Kims Hospitals

Free download. Access the LVAD pamphlet

BENEFITS OF VAD

The overall goal of VAD implantation is improved health and quality of life. The VAD may not make all your symptoms go away, or directly fix the heart failure. However, patients see a marked improvement in symptoms of heart failure. In most cases, blood flow improves, you can expect to have more energy and decreased shortness of breath and fatigue.

Since successful VAD surgery helps deliver more oxygen-rich blood, you may feel well enough to resume many of the activities and hobbies. The improved blood flow may also prolong life. Research studies that have shown, on average, LVAD patients live longer than similar patients with advanced heart failure who are treated with medications alone.

THE DEVICE(S)

A VAD is a pump that assists a weakened heart to improve blood flow to the rest of your body. This most often involves assisting the heart with the placement of a left ventricular assist device (LVAD). There are several different types of artificial heart pump devices designed to meet the needs of individual patients:

Left Ventricular Assist Device (LVAD) helps the left side of the heart pump blood to a large blood vessel called the aorta and to the rest of the body.
Right Ventricular Assist Device (RVAD) helps the right side of the heart pump blood to the lungs.
Bi-Ventricular Assist Device (BiVAD) helps both sides of the heart pump, by using both an LVAD and RVAD.
Total Artificial Heart (TAH) replaces the heart and pumps blood both to the body and to the lungs. TAH is the only device that requires the removal of your own heart and replaces it with an artificial one. An LVAD or RVAD is placed in your own heart to pull blood out of your weakened heart and pump blood forward into the rest of your body.

Are VADs temporary or permanent?

VADs can be used as short and/or long-term therapies. Short-term devices (CentriMag) are used when patients are unstable and need help to pump the blood for a few days or weeks. Short-term devices are easier to put in and take out. This can be important for very sick patients who may not survive a more difficult surgery. Temporary support can be used to support one or both sides of the circulation.

Long-term devices (implantable VADs) are used for patients that need assistance for months or years. Long-term devices require a longer and more complicated surgery, but the device is more securely placed, so patients are able to leave the hospital and go on living life.

Some patients may receive a short-term device before getting a long-term device. Patients who are too sick and very high risk for a long-term LVAD, are given the option of a short-term LVAD temporarily.

The short-term LVAD is also used as a bridge to heart transplantation. While recommending you for an LVAD, our medical team will evaluate your condition and recommend which option is best for you in your current condition.

Bridge-To-Transplant (BTT) therapy is a treatment option for patients who get an LVAD in the advanced stages of heart failure who are awaiting heart transplantation.
Destination Therapy (DT) is a permanent treatment option for patients who get an LVAD in the advanced stages of heart failure that are not eligible for heart transplantation. Some of these patients may become eligible for heart transplantation in the future.

EVALUATION

The evaluation process is designed to help decide if a VAD is the best choice for you. The process involves a series of blood work, other tests, and consultations. The evaluation will assess the patient’s past medical history, previous medical compliance, mental preparedness, and existing support system. We will also work with you to help you understand the financial implications, insurance details, and long-term self-care requirements.

Even if you are being considered for a bridge to heart transplantation, this is subject to change pending the results from your evaluation and the transplant team’s decisions. After the evaluation, the Advanced Heart Failure/VAD/Transplant Team will decide if you meet the criteria to have a heart pump implanted. If the evaluation results in the need to address other medical conditions, then we will proceed with addressing those conditions before VAD implantation is taken up.

If you are considered medically reasonable for VAD implantation, we work with you and your family so that they could arrive at the decision themselves. If you decide that this may not be the best option, we will re-evaluate the condition later as and when the need arises. Every time the tests need to be repeated to be considered medically fit for the procedure.

