Overview, Purpose & Procedure of Ventricular Assist Device (VAD) Implantation

Ventricular assist devices (VADs) serve as a lifeline for individuals whose hearts are too weak to meet their needs. These surgically implanted pumps play a vital role in circulating blood throughout the body, leading to significant symptom improvements and an enhanced quality of life that can extend to several future years.

Understanding Ventricular Assist Device Implantation

A VAD ventricular assist device, also known as a mechanical pump, supports the heart in circulating blood throughout the body. It is commonly used in patients with heart failure severities or those awaiting a transplant of the heart. Surgically implanted, the VAD assists either one or both of the heart’s ventricles, which are its primary pumping chambers.

There exist different types of VADs that cater to specific heart regions. The most prevalent type is the left ventricular assist device (LVAD), aiding the left side of the heart in pumping oxygen-rich blood to the body. Patients with left ventricular failure or end-stage heart failure often benefit from this device.

In certain cases, a right ventricular assist device (RVAD) comes into play to support the right side of the heart in pumping oxygen-poor blood to the lungs. This solution is typically implemented when the right side of the heart is weak or failing.

For cases where both sides of the heart require assistance, a biventricular assist device (BiVAD) is utilised. This device simultaneously supports both the left and right ventricles and is employed in instances of severe heart failure affecting both sides of the heart.

Purpose of Ventricular Assist Device Implantation

To cater to the needs of children and young adults, paediatric VADs are specifically designed. These smaller devices can be customised to suit infants, toddlers, and adolescents requiring circulatory support. VADs play a crucial role in significantly improving the quality of life for patients with heart failure, ensuring adequate blood flow throughout the body. Some VADs serve as temporary measures, providing support until a suitable heart transplant becomes available, while others act as long-term treatment options for those ineligible for transplantation.

Various circumstances warrant the need for a VAD ventricular assist device, including:

1. Advanced heart failure: In cases where advanced heart failure impairs the heart’s ability to pump sufficient blood, a VAD can provide mechanical support and maintain circulation.
2. Path to recovery: Sometimes, a VAD can act as a temporary solution, supporting the heart while it recovers from a weakened state.
3. Transplant: Eligible individuals awaiting a heart transplant can rely on a VAD for providing circulatory support until a fitting donor heart becomes available.
4. Therapy: For individuals ineligible for a heart transplant, a VAD can serve as a long-term or permanent treatment option. This solution significantly enhances survival rates among cardiac patients.

Procedure for Ventricular Assist Device Implantation

The implantation of a VAD involves a surgical procedure encompassing several stages, as discussed below:

Evaluation

The ventricular assist device is not applicable to all individuals with severe heart failure. Upon receiving a diagnosis of advanced heart failure, patients undergo thorough medical and psychological evaluations. These assessments aim to evaluate the current function of the heart and other organs. Additionally, healthcare providers screen for any complex health issues, such as breast cancer, prostate problems, or infectious diseases.

The process of the evaluation involves a range of tests and procedures, which are as follows:

• Electrocardiogram (ECG): This process records the electrical activity of the heart and helps assess its rhythm and function.
• Echocardiogram: This is an imaging test that uses sound waves to create images of the heart, which help understand its present structure and function.
• Computed tomography (CT) scan: This is a specialised imaging technique that provides cross-sectional images of the heart and surrounding blood vessels, allowing for a detailed assessment of cardiac anatomy.
• Exercise testing: This involves monitoring the heart’s response to physical exertion, typically on a treadmill or stationary bike, to assess its functional capacity and identify any limitations.
• Cardiac catheterisation: Both left and right heart catheterisation may be performed to measure pressures within the heart chambers, assess blood flow, and obtain tissue samples if needed.

In addition to these tests, the evaluation process includes discussions about living with a VAD and extensive education on the basic daily tasks involved in caring for the device. The care team also collaborates with the patient to identify potential support systems, such as loved ones or individuals living nearby who can offer assistance if required. The evaluation process helps healthcare providers determine whether a VAD is a suitable treatment option for a particular individual with advanced heart failure.

Process of Surgery

During VAD implant surgery, the following steps are typically followed:

• Anaesthesia: You will be given general anaesthesia, which will induce sleep and temporarily block sensations. This ensures your comfort throughout the procedure, and you will have no memory of it. A ventilator will assist with your breathing during the surgery and initially in the ICU.
• Incision and pericardium: The pericardium, or sac surrounding your heart, will be opened through an incision made by the surgeon in the centre of your chest, near the sternum.
• Cardiopulmonary bypass: Blood clotting is prevented by the anticoagulant heparin. A cardiopulmonary bypass machine will be attached to you, maintaining your blood flow momentarily while your heart is being operated on.
• Driveline: The VAD driveline, which connects it to an external power source and controller, is tunnelled through your abdominal wall for external access.
• Placement: The surgeon inserts the VAD into the appropriate areas of your heart. In the case of a left ventricular assist device (LVAD), the inflow cannula is connected to the peak of the left ventricle, while the outflow cannula is connected to your aorta. However, different configurations may be used depending on your specific condition.
• Activation: Once the VAD is properly positioned, the surgeon activates the device. As the VAD begins supporting your circulatory needs, you will be gradually detached from the cardiopulmonary bypass machine.
• Reversal of heparin: To allow your blood to clot again, the surgeon administers a drug called protamine, which counteracts the effects of heparin.
• Closure: Your surgeon brings your sternum back together using metal wires, ensuring stability and proper healing. The superficial layers are closed with absorbable sutures, and a sterile dressing is applied.

