A Guide to Mechanical Circulatory Support: A Primer for Ventricular Assist Device (VAD) Clinicians

Foreword
Evolution of Pump Design: Disruptive Changes in the Course of AHF Care
Program Structure: Impacted by Research and Regulations
Team Composition and Patient Management: From Organic to Intentional
VAD Clinician Professional Development
Acknowledgments
Contents
Mechanical Circulatory Support: Evolution and History
	History of Mechanical Circulatory Support
	Overcoming Some of the Hurdles
	History of the VAD Coordinator Role
	The Future
	References
Pump Design and Mechanics
	Pump Design and Mechanics
	Pulsatile VAD Designs
		Cannulas and VAD Placements
		Handpump
		Pulsatile Waveforms
	Non-Pulsatile VAD Designs
		HQ Curves
		Suction Events
		Artificial Pulse
		Non-Pulsatile Waveforms
	Common Components for Pulsatile and Non-Pulsatile Devices
		Percutaneous Lines
		Controllers
		Power Sources
		Battery Chargers
		Monitors
		Blood Contacting Surfaces/Biomaterials
		FDA Monitoring
	Future VAD Designs
	References
Mechanical Circulatory Support Indications and Patient Selection
	Introduction
	Indication for MCS
		Intentions for Treatment
		Reimbursement Indications
	Contraindication for MCS
	Patient Selection
	References
Patient Optimization Prior to MCS
	Introduction
	STS INTMERMACS® Score
	Preoperative Concerns and Comorbidities
		Malnutrition
		Anemia
		Hematologic Disorders
		Diabetes Mellitus (DM)
		Peptic Ulcer Disease
		Hepatitis
		Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS)
		Arrhythmias/ICD Shocks
		Sleep Apnea
		Chronic Obstructive Pulmonary Disease (COPD)
		Coronary Artery Disease (CAD)
		Peripheral Vascular Disease (PVD)
		Renal Dysfunction
		Obesity
		Depression and Anxiety
	Psychosocial Readiness for LVAD Implant
		Cognitive Evaluation
		Psychiatric Illness
		Alcohol, Tobacco, and Substance Abuse
		Adherence to Medical Therapies
		Family/Caregiver Support
	Financial Support
	Increasing Physical Conditioning Pre and Post MCS
	Hemodynamic Optimization Before MCS Implant
	Infection Control
	Conclusion
	References
Surgical Insertion of a Ventricular Assist Device
	Preoperatively
	Operative Techniques
	Procedure
	Intra-op TEE
	Anesthesia Pearls
	Intraoperative Management
	During Procedure
Postoperative Management of the VAD Patient
	Immediate Postoperative Care
		Return to the Intensive Care Unit
		Necessity of the Implantable Cardio-Defibrillator
		Inotrope Use
		Chest Tube Output
		Nitric Oxide Use
		Ventilator Management
		Echocardiography Guidance with Speed Optimization
		Management of Surgical Lines
	Antiplatelet and Anticoagulation Use in LVAD
		Heparin
		Warfarin
		Aspirin
	Generalities Due to Pump-Specific and Program-Specific Guidelines
	Timing of Extubation
		Pulmonary Hygiene and Lung Volume Expansion
		Spirometry
	Nutrition in a VAD Patient
	Labs and Imaging of the Hospitalized VAD Patient
		Laboratory Checks
		Imaging Studies and Procedures
		Frequency
	Importance of Right Ventricular Function Following Implantation
		Right Ventricular Strain
		Early Right Ventricular Failure
		Consideration of Right Ventricular Assist Device
		Use of Phosphodiesterase-5 Inhibitors
	Pain Mitigation and Bowel Regimen
	Consideration of Blood Products
	Activity Post VAD
		Sternal Precautions
	Multidisciplinary Team Engagement
	Engagement of Inpatient/Outpatient Rehab Options
	Patient and Caregiver Education Preparation
		How to Carry the LVAD
		How to Shower with the LVAD
		Alarms
		Excursions (Where Applicable)
		Calling the LVAD Team
		Inpatient Driveline Dressing Management
		Equipment and Dressing Supply Distribution
	Discharge Preparation
		Rehabilitation Center Needs
		Local Laboratory
		Community Contacts
	References
Ventricular Assist Device Complications
	Introduction
	Bleeding
		Gastrointestinal Bleeding
		Epistaxis
		Hemorrhagic Stroke
	Right Ventricular Failure
		Arrhythmia
		Infection for Length, Consider Removing this Completely
		Stroke
	Pump Thrombosis
		Causes
		Diagnosis
		Treatment
		Prevention
	Pump Obstruction
	Short-to-Shield
	Conclusion
	References
Infectious Concerns and Prevention for Patients with Ventricular Assist Devices
	Infection Definitions
		Preoperative and Intraoperative Planning
	Driveline Exit Site Infection
		Background and Prevalence
		DLES Pathogens
		DLES Infection Staging
		DLES Diagnosis and Treatment
		DLES Prevention Techniques
		DLES Care
	Pump Pocket Infection
		Pump Pocket Infection Treatment
	Pump/Cannula Infection
	Approach to the Patient with a Suspected VAD Infection
		Imaging
	Bacteremia
	Mediastinitis/Infective Endocarditis
	Stroke
	Transplant Outcomes
	References
Anticoagulation for Ventricular Assist Devices
	Anticoagulation and Antiplatelet Agents
	Perioperative Management of Anticoagulation
	Long-Term Anticoagulation and Antiplatelet Therapies
	Monitoring INR
	Modification of Anticoagulation for Adverse Events
	Reversal of Anticoagulation
