Ventricular Assist Device (VAD)

Heart anatomy

• The heart pumps blood to all organs in the body
• The right heart receives de-oxygenated blood from the body and pumps it to the lungs
• The left heart receives oxygenated blood from the lungs and pumps it to the body
• The heart has 4 chambers
  • Two upper atria – receiving chambers
  • Two lower ventricles – pumping chambers
• Heart valves ensure blood flows in the correct direction in the heart

 How blood flows through the heart

• De-oxygenated blood from the body enters the right atrium, passes through the tricuspid valve, enters the right ventricle, gets pumped through the pulmonary valve to the lungs. The tricuspid valve closes afterwards to prevent blood from flowing backwards into the right atrium.
• Blood picks up oxygen in the lungs
• Oxygenated blood from the lungs enters the left atrium, pass through the mitral valve, enters the left ventricle, gets pumped through the aortic valve and into the aorta to the rest of the body. The mitral valve closes afterwards to prevent blood from flowing backwards into the left atrium.

The heart has its own blood supply

• The heart is an organ and needs oxygenated blood like all the rest of the body
• The heart receives oxygenated rich blood through the coronary arteries, which are embedded in the wall of the heart; it does not receive any oxygen from the blood passing through the chambers.

 How the heart beats

• Each heartbeat is from an electrical signal from the top of the heart that travels through the two atria and then through the two ventricles. 
• The sinus node is a pacemaker at the top of the heart.
• The electrical signal fires from the sinus node, travels through the two atria, causing them to pump blood into the ventricles. The electrical signal travels to the atrioventricular node in the middle of the heart, and then to the two ventricles, causing them to pump the blood to the rest of the body.

What Is Heart Failure?

• Heart failure occurs when the heart cannot pump enough blood for the body.
• Symptoms include shortness of breath, fatigue, and swelling.
  • This occurs because as the heart is not pumping blood appropriately, fluid accumulates in the lungs and elsewhere in the body, causing “congestion” with extra fluid.
• For most patients, heart failure gets worse over time and can lead to death.

A VAD is a device that can help heart function when neither medication nor heart transplant is an option for patients diagnosed with advanced heart failure. It is a finger-sized pump implanted inside the chest next to the heart, where inside the body the pump helps move blood from the left ventricle to the aorta so blood can reach the rest of the body. It is powered by a battery pack connected outside the body.

What are the parts of a VAD? 

• Pump – part of the device that is implanted inside the chest and attached to the heart. It includes a small tube that carries blood from the heart into the pump, and another tube that carries blood from the pump to the blood vessels to deliver blood to the rest of the body.
• Controller – small computer that monitors the pump, carried outside the body.
• Driveline – cable that connects the pump inside the body to the external controller, carried outside the body.
• Batteries – power source for the pump and controller, carried outside the body.

Who should be considered?

Getting a VAD is a major decision with risks, benefits, and significant lifestyle changes that impact patients and their caregivers. If offered VAD therapy, patients have the option to choose to get a VAD or not, and the decision depends on the individual and how they hope to live their life.

• Destination therapy (DT) - patients diagnosed with severe heart failure and neither medication nor heart transplant is an option for treatment; these patients will live with a VAD until their death
• Bridge to transplant therapy (BTT) - patients awaiting heart transplantation
• Bridge to recovery - patients whose heart function is expected to improve over time

What are the benefits?

• VADs can improve the quality of life and symptoms of heart failure, including:
  • Less fatigue
  • More strength
  • Better breathing
• Many patients treated with VADs go on to lead active lives, participating in activities like hiking, golf, and camping.
• Survival rates of patients with VADs is approaching those who receive heart transplants.
  • After one year, 8 out of 10 patients who received a VAD are still alive.
  • VADs are designed to last for years and nationally, patients are living more than 10 years with a VAD.

What are the risks?

There are several important risks of having a VAD implant that your doctor will review, including:

• Blood clots
  • As blood moves through the VAD, blood clots may form. These can slow or block flow of the VAD pump. This can lead to stroke if the blood clot travels to the brain. Blood clots can also cause the VAD to stop working.
  • Blood thinner medications will help prevent the formation of blood clots.
• Bleeding
  • VAD implantation requires heart surgery, which can cause bleeding
  • Bleeding from the intestinal tract and nose bleeds may occur in some patients
  • Patients are at increased risk of bleeding as they will be on blood thinning medication to prevent clotting of the VAD pump.
• Infection
  • Although the VAD is inside the body, it is attached to parts outside the body through holes in the skin at the driveline site. These holes increase the risk of bacteria from the skin and outside the body getting inside and causing infection.
• Device malfunction
• Respiratory failure
• Kidney failure
• Right heart failure
• Stroke

Evaluation

• Patients who are potential VAD candidates will be seen by a large team, including surgeons, cardiologists, financial counselors, and palliative care.
• Patients should thoroughly reflect if getting a VAD is the best option for them.
  • Watch:
    • LVAD Decision Aid
    • Considering an LVAD
    • LVAD Surgery & Recovery
    • Life with an LVAD
    • Caregiver's Perspective
• Extensive testing beforehand
  • Blood tests
  • CT scans
  • Ultrasound scans
  • X-rays
  • Echocardiogram (ultrasound of your heart) – sound waves in the form of ultrasound are used to show the structure of your heart and hear valves.
  • Cardiac catheterization – a catheter is inserted into a blood vessel usually in the wrist and moved up to the heart using the guidance of X-ray imaging, to measure the pressures and flows in the heart; this helps determine if a patient is a good candidate for a VAD.