MEDICAL REQUIREMENTS FOR VAD IMPLANTATION

VAD improves the blood flow from the heart to the rest of the body. Implantation of VAD is major surgery and hence requires several medical conditions to be tested. The long-term maintenance of VAD also requires a lot of care. Some of the reasons implantation of VAD may not be a good option include the following:

Certain medical conditions could make the surgery very difficult or dangerous. The risks of a VAD surgery include - high lung artery pressures and right heart failure, problems with the existing heart valves, a small left ventricle, a damaged aorta, blood clotting disorders, poor food intake, current pregnancy, and high risk of infection. If the medical team evaluates that any of these risks are very high in a patient, they will not be recommended for the surgery.
Diseases of other parts of the body could also increase risks during the surgery for VAD implantation. Diseases/ conditions such as cancer, permanent kidney disease, liver disease, severe emphysema of the lung, blockages of the arteries to the legs or the brain, uncontrolled diabetes, and frailty, are also considered high risk.
If the patient is unable to care for the VAD in the long-term, they will also not be considered for VAD implantations. Patients with a severe psychiatric disorder, patients who are habitual users of illicit drugs or alcohol, patients with a history of not following medical recommendations, patients with inadequate social support (patients with VAD must identify a primary caregiver), and those with financial hardship may not be able to follow the self-care required in the long term.

ALTERNATIVES TO LVAD/ VAD

After evaluation, if you are not medically fit for VAD implantation, or if you and your family decide that this is not the best option, you will continue to get standard medical care. However, VAD implantation is suggested when current therapies do not adequately treat heart failure. For patients with advanced heart failure who do not proceed with VAD implantation, we suggest palliative treatment for end of life care.

RISKS

As with any surgery or procedure, there are risks and the possibility of complications with the VAD/ LVAD implantation surgery. These include risks related to the surgery, risks of undergoing anesthesia, and risks related to the VAD itself. On average, properly selected patients after detailed evaluation feel better and live longer with the VAD. However, there could be a few individuals who might have complications during and after the surgery. Our medical team will discuss the risks in detail with the patient and family. Here is a list of risks with the VAD implantation surgery.

Short-Term Risks around the time of surgery:

Risks which are likely, and could be serious:

Discomfort after surgery similar to any major heart surgery
Bleeding
Right-sided heart failure and/or failure to increase blood flow, resulting in ongoing symptoms of heart failure

Less likely risks, but, are usually serious:

Need for re-operation (surgery)
Kidney failure, potentially with a need to start dialysis
Lung failure, possible need to remain on a mechanical breathing machine (ventilator)
Blood clots that can travel to other parts of the body; this could result in stroke or loss of a limb or organs
Liver failure
Infection
Irregular heartbeat

Longer-Term Risks after the surgery:

Bleeding: Nose bleeds, which can be severe enough to require medical help. Stomach or intestinal bleeds. Bleeding is very common because

Patients with VADs require some form of blood-thinning medication to reduce the risk of clot-forming in the pump.
Many VAD’s affect the body’s natural ability to prevent bleeding

Blood clots: Clots in the device make it malfunction, leading to other problems and may require major surgery to replace the device.
Stroke
Infection
Disturbances in thinking or emotions, behavioral changes
Ongoing pain, particularly discomfort around the area that the driveline (power cord) exits your body
Device malfunction and need for re-operation (surgery)
Decrease in quality of life, either from complications or from the natural limitations and ongoing care required of the VAD
Caregivers (spouse, family, friend) may experience increased stress and caregiving responsibilities

In particular, bleeding, stroke, and infection of the VAD are common risks which could also be life-threatening.

Our medical team including the surgeon will discuss all the risks with you in detail. The patient, caregiver, and family need to understand the risks in detail before deciding about the surgery.

THE VAD IMPLANTATION SURGERY

The surgery to implant the VAD will be open-heart surgery and can take between 6-12 hours. The surgeon will make an incision (cut) down the front of your chest to reach the heart. You will have a breathing tube and be under general anesthesia. In some cases, you will be on a heart/lung machine during the surgery. The VAD is placed below the heart and the surgeon will connect the pump to the heart and secure it in place. Once the pump is in place, the VAD and the heart will together pump blood through your body. After the surgery is completed, you will return to the intensive care unit.

POST-OPERATIVE CARE

Post-Operative Stay in the Hospital

Upon arrival to the ICU, you will receive close monitoring and support. You will have a breathing tube, drainage tubes (chest tubes), and a catheter in your bladder. You will receive medications for sedation and pain control. You will also be on intravenous (IV) medications until your blood pressure is stable. Your length of stay in the ICU will depend on how fast you recover. Once you are breathing on your own and more stable, you will be transferred to a general care unit where you can expect to stay for another 1-3 weeks. On average, patients spend about three weeks in the hospital after the VAD surgery, but this can vary depending on how sick you were before the surgery and if there are any complications after the surgery. Most patients can return home after VAD surgery. You will need additional rehabilitation and recovery at an inpatient rehabilitation facility.