It’s important to note that variations in the surgical procedure may occur based on individual patient factors and the specific type of VAD being implanted.

Recovery Procedure

After undergoing the implant surgery, you will have to stay in the intensive care unit (ICU), where you will be put under close monitoring and specialised care. The ICU serves as a safe place for several days, allowing your condition to stabilise. Once this is done, a transfer to the cardiac step-down unit will be arranged in the hospital.

During the postoperative period, a diligent team of healthcare providers will dedicate themselves to vigilantly tracking the intricate workings of your organs. From your heart and kidneys to your brain, lungs, and liver, every aspect of your bodily health will be under precise supervision. Their purpose is to ensure that all areas of concern are well managed and that any potential complications receive prompt attention.

Beyond organ function monitoring, a diverse ensemble of specialists will enter the scene to help you adapt to life with the VAD. These specialists, ranging from physical therapists to occupational therapists, will act as your guides. Their expertise will assist you in navigating the necessary steps toward familiarising yourself with the new device and regaining your lost strength. The holistic approach will assist you to recover faster and help you lead a normal life.

As a part of your treatment plan, your healthcare providers will prescribe a blood-thinning medication. This vital medication plays a pivotal role in the prevention of blood clotting within the VAD. To maintain its effectiveness, it is of utmost importance to follow the prescribed dosage. Regular monitoring will ensure that the blood-thinning effect remains within the desired therapeutic range.

The committed healthcare team will provide thorough treatment, instruction, and support during your hospital stay. You can discuss your concerns with the associated caregivers to shorten your hospital stay.

Benefits and risk factors of Ventricular Assist Device Implantation

The benefits of a VAD surgery include improved breathing, organ function, reduced fatigue, and increased energy. However, potential risks and complications associated with VADs include arrhythmias, bleeding, blood clots, infection, device malfunction, right-sided heart failure, and cerebrovascular accidents.

Who are not eligible for VAD?

Not all individuals are eligible for VADs due to factors such as the inability to perform VAD maintenance tasks, intolerance to lifelong blood-thinning medication, or severe co-existing end-organ dysfunction that increases the risks associated with surgery.

Restrictions after surgery

Upon recovering from VAD surgery, individuals must adhere to specific restrictions and responsibilities that come with living with a ventricular assist device:

1. Power source: Continuous connection to a power source, either through batteries or a wall socket, ensures the device functions properly.
2. Blood thinners: Regular intake of prescribed blood thinners is necessary. Ongoing laboratory tests monitor the therapeutic effect of these medications.
3. Water restrictions: To protect the VAD, individuals must avoid activities that may expose the device to moisture. This includes avoiding baths and swimming. Healthcare providers provide guidance on safe showering techniques while ensuring the VAD remains covered.
4. Activity limitations: Engaging in contact activities or those that pose a risk of excessive bleeding in the event of an injury should be avoided. Healthcare teams provide specific instructions on safe activities.

Daily Life Routine with Ventricular Assist Device Implantation

Daily life with a ventricular assist device involves certain responsibilities, including:

1. Medications: In addition to blood thinners, patients may require other cardiovascular medications to control blood pressure and prevent abnormal rhythms. Adhering to the prescribed medication regimen is essential.
2. Heart-healthy lifestyle: Adopting a heart-healthy lifestyle contributes to overall well-being. This includes quitting smoking or tobacco use, following a healthy diet and regular physical exercise.
3. Rehabilitation: Regaining strength takes time after receiving a VAD. Participating in a cardiac rehabilitation program assists in safely transitioning back to daily activities and regaining physical strength and confidence.
4. VAD maintenance: Proper care and maintenance of the VAD are crucial. The medical team usually provides education on performing necessary maintenance tasks and offers assistance for any issues that may arise.

Surviving with a ventricular assist device can also impact mental health, potentially leading to depression and anxiety. Communicating any distressing feelings to healthcare providers ensures appropriate support and resources are provided to cope with these challenges.

Important Check-ups

Following VAD implant surgery, regular follow-up appointments with healthcare providers are necessary. Initially more frequent, these visits decrease in frequency as patients become more independent. These appointments optimise care, monitor for complications, and make necessary adjustments. During these visits, healthcare providers will carry out the steps discussed further.

1. Monitor and manage blood pressure, as it is common for individuals with VADs to develop high blood pressure.
2. Review and adjust medications, especially anticoagulants, to ensure appropriate dosage.
3. Download data from the VAD to assess alarms or function issues.
4. Make adjustments to VAD settings if required.
5. Discuss progress with lifestyle changes and provide guidance and recommendations.

Complications

In the event of potential complications or concerns, individuals should contact their healthcare providers. Complications may include chest pain, coughing up blood, dark-coloured urine, fever or chills, joint pain, redness or tenderness near incisions or the driveline exit, sudden gain in weight, or swelling in the hands or feet. Additionally, any issues with the VAD, such as damage to the controller, driveline, or battery pack or encountering error messages or alarms on the controller, should prompt immediate contact with healthcare providers for assistance.

Ventricular assist devices serve as mechanical pumps that assume the vital role of your heart’s pumping action. They offer a lifeline to individuals whose hearts are unable to meet the necessity of their bodies. Having a VAD can make remarkable improvements to your life, with enhanced survival rates and an overall better quality of life. To optimise these outcomes, it is paramount to prioritise self-care and diligently attend to both you and the maintenance of VAD implantation.