Preparation

• If you are recommended VAD therapy after your testing and evaluations, you may be considered for surgery.
• Patients and their caregivers will view training videos prior to surgery.
• Patient’s primary caregiver will need to plan to be at the hospital for in-person training during business hours at least 3-4 days per week after VAD implantation to practice skills to take care of the VAD (such as driveline dressing care and changing battery sources).
• Lodging for family and caregivers include Harbor House, located two blocks from the hospital. Visit harborhouseofrochester.org or call (585) 473-1779 for more information.

Surgery

• Patients are under general anesthesia with a breathing tube for this procedure, meaning patients will be put to sleep before the surgery begins.
• The surgery is considered “open-heart surgery.”
• The surgeon will first access the heart to implant the VAD. The heart will then be temporarily stopped and put on a heart-lung machine to supply the body with blood and oxygen. The VAD will be attached to the left ventricle, the aorta, and also connected to a battery pack that will remain outside the body. Once the VAD is in place, the patient is disconnected from the heart-lung machine, the heart will be restarted, and the incision will be closed.
• Patients will be on several new medications after implant, including a blood thinner to prevent clots in the VAD.

Recovery

• After surgery, patients will stay in the cardiovascular intensive care unit (ICU) for 2-3 days, followed by transfer to a regular hospital room.
• Patients may have the following symptoms after surgery:
  • Pain - For which they can receive pain medication
  • Soreness in the nose and throat - From the breathing and stomach tubes placed during the surgery, for which they can be treated with lozenges and throat sprays to ease the discomfort
  • Bruising at the wrist - From the arterial and IV lines; this will resolve with time.
  • Pressure on the bladder or burning sensation with urination - After the foley catheter is removed; this will resolve with time.
• While in the hospital, patients will work with nurses and physical therapy to recover their strength after surgery.
  • Activity - Patients will be getting out of bed as soon as the doctor allows, at first with getting up to sit in a chair, and then short walks in the hallways with nurses and physical therapists.
  • Deep breathing exercises and coughing - Coughing reduces risk of pneumonia infection developing in the lungs.
  • Dressing changes - Healthcare providers will perform dressing changes while patients are in the hospital.
  • Nutrition – Dietitians will ensure patients are eating well during the recovery period while in the hospital.
• Most patients receiving a VAD are discharged 10-14 days after surgery.
• Patients require 24/7 support system of 2-4 caregivers who will come for in-person VAD care training, assist you with recovery after surgery, and come in for clinic appointments.
• Most patients will have weekly checkups with your doctors for about the first month after surgery to make sure the device is working properly. As patients recover, they will eventually need fewer follow-up appointments.
• Patients may be recommended to start cardiac rehabilitation after surgery, which is an exercise and education program to help make healthy life changes.
• Getting back to routine daily activities is a gradual process.

• Lifestyle Changes
  • Do not use tobacco products
  • Do not drink alcohol
  • Do not use recreational/illegal drugs
  • Eat a healthy diet
  • Exercise regularly
  • Tell all of your healthcare providers that you have an LVAD.
• Power Source
  • You must be connected to a power source at all times
  • When you are sleeping, you will plug into an electrical outlet
  • During the day, you can use batteries that last up to 17 hours.
  • Loss of power to the pump can result in death
• Carrying Equipment
  • You will need to carry around the batteries and controller at all times;
  • Equipment that weighs 3-7 pounds can be carried in a vest or on a belt
  • You may need to carry extra batty packs in case of an emergency
  • You should discuss with your cardiologist if you plan to fly on a plane.
• Driveline Care
  • Bandages that protect the driveline site must be changed several times per week
  • Lack of appropriate care can lead to serious infections
• Medications and Medical Care
  • Blood thinners for as long as you have a VAD
  • Continue heart medications
  • Regular doctor office visits
  • Outpatient cardiac rehabilitation
• Water Precautions
  • You will not be able to swim or take baths; the equipment and driveline site cannot be submerged in water
  • Special water protection equipment to shower with your device
• Activity Precautions
  • You will not be able to participate in contact sports
  • You will not be able to have MRI scans, as the magnets in the scanner may cause the pump to stop.
  • You will need to discuss with your doctor about any travel plans ahead of time to facilitate information of medical facilities with a VAD program near to where you are traveling.
• Cost
  • You may have extra costs for supplies and co-payments, depending on your insurance
• Sex
  • Some patients and their partners report changes in sex life with a VAD
  • For most patients, sex is safe after recovery from surgery
• Emotions
  • Some patients and their caregivers are grateful for the VAD and get use to lifestyle changes as noted above.
  • Some patients may worry or feel overwhelmed with taking care of the device, creating stress that can lead to depression and anxiety.