Discharge Process

Daily you will be followed by the medical team, including your surgeon, your cardiologist, VAD coordinators, nurses, nurse practitioners, physician assistants, pharmacists, physical/occupational therapists, and social workers. They will monitor your recovery and help you adjust to life with your VAD. Soon after your surgery, it will be very important to begin preparing to go home. You will have to be both physically strong and able to care for your VAD to be discharged from the hospital. Most patients return home, but some patients choose to live with a caregiver or need a rehabilitation facility for a short time before returning home. If necessary, a home health nurse may come to your home for a few hours a week to help with your care.

Going Home with a VAD

During the time in the hospital after surgery, it is expected that you, your caregiver, and your family will learn how to take care of you and the VAD at home. You and your caregiver(s) will be trained by a VAD coordinator to take care of your VAD. Other staff, such as your bedside nurse, occupational and physical therapists, and cardiac rehabilitation therapists will also provide training.

You and your caregiver(s) must be able to manage the VAD, understand how it works, troubleshoot problems, and care for your driveline exit site. Your driveline will require special care. You and/or your caregiver will be taught the process for sterile dressing changes while in the hospital. Sterile dressing changes to the VAD exit site will be a lifetime requirement.

The caregiver has to be present and available at the hospital to learn the care instructions for the VAD. This education will be ongoing while you are in hospital. Before going home, you need to ensure consistent electricity and phone services as a prerequisite. VAD requires significant self-care responsibility and a willingness to participate with your VAD team. You must keep the team informed regarding your contact information and address.

Follow-Up Care

After you are discharged, you will follow up in the clinic with your medical team. They will work together to care for you and make decisions about your treatment. Typically, your first visit will be every alternate day for the first week after discharge. As your health improves, visits may be further apart. Once you are considered stable, your doctors may decide that you can follow-up every 2-3 months. Along with seeing a cardiologist for your heart failure, you will need tests regularly to monitor and maintain your health. The types of testing that you may need will be decided by you’re the medical team but the most common tests include blood tests, electrocardiogram (EKGs), echocardiogram (ECG), an implantable cardioverter-defibrillator (ICD) checks.

On average, about 8-12 weeks after surgery you can expect to be able to do most activities, with the permission of your doctors.

AT HOME TRAINING FOR PATIENT AND CAREGIVER

Our medical team focuses on three fundamental things while training the patient and caregiver.

Care of the Driveline
Blood pressure control and monitoring/li>
Anticoagulation and anti-platelet management - Patients who have a VAD need to take anticoagulation medications (blood thinners such as warfarin/coumadin) which require regular monitoring with blood tests. /li>

You will also be in frequent contact with a VAD coordinator who will make phone calls to see how you are doing at home and assist you with any problems. At the KIMS Heart and Lung Transplant Institute, the VAD coordinator is available 24 hours a day for any questions or emergencies.

Care for the Device and Connected Equipment

Along with the VAD that is implanted inside your body, you will have several other external pieces of equipment that will require care and maintenance. You will have a driveline that exits your body through your abdomen which is attached to a controller (computer) that runs the heart pump. The controller will sound an alarm if there are any problems with the pump or the controller itself. To power the VAD and the controller, you will have batteries, a battery charger, and an electric (AC) power device. The batteries allow you to move around freely without being attached to outlet power. The battery charger allows you to re-charge your batteries when needed. And the AC power device allows you to be connected to electric (wall) power for long periods such as when you are sleeping. The equipment will be specific to your type of VAD.

LIFESTYLE CHANGES WITH VAD

Living with the VAD will call for certain lifestyle changes. While you will experience certain limitations in your everyday life, a few activities could be dangerous. One of the biggest lifestyle changes with VAD is the lifetime follow-up to monitor device function and health status.

