The Pre-brief
STEP 1: Establish whether or not perfusion exists, either from the LVAD or the native heart. The bottom line (placed–ironically–at the top of this article) very specifically does not mention pulses. Many LVAD patients will not have pulses even when everything is fine, so replace the pulses concept with perfusion. Get a doppler, and establish whether or not there is a MAP.
Yes MAP: Treat like any other peri-arrest
No MAP: Start ACLS like any other patient, including compressions
That’s it.
No, really, that’s the algorithm for in-the-moment ACLS–just replace examination of pulses with examination of perfusion, and you’re good to go. A few questions tend to come up, though.
Question: Do I perform compressions?
Answer: If there is no perfusion or the MAP is very low (expert opinions vary; consider compressions when the MAP is somewhere in the 30’s or 40’s), then yes. There had been great consternation in the past about compressions on LVAD patients. However–to put it in slightly crass terms–you can’t hurt dead. There’s nothing to lose by doing compressions on a patient who truly has no perfusion. Additionally, a few studies now have shown that modern LVADs do not tend to become displaced after compressions (1, 2). Nonetheless, it should be noted that some experts advocate for abdominal compressions (3), although my take is that the general consensus is moving towards chest compressions.
Question: Can I perform direct current cardioversion? How?
Answer: Yes, exactly as you would any other patient, taking care to avoid the LVAD and other devices (e.g., PPM) when placing the pads. A standard anterior/posterior approach works fine, and the standard AHA ACLS guidelines should be followed for energy recommendations. Do NOT unplug the LVAD.
Question: What if I can hear the LVAD? What if I can’t?
Answer: Does not matter because whether or not the LVAD is on, it is not working if there is no perfusion or there is very low perfusion such that life is unsustainable. Start the ACLS algorithm immediately.
Question: What if I achieve ROSC? Then what?
Answer: Various centers have different protocols, but they all center on quickly identifying the underlying cause and preparing for a back-up plan such as VA ECMO (4, 5, 6). Guglin et al. provide a nice summary of algorithms, including their own, shown here. An arterial catheter and central access should be priorities as well in case the blood pressure drops again.
Question: Do I follow ACLS to the letter, or are there some adjustments to be made?
Answer: The AHA posted a scientific statement on some specific issues for mechanical circulatory support devices and ACLS, but did not deeply address LVADs and ACLS. Most of the ACLS specific issues were around total artificial hearts (7). Even the other articles that propose algorithms for LVADs do not really address drugs and dosages (4, 5, 6). So, without great literature to reference, I can share that anecdotally, many physicians, myself included, tread lightly with afterload and focus on inotropy when it comes to LVADs. Giving a full 1 mg of epinephrine can end up causing more problems because if/when ROSC occurs, the commonly-encountered very high MAPs can will reduce the LVAD flow since LVADs are very afterload-sensitive. This can end up causing such a decrease in flow that perfusion becomes too low (despite a high blood pressure), and the patient has a repeat arrest. Similarly, if the afterload is too high, flash pulmonary edema can be caused or exacerbated, which worsens hypoxia, which can, yes, cause the patient to arrest again. To this end, many intensivists will give 0.2 mg of 0.5 mg of epinephrine at a time, re-dosing up to a total of 1 mg over the course of several minutes. Epinephrine is generally the drug of choice because of its (relatively) balanced inotropy and afterload effects.
The Debrief
- Establish perfusion, not pulses.
- Shock and do compressions as you would with anyone else in the ACLS algorithm.
- Consider gingerly providing epinephrine in complete arrests, rather than full, 1mg slugs q3-5 min.
References
- Prete J, Pelka M, Liebo M. ACLS and chest compressions in patients with durable LVADs. J Cardiac Failure. 2018;24(8):S123.
- Shinar Z, Bellezzo J, Stahovich M, Cheskes S, Chillcott S, Dembitsky W. Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs). Resuscitation. 2014;85(5):702-4. doi: 10.1016/j.resuscitation.2014.01.003.
- Rottenberg, E.M., Heard, J., Hamlin, R. et al. Abdominal only CPR during cardiac arrest for a patient with an LVAD during resternotomy: A case report. J Cardiothorac Surg 6, 91 (2011). https://doi.org/10.1186/1749-8090-6-91
- Guglin, Maya. Approach to unresponsive patient with LVAD. The VAD Journal. 2018;(4):2. doi: 10.13023/VAD.2018.02.
- Yuzefpolskaya M, Uriel N, Flannery M, et al. Advanced cardiovascular life support algorithm for the management of the hospitalized unresponsive patient on continuous flow left ventricular assist device support outside the intensive care unit. European Heart Journal: Acute Cardiovascular Care. 2016;5(8):522-526. doi:10.1177/2048872615574107
- Garg S, Ayers CR, Fitzsimmons C, Meyer D, Peltz M, Bethea B, Cornwell W, Araj F, Thibodeau J, Drazner MH. In-hospital cardiopulmonary arrests in patients with left ventricular assist devices. J Card Fail. 2014 Dec;20(12):899-904. doi: 10.1016/j.cardfail.2014.10.007.
- Peberdy MA, Gluck JA, Ornato JP, et al.: Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association. Circulation 2017;135:e1115-e34.
