Left Ventricular Assist Device Complications

Author: Nicolas Stadlberger, MD
Updated: 11/23/2016

Left Ventricular Assist Device Complications

LVAD diagram

  • These patients MAY NOT HAVE A PULSE
    • May need an ABG since pulse oximetry may be inaccurate without a pulse
  • Contact your hospital’s or network’s LVAD Coordinator immediately to help with management and troubleshooting.
  • Patients are usually on diuretics, and may be intravascularly depleted or have electrolyte abnormalities

LVAD Patient in Extremis: Step-Wise Diagnostic Approach

Step 1

  • Address airway, breathing, circulation
  • Obtain IV, O2, monitor
  • Measure blood pressure: May need manual cuff with Doppler to obtain mean arterial pressure (MAP), or use arterial line (MAP goal 70-80 mmHg)
  • Assign someone to call LVAD Coordinator

Step 2

  • A uscultate precordium. Is there a hum?
    • Yes - LVAD is working.
    • No - LVAD is not working.
  • B attery: Make sure it is plugged in.
  • C ontroller: Check for alarms.
  • D riveline: Check device type and evidence of infection or damage
  • E chocardiogram

Step 3

  • Obtain VAD variables: Flow, Power, Speed, Pulsatility Index

Step 4

  • Obtain ECG
  • Obtain labs:
    • CBC
    • Electrolytes
    • Coagulation studies
    • LDH
    • Type and screen given GI bleed risk
    • ± Blood cultures if infection concern
    • ± ABG

Echocardiogram Findings - Causes & Management

Big right ventricle, big left ventricle

Potential Causes

  • Pump failure
  • Pump thrombosis
  • Valve disorders


  • Heparin
  • Antiplatelet agents
  • Thrombolytics

Big right ventricle, small left ventricle

Potential Causes

  • Right heart failure
  • ST-elevation MI
  • Pulmonary hypertension
  • Note: If LV to outflow cannula size ratio is 1:1, then high risk for suction event


  • IV fluids
  • ECG
  • Consider inotropes

Small right ventricle, small left ventricle

Potential Causes

  • Hypovolemia
  • Sepsis
  • GI bleed


  • IV fluids
  • Consider blood transfusion
  • Antibiotics

LVAD Complications


  • Up to 50% experience sustained VT/VF in first 4 weeks after LVAD placement
  • Difficult to determine primary vs. secondary cause:
    • Primary: Compromised myocardium + scar tissue
    • Secondary: Electrolyte abnormalities, hypotension, suction events
  • Management depending on the cause:
    • IV fluid challenge is reasonable
    • Reduce pump speed
    • Correct electrolytes
    • Electrical or pharmacologic: amiodarone, cardioversion


  • Up to 42% experience sepsis within 1 year (REMATCH Study). Most infections are in first 3 months, and 9% are fungal.
  • Treat with broad spectrum antibiotics + antifungal

Thrombus (pump thrombus, PE, stroke/TIA)

  • High risk despite anticoagulation.
  • Pump thrombus suggested by warm device and increased power output.
  • Lab finding: Elevated LDH
  • Treat with Heparin, thrombolytics, antiplatelet agents


  • Patients may have an acquired Von Willebrand Disease coagulopathy.
  • If life-threatening, reverse anticoagulation and transfuse as needed.

Suction Event

  • An underfilled LV causing suction of myocardium into LVAD
  • Can be caused by right heart failure, hypovolemia, sepsis, restrictive cardiomyopathy, arrhythmias
  • Treat with IV fluids to increase LV filling.

RV Failure

  • Due to acute myocardial infarction (AMI) or previous RV failure
  • Treat with IV fluids and consider inotropes.
  • Start aspirin and heparin, if AMI.

Cannula Malposition

  • Consider in setting of new VT, suction event, chest compressions, or trauma
  • Requires surgical exploration

Device Malfunction, Pump Failure

  • Suggested if no hum and mean arterial pressure (MAP) <40 mmHg.
  • Treat cardiogenic shock: IV fluids, vasopressors, ACLS protocols, consider heparin for thrombosis

Cardiac Arrest

  • Multiple potential causes including all those listed above.
  • Follow ACLS algorithms EXCEPT:
    • Chest compressions are controversial as they could dislodge the device.
    • Do NOT place defibrillation pads directly over device.
    • Assign one person to assess device placement during and after code.

Altered LVAD Patient

Altered LVAD patient clinical pathway diagram


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