Left Ventricular Assist Device Management Strategy

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Abstract

Introduction

Heart transplantation is the gold standard treatment for end-stage heart failure. The use of left ventricular assist devices (LVAD) is increasing due to the large number of transplant candidates and donor organ limitation. In the final consensus, the LVAD velocities are adjusted according to the interventricular septum position and aortic valve opening frequency. In this study, we aim to present the parameters that we use in patients with LVAD and to find out the answer to the question whether we can recognize in advance the development of right ventricular failure, especially in the context of these parameters.

Materials and Methods

62 patients who had LVAD implantation in our clinic between April 2013 and November 2017 were evaluated. Our routine LVAD follow-up includes physical examination findings (hepatomegaly and pretibial edema), LVAD parameters (speed, power, flow), renal and liver function tests, and prothrombin time. Interventricular septum position, right ventricular end diastolic (RVED) and end-systolic diameters and volumes, right ventricle (RV) diastolic and systolic areas, ratio of the short axis of the RV to the long axis of the RV, RV fractional areas, inferior vena cava diameter and association with respiration, tricuspid annular plane systolic excursion (TAPSE), left ventricular end-diastolic (LVED) and end-systolic diameters and volumes and aortic valve expansions were assessed by echocardiography.

Results

We decided not to use only septum position and aortic valve opening parameters in order to adjust the LVAD rate but looking at all of the parameters mentioned above. In a patient with a volumetric load, although the septum is in the midline, we have found that the LVED diameters and volumes and RVED diameters and volumes have increased compared to the previous findings. Instead of increasing pump flow rates in these patients, we arranged diuretic treatments. The increase in the ratio of the short axis to the long axis of the RV, the RV fractional area and the inferior vena cava diameter was determined as cautionary parameters for developing right ventricular failure.

Discussion

Various invasive and non-invasive methods are available for optimal adjustment of the speed of the LVAD. Echocardiography is one of the non-invasive methods. Intermittent aortic valve opening and septum position are assessed with echocardiography when LVAD velocity is set. However, these parameters alone may not be enough to evaluate the right ventricular failure that may occur due to long-term use of the device (destination therapy), and may lead to missed sight.

Conclusion

A complete patient follow-up chart including aortic valve opening and septum position together with LVED volumes and diameters and RV parameters helps to reduce the error margin to a minimum and helps us to organize our treatment strategy.

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