	Management of Anticoagulation in Patients Who Refuse Blood Products
	Anticoagulation in Pediatric Patients with LVADs
	Conclusion
	References
Exercise and Physical Therapy with Ventricular Assist Devices
	Cardiac Rehabilitation in Literature
	Clinical Assessment
		Factors That Can Limit Functional Exercise Training
	Monitoring Exercise Training
	Implementation of Exercise Training
	Acute Hospitalization
		Early Mobilization
		Sternal Complications and Precautions
	Sub-acute Phase
		UL Strength Training
	Long-Term Phase
	Contraindications and Precautions to Exercise
	Infection Control
	Multidisciplinary Team (MDT)
	Recommendations for Research
	References
Nutrition for the Advanced Heart Failure and VAD Patient
	Importance of Nutrition and the Role of the Registered Dietitian Nutritionist in Patient Care
	Malnutrition in Heart Failure and the Nutritional Implications of Cardiac Cachexia
	Nutrition Screening and Assessment Parameters
	Nutritional and Surgical Interventions
	Nutrition Support for Perioperative and Postoperative Critical Care
	Postoperative Education, Discharge Process, and Role of Interdisciplinary Care Team
	Outpatient Follow-Up
	Hospital Readmissions and Other Barriers to Nutrition Progress
	References
Outpatient Management for the VAD Patient
	Upon Discharge
	Clinic Visits
	Routine Parameters to Be Monitored in Clinic
	Labwork Monitoring
	Pump Speed Optimization
	Telemonitoring
		Types of Remote Monitoring
	Multidisciplinary Team Involvement
	Leaving the Home and Traveling
	Conclusion
	References
Regulatory Agencies Impacting Mechanical Circulatory Support Programs
	Introduction
	Industry and Clinical Investigation Oversight
	Registry Participation
	Centers for Medicare and Medicaid Services
	Program Certification
	Non-U.S. Programs
	Summary
	References
Reimbursement in Ventricular Assist Device Implant and Care
	Defining Reimbursement and Terminology
	Demystifying Insurance Payers: Government vs. Private
	Prior Authorizations and Medical Necessity
	Patient Impact
	Program Impact
	Coding
	Outpatient Supplies
	Program Financial Success
	Additional Resources
Ventricular Assist Devices for the Pediatric Population
	Introduction
	General Pediatric Indications and Contraindications
	Pre-implant Considerations
	Single Ventricle VAD Support
	Paracorporeal Pumps in Pediatric VAD Support
	Nutrition
	Unique Psychosocial Needs for the Pediatric VAD Patient: Top  Five Differences and Considerations
	Rehabilitation
	Discharge and Community Reintegration
	Destination Therapy (DT)
	References
Temporary Mechanical Circulatory Support
	Introduction
	Intra-Aortic Balloon Pump (IABP)
		Configuration and Mechanism of Action
		Indications and Contraindications
		Complications
	Impella (Abiomed)
		Engineering and Function
		Indications/Contraindications
		Complications
		Indications for Surgical Impella/Escalation
		Weaning
	Left Atrial to Femoral Arterial Bypass
		Configuration
		Indications and Contraindications
		Complications
	Right Atrial to Pulmonary Artery Bypass
		Configuration
		Indications/Contraindications
		Complications
	Extracorporeal Membrane Oxygenation (ECMO)
		Configuration
		Indications/Contraindications
		Complications
	Conclusion
	References
Administrative Aspects of the Ventricular Assist Device Program
	Development
		Upfront Costs
		Leadership and Team Structure
		Cost Analysis
		Preparing for Implantation
	Programmatic Guidelines
	Certification
	Equipment
	Growth and Evolution
		Continued Coverage
		Outreach
	Conclusion
	References
Psychosocial and Palliative Aspects of VAD Care
	Psychosocial Risk at Selection
	Stress, Coping, and Support After VAD Implant
	Palliative Care Consultation Before LVAD Implantation
	End of Life with LVAD
	References
Professional Organizations in the Mechanical Circulatory Support Community: An Opportunity to Network
	Organizing Your Search
	Technology-Specific Search
	Nursing Community of Practice-Specific Search
	Interdisciplinary-Specific Search
	Additional Benefit to Professional Organizations: Networking
	Summary
	References
Clinical Research and Applications to Mechanical Circulatory Support
	Basics
		Forming the Research Idea
		Principal Investigator
		Protocol
		Types of Trials
		Randomization
		Regulatory
	Data Collection
		Quantitative
		Qualitative
		Data Analysis
	The Report
		Authorship
		Abstract
		Methods
		Results
	Implementation of Research
		Grant Applications
		Project Budget
		Timely Completion of Data Points
		Monitoring, Auditing, Inspection
	Dissemination of Research
		Oral Presentation of the Report
		Poster Presentation of the Report
		Manuscript Publication of the Research
	Conclusion
	References
Mechanical Circulatory Support in the Era of COVID-19
	Introduction
	COVID-19 and Cardiac Disease
	MCS and COVID
	Treatment for VAD Patients with COVID-19
	Implantation and Follow-Up of Durable MCS in the COVID Era
	References