if all other causes of arrhythmias are ruled out and device therapy was not already in place prior to LVAD implantation [36].

Infections in LVAD patients remains one of the most common complications. While a significant proportion of patients developing postoperative infections unrelated to the LVAD had a higher observed mortality, infections of the driveline after 90 days contributes to significant morbidity and affects over 50% of patients at many institutions [37, 38]. In terms of prophylaxis, antibiotic protocols employed in these studies generally favor the use of vancomycin, a cephalosporin, a beta-lactam, and a quinolone. Many centers may also opt for fungal protection as well and add fluconazole. Some centers will even treat MRSA of the nares with mupirocin. Antibiotics prophylaxis is recommended to begin prior to implantation and continue throughout the peri and post operative periods. The major culprits of pocket and driveline infections are gram-positive Staphylococcus species and gram-negative Pseudomonas species. There were eight retrospective studies and two prospective studies, including one randomized controlled trial (RCT), which describe the optimal antibiotic regimen, however large scale RCTs are needed to assess and validate the efficacy of each regimen [39].

5. Medication management

LVADs contribute to reverse remodeling through various mechanisms. One of those comes from mechanical unloading resulting in improved cardiac output. Simultaneously, the neurohormonal axis begins to normalize with improvement in beta-adrenergic receptor density and reversal of ryanodine-receptor 2 hyperphosphorylation. Additionally, increasing cross-linking of collagen leads to decreased compliance of the left ventricle [40]. This can be augmented with neurohormonal blockade using: angiotensin-converting enzyme inhibitors, B-blockers, angiotensin-II antagonists, neprilisin inhibitors, and aldosterone antagonists. With improved cardiac function, higher doses of these medications can be tolerated to further augment reverse remodeling [41]. Digoxin is also frequently added to this regimen for its ionotropic and antiangiogenesis effects [42].

6. Lifestyle modifications and rehabilitation

Early mobility with physical therapy remains a key to recovery in patients with LVADs. Physical therapy will work with these patients as soon as they are able to participate. Patients work with occupational therapy to ensure that they can perform their self-grooming and may demonstrate the ability to bathe prior to hospital discharge. Rarely, patients may perform well enough to not require discharge to rehabilitation. In patients with a prolonged recovery, cardiac rehabilitation plays a critical role in return to independence. Post-LVAD rehabilitation allows caregivers to continue education in management of this complex device [43].

7. LVAD complications and emergency situations

Strokes, infections, bleeding, right heart failure and device dysfunctions account for most of the long term complications that arise in LVAD patients. Neurologic complications appeared to have the most significant effect on survival with recurring events being detrimental to morbidity and mortality [44]. Patients with high or low INR (>3 or < 1.6), low albumin, or previous stroke seem to be at a much higher risk for post-LVAD strokes. Post-hemorrhagic management is with initiation of aspirin and an individualized approach to determine the safety of further anticoagulation. On the other hand, pump thrombosis leads to embolic stroke, noted mostly in HeartMate II. With the transition to HeartMateIII rates of pump thrombosis have declined [45]. A retrospective study noted the relationship between pre-LVAD cognitive assessment score and 900 day postoperative survival and neurological events [46]. Further evaluation of cognition may be beneficial in improving patient selection and outcomes.

Patients with LVADs are susceptible to postoperative infections, including infections that are unrelated to the LVAD. Infections in patients with LVADs have a significant effect on mortality [47]. After the post-operative course, infection of the driveline is the most dreaded, but almost inevitable complication. Despite attempts at innumerable educational sessions and sterile techniques, driveline infections will frequently occur. Once infected, it is a pathway to LVAD pocket infection as well. The only true treatment for the disastrous development of a device infection is explantation. Patients with controlled infections have been transplanted without a notable increase in mortality risk, but patients rejected due to multidrug resistant infections were not included in this assessment [48]. Most efforts have focused on preventing infection with some benefit to the silicone-to-skin interface at the driveline exit site. Progress in this area is lacking and may partly be due to non-standardized driveline implantation during surgery. Various studies using different antibiotics or horizontal orientation of the driveline have been attempted without significant differences [49].

Gastrointestinal bleeding is a notable comorbidity affecting 24–31% of LVAD recipients. There are no confirmed treatments that reduce its incidence. Some studies noted GDMT to decrease bleeding, however, no association was found during an INTERMACS registry analysis [50]. Acquired von Willebrand Syndrome had a notable increase in the post-LVAD population. Various factors from area of shear stress, to age, CRP, sex, blood type, and time with LVAD did not change prevalence. The effect of this syndrome was investigated in bleeding complications and no association was noted [51]. The typical approach to an LVAD patient with a GI bleed should start with an endoscopy plus colonoscopy, and push enteroscopy if negative. If the source is not found, capsule endoscopy is warranted. In patients with no visible source of bleeding then hemolysis, anemia of chronic disease, or arteriovenous malformations (AVMs) are expected etiologies. In patients with AVMs, antiangiogenic medications can be considered [52].

8. Caregiver support and education

Extensive education is needed before LVAD placement. At times, when the primary implanting LVAD center is not geographically feasible for scheduled follow-ups, a shared care site can be utilized [53]. Caregivers and patients must be educated in anticoagulation management, driveline site inspection and cleaning, and a basic understanding of LVAD alarms. Caregiver support is essential given the high care burden posing a risk for isolation and depression [54].

9. Ethical and palliative care considerations

In patients with heart failure, the end of life is due to failure of the pumping function of the heart. In patients with an LVAD, the end of life is typically due to a complication of their devices. Palliative care providers need to be familiar with these complications to treat their symptoms. Goals of life should be addressed prior to implantation. An LVAD is a heavy burden for the patient and their family and the true cost for all those who will be involved needs to be discussed. Families often need assistance with conversations to determine what their loved one would want once they are no longer able to communicate for themselves and this should be established prior to implantation. It should also be discussed that when choosing comfort care, turning off an LVAD does not equate to assisted death and may or may not lead to an immediate death. It can happen at any location with hospice guidance. Depression in the setting of a high healthcare burden is common and should be monitored and treated [55].

Patients and families without long-term comorbidities have a lower perceived treatment burden [56]. A thorough evaluation of capacity and discussion on all LVAD challenges should occur prior to implantation. While this may not always be possible in emergent situations, the realization of lifestyle changes, recurring hospitalizations, or lack of symptom improvement post-implantation can create an ethical dilemma [57]. Patients have a right to refuse medical care and request LVAD deactivation when that is their desire. Physicians of record should provide resources to respect a patient’s wishes in the hospital or at home [58].

10. Future directions in LVAD continuing care

In patients with nonischemic cardiomyopathy, severe HF can be reversed with consideration for LVAD explantation. While recovery is possible at very low rates, relapse rates were high [41].

11. Conclusion

By addressing topics such as LVAD functioning, post-operative care, medication management, lifestyle modifications, complications, caregiver support, and ethical considerations, this chapter aims to provide a comprehensive guide to LVAD continuing care. The information presented will empower healthcare professionals, patients, and caregivers with the knowledge and tools necessary to ensure optimal long-term outcomes for LVAD recipients.