With the population of stage D heart failure (HF) patients supported with durable left ventricular assist devices (dLVAD) rapidly expanding, a State-of-the-Art Review published in JACC provides a comprehensive overview of support and management of dLVAD-related emergencies, with an intent to provide a rapid-response guide for clinicians who encounter emergencies in patients with dLVADs.

Aniket Rali, MD, FACC, along with other members of ACC’s Critical Care Cardiology and Advanced Heart Failure & Transplantation Member Sections, discuss the basic components of dLVADs, dLVAD implantation and basic clinical assessments of patients with dLVADs. They also discuss hemodynamic assessment and monitoring, and why it is “important in troubleshooting and providing individualized management during dLVAD emergencies.” Additionally, they provide an algorithm to guide the initial encounter and first-hour decision tree.

The authors also look at different types of dLVAD emergencies and how to approach them efficiently, including HF-related events, cardiogenic shock, hematological emergencies, arrhythmias, device-specific complications and cardiac arrest. Notably, dLVAD pumps are both preload and afterload sensitive, meaning abnormalities in either can affect pump flow, increasing risk of a dLVAD emergency.

The review offers perspectives on the role of chest compressions in dLVAd patients, which is often “an area of uncertainty and debate,” and confirms chest compressions are safe and should not be delayed once cardiac arrest is confirmed. Additionally, the authors discuss end-of-life care for patients with dLVADs, which requires a multidisciplinary team approach and a clear understanding of device deactivation.

According to Rali, et al., “…facility in the prompt diagnosis and management of common dLVAD-related emergencies is paramount for clinicians across acute care, cardiovascular care and critical care settings.” Their review emphasizes the growing need for “cardiovascular intensivists that integrate epidemiology, diagnostic workup and multidisciplinary medical management of acute emergencies in patients supported with dLVADs.”