From the Guidelines
Hypotension in patients with Left Ventricular Assist Devices (LVADs) is a critical condition that requires immediate attention, and the most recent evidence suggests that optimizing LVAD settings, administering intravenous fluids, and using vasopressors like norepinephrine are essential management strategies 1. The most common causes of hypotension in LVAD patients include inadequate LVAD pump speed settings, hypovolemia due to dehydration or bleeding, right ventricular failure, cardiac tamponade, LVAD thrombosis, or sepsis. When an LVAD patient experiences hypotension, immediate assessment should include:
- Checking pump parameters (flow, power, speed)
- Evaluating for signs of bleeding
- Assessing right ventricular function with echocardiography Management typically involves:
- Optimizing LVAD settings
- Administering intravenous fluids if hypovolemic
- Using vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) for persistent hypotension
- Treating any underlying causes such as infection or arrhythmias Right ventricular support with inotropes like milrinone (0.25-0.75 mcg/kg/min) may be necessary if right heart failure is present, as suggested by the European Society of Cardiology guidelines 1. LVAD patients require specialized care as their hemodynamics differ from those without mechanical support, and traditional blood pressure measurements may be difficult to obtain due to continuous flow physiology, highlighting the importance of prompt recognition and treatment of hypotension to prevent end-organ damage and increased mortality in this vulnerable population 1.
From the Research
LVAD and Hypotension
- Hypotension is a potential issue in patients with Left Ventricular Assist Devices (LVADs) 2
- The use of continuous flow LVADs can lead to a reduction in pulsatility, which may contribute to hypotension 2
- Orthostatic hypotension (OH) is a less frequently observed side effect in patients supported with LVAD therapy, and may be related to acquired autonomic dysfunction 2
Blood Pressure Management in LVAD Patients
- Maintaining low mean arterial pressure (MAP) in LVAD recipients is associated with a reduced risk of stroke/death, but the lower limit of the optimal MAP range has not been established 3
- A MAP ≤75 mmHg is associated with increased risk of death, stroke, and stroke/death in LVAD recipients 3
- The management of blood pressure in LVAD patients requires careful consideration of the potential risks and benefits of different blood pressure targets 3
Clinical Evaluation and Management of LVAD Patients
- The clinical examination of LVAD patients is unique and requires consideration of blood pressure and heart rate assessment, LVAD "hum" auscultation, driveline and insertion site inspection, and device parameter recording 4, 5
- LVAD patients may present with a range of complications, including device malfunction, pump thrombosis, suction event, bleeding, cerebrovascular event, infection, right ventricular failure, dysrhythmia, and aortic regurgitation 5
- A team-based approach to the management of LVAD patients is recommended, with consultation with an LVAD specialist as needed 4, 5, 6