Ventricular assist device (VAD)

Overview

A ventricular assist device (VAD) — also known as a mechanical circulatory support device — is an implantable mechanical pump that helps pump blood from the lower chambers of your heart (the ventricles) to the rest of your body. A VAD is used in people who have weakened hearts or heart failure.

Although a VAD can be placed in the left, right or both ventricles of your heart, it is most frequently used in the left ventricle. When placed in the left ventricle it is called a left ventricular assist device (LVAD).

You may have a VAD implanted while you wait for a heart transplant or for your heart to become strong enough to effectively pump blood on its own. Your doctor may also recommend having a VAD implanted as a long-term treatment if you have heart failure and you're not a good candidate for a heart transplant.

The procedure to implant a VAD often requires open-heart surgery and has serious risks. However, a VAD can be lifesaving if you have severe heart failure.

Why it's done

A ventricular assist device (VAD) is a mechanical device that supports the lower left heart chamber (left ventricular assist device, or LVAD), the lower right heart chamber (right ventricular assist device, or RVAD) or both lower heart chambers (biventricular assist device, or BIVAD).

Your doctor may recommend that you have a VAD implanted if:

• You're waiting for a heart transplant. You may have a VAD implanted temporarily while you wait for a donor heart to become available.

  A VAD can keep blood pumping despite a diseased heart and will be removed when your new heart is implanted. It may also help improve the function of other organs in your body that may not be working properly and may improve other medical conditions.

  When a VAD is implanted while you're waiting for a heart transplant, it's referred to as a "bridge to transplant."

• You're not currently eligible for a heart transplant because of age or other conditions. A VAD may sometimes be implanted if you have heart failure, but you're not eligible for a heart transplant due to age or other medical conditions. This is called "destination therapy."

  In selected cases, the VAD may help improve the function of other organs that aren't working properly or improve other medical conditions that may be keeping you from being a candidate for a heart transplant. In some cases, the VAD may improve these conditions so that you can become a heart transplant candidate, or you may keep the VAD as a permanent treatment.

  VADs are increasingly being used as a long-term treatment for people who have heart failure but aren't good candidates for a heart transplant. Generally if you're older than age 65, you may not be eligible for heart transplantation. In that situation the VAD would be implanted as therapy for heart failure. A VAD can enhance your quality of life.

• Your heart's function can become normal again. If your heart failure is temporary, your doctor may recommend implanting a VAD until your heart is healthy enough to pump blood on its own again. This is referred to as "bridge to recovery."

  It's also possible you'll have a VAD implanted for a short time during or after having heart surgery. You may have a VAD implanted for a few weeks or months.

  RVADs may be temporarily implanted after some heart surgeries. A RVAD can help keep blood flowing from the right ventricle to your lungs.

If a VAD can't help your heart, your doctor may consider a total artificial heart as a treatment option. This device replaces the two lower heart chambers (ventricles) of your heart. This option is generally only considered in people with severe heart failure whose conditions haven't improved through other treatments. It may be an option while you're waiting for a heart transplant. Your doctor will discuss with you whether a total artificial heart is an appropriate treatment option for you.

Risks

Implanting and using a ventricular assist device (VAD) involves risks that may include:

• Blood clots. As your blood moves through your VAD, blood clots may form. Blood clots can slow or block normal blood flow through your heart, which can lead to stroke or heart attack, or cause your VAD to stop working.

  Your doctor will prescribe blood-thinning medications, including warfarin (Coumadin, Jantoven) and aspirin to help prevent blood clots after your VAD is implanted. You'll need to have regular blood tests to monitor warfarin's effects.

  It's very important to follow the instructions for taking warfarin carefully. Warfarin is a medication that can have dangerous side effects if not taken exactly as instructed, so talk to your doctor about any special instructions you'll need to follow.

• Bleeding. Implanting a VAD requires open-heart surgery. Having open-heart surgery can increase your risk of bleeding during or after your procedure. Taking blood-thinning medications to reduce your risk of blood clotting also increases your risk of dangerous bleeding into the gastrointestinal tract and the brain.

• Infection. Because the power source and control unit for your VAD are located outside your body and are connected through a port in your skin, there's an increased risk of germs getting in the port and causing a serious infection.

  You, your family and your treatment team will need to watch carefully for signs of infection, such as soreness or redness near the port, fluid draining from the site, or a fever.

• Device malfunctions. It's possible that your VAD may stop working properly after it's implanted. The pumping action of the device might not work correctly, making it so not enough blood pumps through your heart. The power supply to the device could also fail, or other parts of the device may quit working properly. Each of these problems requires immediate medical attention.

• Right heart failure. If you have an LVAD implanted, it will pump more blood from the left ventricle of your heart than what your heart might have been used to. Your right ventricle may be too weak to pump the increased amount of blood.

  If you develop right heart failure, medications or other therapies may help improve the pumping ability of the right ventricle. An RVAD might be implanted to support the right ventricle if you develop this complication.

How you prepare

Before surgery to have a ventricular assist device (VAD) implanted, your doctor and treatment team will explain to you what to expect before, during and after the surgery and potential risks of the surgery.

