Can cardiopulmonary resuscitation (CPR) be performed on an adult patient with advanced heart failure and a left ventricular assist device (LVAD) failure?

CPR in LVAD Patients with Device Failure

Yes, you can and should perform CPR on a patient with LVAD failure if they are unresponsive and without a definite pulse, but assessment and initiation require specific modifications due to the continuous-flow nature of modern LVADs.

Initial Assessment Modifications for LVAD Patients

The standard pulse check is unreliable in LVAD patients because modern continuous-flow devices do not generate a palpable pulse in most cases 1, 2. You must use alternative perfusion assessment methods:

• Check for consciousness and responsiveness by shouting and tapping the patient 3, 4
• Assess perfusion using multiple modalities including:
  • Doppler ultrasound over carotid or femoral arteries to detect flow 5, 2
  • Blood pressure measurement via Doppler (mean arterial pressure >60 mmHg suggests adequate perfusion) 5, 2
  • Arterial line monitoring if available 5
  • Capillary refill and skin perfusion 2
• Listen for the LVAD "hum" - absence suggests device malfunction 2
• Check device parameters on the external controller 2

When to Initiate CPR

Begin chest compressions immediately if:

• The patient is unresponsive AND
• You cannot confirm adequate perfusion within 10 seconds using the methods above 6, 5

The critical pitfall: Studies show significant delays in CPR initiation for LVAD patients - only 56% received CPR within 2 minutes compared to 100% of non-LVAD patients, highlighting the confusion around assessment 5. When in doubt, start compressions, as the risk of harm from unnecessary CPR is low compared to delayed resuscitation 6.

CPR Technique for LVAD Patients

Standard CPR guidelines apply with full chest compressions:

• Push hard (at least 5 cm depth) and fast (100-120/min) 6, 3
• Perform cycles of 30 compressions and 2 breaths 3, 4
• Minimize interruptions in compressions 6
• Allow complete chest recoil between compressions 6, 3

There is no evidence that chest compressions damage the LVAD device - the pump is designed to withstand normal physiologic pressures 5, 2. The LVAD continues to provide some forward flow during compressions if still functioning 2.

Advanced Life Support Considerations

• Establish IV/IO access and administer epinephrine 1 mg every 3-5 minutes 6
• Check rhythm every 2 minutes - if VF/pVT, deliver shock and resume CPR 6
• Consider reversible causes specific to LVADs:
  • Pump thrombosis 1, 7
  • Device malfunction/failure 1, 2
  • Right ventricular failure 1, 7
  • Hypovolemia 6, 1
  • Arrhythmias (common in LVAD patients) 1, 7
  • Massive bleeding (GI bleeding, stroke) 1, 7

Critical Team-Based Approach

Immediately contact the LVAD specialist team while resuscitation is ongoing 1, 2. They can:

• Troubleshoot device parameters remotely 2
• Guide pump speed adjustments 7, 2
• Determine if device exchange is needed 7
• Provide device-specific guidance (HeartMate 3, HVAD have different considerations) 7

Special Circumstances

If the LVAD is confirmed to be functioning (audible hum, normal parameters) but the patient is unconscious:

• The issue may be arrhythmia, stroke, or other non-pump pathology 1, 7
• Continue standard ACLS protocols while addressing the underlying cause 2

If device failure is confirmed:

• CPR becomes the primary means of circulation 5
• Prepare for emergent device exchange or escalation to ECMO if available 7, 2

The fundamental principle remains: when faced with an unresponsive LVAD patient without confirmed perfusion, initiate CPR immediately rather than delay while attempting complex assessments 6, 5. The 2020 AHA guidelines emphasize that the risk-benefit ratio strongly favors providing CPR for presumed cardiac arrest 6.