Water: Persons with implantable VADs must not allow their controller/computer and electrical equipment to submerge in water. Showering is possible with proper protective equipment. You may only resume showering once your driveline has healed and your physician gives permission. In most cases, swimming and a dip in the bathtub are not allowed. However, patients who are implanted with the Jarvik 2000 device and a postauricular implant, are discharged with a long extension cable that can be utilised for a dip in a pool too.

This VAD could be a preferred choice for patients (especially young adults, and younger children) who desire a bit of extra mobility. You will be offered this option as a part of the counseling during the VAD work up and counseling phase.

Activities: Contact sports or repetitive jumping are examples of activities that may cause trauma to the pump attachments and must be avoided after the VAD implantation.
Travel: One of the goals of this procedure is to improve the quality of your life. We encourage you to travel if this something you enjoy doing. However, if you travel outside of the city, please let your medical team know in advance so that we can provide you additional information and assist you with an emergency plan that you may need for air travel.
Driveline and Device Care: Driveline exit site dressings must be performed as directed by the VAD team. Maintenance care of the equipment, batteries, and driveline is necessary to prevent pump failure, infections, or other serious complications.
Substances, tobacco, and alcohol: If alcohol, tobacco, or other substance abuse has been identified as an issue, you must commit to stopping these activities. You may be screened for drugs, alcohol, or nicotine use.
Driving: In general, you won’t be allowed to drive until your chest bone (sternum) has healed, which normally takes about 8 weeks, and you have physically recovered from the implant surgery. Other medical issues may prohibit driving but, in most cases, patients with a VAD will be able to continue driving.
MRI: You should never get an MRI test because of the magnetic fields.

Although there are limitations, the majority of patients who undergo VAD implantation eventually feel better than they did before the surgery and resume many of the activities they previously enjoyed.

EMOTIONAL WELLBEING WITH VAD

The potential emotional risks after VAD include (but are not limited to) depression, post-traumatic stress disorder, and generalized anxiety. The responsibility of having a VAD, taking a new medication, and adjusting to life with a VAD can be overwhelming and you may find yourself feeling anxious about these changes. Depression is very common in patients who have been diagnosed with heart disease. It is also very common to experience feelings of depression and/or anxiety after surgery and once you are home from the hospital.

Symptoms of Depression:

feeling “down in the dumps”, unable to identify how you are feeling
loss of interest or pleasure in activities you used to enjoy
being irritable
unable to sit still, pacing, pulling or rubbing on skin clothes or other objects
increase or decrease in appetite
increase or decrease in the amount of sleep
fatigue decreased level of energy
feelings of worthlessness or guilt, difficulty thinking, concentrating, deciding or remembering things
thoughts of death or self-harm

Symptoms of Anxiety

restlessness or feeling on edge
getting tired easily
difficulty concentrating
being irritable
muscle tension
sleep disturbances (difficulty falling or staying asleep, restlessness)
racing thoughts
excessive worry

Surgery and hospitalization can be a traumatic event and can sometimes bring up feelings or reactions from past traumatic events (such as illness, loss of a loved one, natural disaster, car accident, etc.).

an intense feeling of fear
feeling helpless
agitated behaviors (angry outbursts)
avoiding things that remind you of the traumatic event
feeling “numb”
being overly attentive to your surroundings, easily startled
nightmares or “flashbacks” related to the traumatic event
being irritable
difficult concentrating or completing tasks

Temporary feelings of sadness are normal and should gradually go away within a few weeks as you get back to your normal routine and activities. If you experience any of the above symptoms and feel they are interfering with your ability to live a fulfilling life, please contact your VAD team for help.

We will provide the necessary psychological support and counseling. If your doctors feel that you would benefit, you may be placed on antidepressant therapy to control these symptoms. If required additional help from a qualified psychiatrist will also be arranged to help the patient and family, cope with their challenges.

END OF LIFE WITH VAD

Our goal is to support VAD patients from admission through recovery, so they may return to a state of good health and return home. However, despite all efforts sometimes a patient who has no reasonable chance of surviving may eventually be faced with deciding whether the VAD support is no longer serving its original purpose. Owing to national policy, we do not have the right as a clinical team to make these decisions or directly assist you with the same. This, unfortunately, is a legal matter and the service and its clinicians are bound by the national directive.