Your doctor and team will discuss concerns you may have about your VAD surgery. Your doctor or another member of your treatment team may discuss with you advance directives or other information to consider prior to your surgery.

You'll need to have your hair shaved off at the location of your body where the procedure will take place.

Before being admitted to the hospital for your surgery, talk to your family about your hospital stay and discuss help you may need when you return home. Your doctor and treatment team may give you specific instructions to follow during your recovery when you return home.

Food and medications

Talk to your doctor about:

• When you can take your regular medications and whether you can take them before your surgery
• When you should stop eating or drinking the night before the surgery

Clothing and personal items

Your treatment team may recommend that you bring several items to the hospital including:

• A list of your medications
• Eyeglasses, hearing aids or dentures
• Personal care items, such as a brush, comb, shaving equipment and toothbrush
• Loose-fitting, comfortable clothing
• A copy of your advance directive
• Items that may help you relax, such as portable music players or books

During surgery, avoid wearing:

• Jewelry
• Eyeglasses
• Contact lenses
• Dentures
• Nail polish

Precautions regarding medications and allergies

Talk to your doctor about:

• Any medications you have brought to the hospital and when you should take medications on the day of the procedure
• Allergies or reactions you have had to medications

What you can expect

Before the procedure

Before your ventricular assist device (VAD) is implanted, you'll likely need to stay in the hospital for several days preparing for your surgery. While you're in the hospital, you may have other treatments for your weakened heart or heart failure.

Your doctor may review several factors to decide if a VAD is the most appropriate treatment for your condition and to determine which VAD may be most appropriate for you, including whether:

• The severity of your heart failure is appropriate for a VAD.
• You have other serious medical conditions that may affect your health or quality of life with a VAD.
• You need support for the left ventricle, the right ventricle or both ventricles.
• You're able to take blood-thinning medications for a long period of time.
• You have appropriate social support from your family and friends.
• You are mentally and emotionally able to take care of a VAD.

Your doctor will also evaluate your condition and ensure that you're healthy enough for surgery to implant a VAD. Your doctor may order several tests, including:

• Echocardiogram. In an echocardiogram, sound waves are used to produce a video image of the heart. Your doctor uses an echocardiogram to determine the pumping function of your heart, check your heart valves and help determine the cause of your heart failure. This can help your doctor decide if you're a candidate for a VAD or if another treatment option may be appropriate.
• Chest X-ray. An X-ray image helps your doctor to see the size and shape of your heart and lungs.
• Blood tests. Your doctor may order blood tests to check your liver, kidney and thyroid function before surgery to implant a VAD. Your doctor might also test for other chemicals in your blood that show how well your heart is working. Blood tests may also be used to check for symptoms of infection, which need to be treated before surgery.
• Electrocardiogram (ECG). An electrocardiogram records the electrical activity of your heart. An ECG measures the timing and duration of each electrical phase in your heartbeat.
• Cardiac catheterization. In this test, a doctor inserts a thin, flexible tube (catheter) into a vein or artery in your upper leg (groin), arm or neck and guides it to your heart using X-ray imaging. Doctors may use this test to measure the pressure and blood flow in your heart. This test may help your doctor determine if you're a candidate for a VAD or if you may need alternative devices.

While you're in the hospital before your surgery to implant a VAD and after the VAD has been implanted, your treatment team will educate you and your family about how your VAD works and how to live with a VAD, including:

• How your VAD works to support your heart
• Safety precautions
• What to do if your control unit signals a problem with your VAD
• How to respond to emergencies, such as a failed battery or other loss of power to your VAD
• How to care for your VAD, such as how to clean and check the equipment
• How to shower without damaging your device
• How to monitor for infections or complications after surgery
• How to travel with your VAD
• How you and your family can manage stress and anxiety regarding your device, and how you can adjust to your new lifestyle

During the procedure

A surgical team of heart (cardiac) surgeons, surgical nurses, doctors trained in giving medication that causes you to sleep during surgery (anesthesiologists) and others work together to perform your surgery.

The procedure to implant a ventricular assist device (VAD) is typically an open-heart surgery that generally takes four to six hours. You'll be asleep during the procedure, so you shouldn't feel any pain during the procedure.

You'll be connected to a machine that helps you breathe (ventilator) during your surgery. A tube will be run down your throat to your lungs and connected to the ventilator. You may need to remain connected to the ventilator for several days after your surgery.

In this procedure, your surgeon will make an incision down the center of your chest. Your surgeon will separate your chest bone (sternum) and open your rib cage so that he or she can operate on your heart.

Your heart may be stopped using medications during the surgery. You'll be connected to a heart-lung bypass machine that keeps oxygenated blood flowing through your body during surgery if your heart is stopped during surgery.

Your surgical team will implant your VAD during surgery. An implanted left ventricular assist device (LVAD) has many parts. A tube carries blood from the left ventricle of your heart to a pump. The pump delivers blood through another tube to the aorta — the artery that leads out to the body from the heart — which then delivers blood to the body. A cable inserted through the skin connects the pump to the control unit and battery pack outside your body.

After your VAD is implanted and working properly, your doctors will take you off the heart-lung bypass machine so that the VAD can begin pumping blood through your heart.

Certain types of VADs pump blood similar to the way your heart does, using a pumping action. They help pump blood from one or both lower chambers of your heart (ventricles) and on to the rest of your body.

Other types of VADs — continuous flow devices — are smaller. These devices allow a continuous stream of blood to flow through your heart. If you have a continuous stream of blood flowing through your LVAD, you or your doctor may not be able to check your pulse or your blood pressure using standard methods. Doctors may use other tests to check your heart rate and rhythm and to measure your blood pressure.

Certain types of VADs have pumps located outside of the body. These VADs may have external pumps connecting to a large console, while some have smaller external pumps located next to the body that are connected to portable devices. These VADs may be used for a temporary period of time, such as during or after heart surgery, but some may be used while waiting for a heart transplant or a longer-term VAD.

In one type of short-term VAD, the pump is inserted through a catheter in the leg, neck or armpit, which doctors guide through the arteries to the heart. Another type uses catheters to access the heart, but the pump is located outside the body.

After the procedure

After surgery to implant a VAD, you'll stay in the intensive care unit (ICU). You'll be given fluids, nutrition and medications through intravenous (IV) lines. Other tubes will drain urine from your bladder and drain fluid and blood from your heart and chest. Your treatment team will monitor you for signs of infection or other complications.

Your lungs may not work properly immediately after your surgery, so you may need to remain connected to a ventilator for a few days after surgery until you're able to breathe on your own.

After a few days in the ICU, you'll generally be moved to a regular hospital room. The amount of time you'll spend in the ICU and in the hospital can vary, depending on your condition before the procedure and how well you recover after your VAD is placed.

As you recover, your nurses and other members of your treatment team will help you become increasingly active. They may help you sit up, get out of bed and walk in the hallways of the hospital. You may have visits with a physical therapist to help you continue to increase your strength and get used to performing daily life activities.

Your treatment team will work with you to help you gain strength and prepare you for going home. They may explain how to live with a VAD and care for your VAD after you go home, and they can help answer your questions about the VAD. Your treatment team may also discuss with you nutrition and cardiac rehabilitation plans they may recommend during your recovery after you return home.

Your doctor will likely prescribe antibiotics and blood-thinning medications to prevent infection and other complications while you're in the hospital. You'll usually need to continue to take blood-thinning medications, including aspirin and warfarin (Coumadin, Jantoven) during the time you have a VAD to prevent blood clots.

It's very important to follow the instructions for taking these medications carefully. You'll need to have regular blood tests to monitor the effects of warfarin. Contact your doctor if you have any questions about your medications or if you experience any side effects. You'll also need to continue to take any medications you're taking for other conditions.

Your treatment team may encourage you to have visitors, such as family and friends, while you're recovering in the hospital. Visitors may be able to help you perform some physical activities. Your nurses and treatment team will also educate your family about many aspects of your care, such as training on how to care for and manage your VAD, how to watch for signs of infection after surgery, how to perform dressing changes, how to respond to emergencies related to the VAD, and how they can assist you at home.

Once you have recovered and gained your strength, your treatment team will determine when you're healthy enough to be released from the hospital. If you need more time to recover your strength before returning home, you may stay at a special care facility, such as a nursing home, for a period of time after leaving the hospital.

Results

You'll likely have follow-up appointments with your doctor and other members of your treatment team once a week for the first month after your procedure to check how well your ventricular assist device (VAD) is working and to check for complications.

Follow-up appointments may include a physical examination, several tests and an evaluation of the device's function. You'll generally need follow-up appointments less frequently over a period of time, as you continue to recover. Appointments may take place in clinics staffed by a medical team trained in ventricular assist devices.

Your doctor may also recommend that you participate in a cardiac rehabilitation program. Cardiac rehabilitation is a customized program of exercise and education, designed to help you improve your health and recover from a heart attack, other forms of heart disease or surgery to treat heart disease. Cardiac rehabilitation staff may help you incorporate healthy lifestyle changes — such as exercise, a heart-healthy diet and stress management — into your life.

Depending on your condition, you may be able to return to many of your daily life activities, such as returning to work, driving, being sexually active, participating in hobbies and exercising. Your doctor can discuss with you what activities are appropriate for you.

Living with a VAD can seem stressful. You may worry that your VAD will stop working or that you'll get an infection. If you're a candidate for a heart transplant, you may worry that your VAD won't keep working long enough for you to receive a donor heart.

Talk to your treatment team, family and friends if you feel stressed, worried or depressed. It may help to discuss how you're feeling. You may want to consider joining a support group of people who have VADs or talking with a professional counselor.

VADs and heart transplants

If you have a VAD implanted to help your heart pump blood while you wait for a heart transplant, you'll remain in close contact with your doctor and transplant center while you remain on the waiting list. It's likely you won't be allowed to travel farther than two hours' driving time of your hospital in case a donor heart becomes available.