AN INTERESTING CASE…Karen Neoh

Case History• 68 year old man with ischaemic cardiomyopathy• Left ventricular assist device (LVAD) inserted July 2012• Recurrent GI bleeds exacerbated by anti coagulation• Admitted to Royal Freeman (Newcastle) with 2nd pump

thrombus

• Admitted to hospice Friday, I was on call Saturday/Sunday

Overview• Left ventricular assist device (LVAD)• Case history• Ethical issues• Practical issues

LVAD• Left ventricular assist devices are implanted in patients with

severe heart failure• May be temporary, while patient awaits a heart transplant• Can be a lifesaving procedure in themselves, some patients are

not fit enough to go on to have transplant or die before

LVAD• Mechanical pump which contracts and circulates blood around

the body, essentially taking over the job of the left ventricle • LVAD is surgically implanted just below the heart. Attached to

the left ventricle and aorta. • Blood flows from the ventricles into the pump which passively

fills. When the sensors indicate it is full, the blood is ejected out of the device • A tube (the driveline) passes from the device through the skin

and connects the pump to the external controller and power source

www.nhlbi.nih.gov/health/health-topics/topics/vad/

Facts• Approximately 100 people in the UK currently living with an

LVAD • Number of heart transplants performed in the UK in 2011/12

138• Approximately 80 people have an LVAD implanted each year in

the UK

Potential complicationsEarly complications Late complications

Perioperative haemorrhage

Right ventricular failure (worsened by improvement in left ventricle).

Bulkier pulsatile devices inserted into the abdomen can lead to gastrointestinal (GI) obstruction, fistula and adhesions

Infection

Thromboembolism

Haemolysis

Device failure

Bleeding complications due to anti coagulation

2013 admission to Royal Freeman• August 2013 had a pump thrombus which was treated with IV

heparin and antiplatelet therapy • This dissolved the thrombus but during this stay he

experienced a GI bleed• CT scan of his abdomen was normal• The GI bleed had ceased when his anticoagulation had been

reduced once the thrombus had cleared

History prior to transfer• Admitted to cardiology centre after patient noted high watt

value• Diagnosed with second pump thrombus• Commended IV heparin and increased doses of antiplatelet

therapy.• Developed haematemesis and malaena – has happened before • Given blood transfusions and due to on-going bleeding issues it

was not possible to fully anticoagulate him• Invasive attempt via cardiac catheter was made to remove the

thrombus but this was also unsuccessful

Why transfer to the hospice? • After discussion with the patient and his family (and the

hospice) it was decided to transfer the patient to a hospice closer to home as his prognosis was felt to be very poor • The cardiology team expected that over time the wattage

would rise and the pump would eventually fail (less than a week)• Patient reliant on the device for his cardiac output, will die

when the pump started to reach it’s maximum power

Medications on admission • Tinzaparin 12000 units then warfarin• Aspirin 150mg bd• Bisoprolol 1.25mg od• Frusemide 40mg od• Lisinopril 2.5mg od• Omeprazole 40mg bd• Paracetemaol• Prasugrel 10mgod

• Admitted 21/2/14 for terminal care • The LVAD nurse, who had known him for 18 months, came to

our centre to deliver training on the device• Symptoms dyspnoea, poor appetite, poor sleep• Nose bleeds• Haematuria

Issues

• Level of knowledge and objective indication that the patient had of his own deterioration.• Patient fully aware of the implications of rising watt value • Told expected death in less than a week• The hospice had to monitor the device readings in order to

assess the patient and allow preparation to be made by the patient, staff and family for any events• Maximum value the pump could work to was 25 watts. We

were informed by the cardiologists that once the value started to get up towards 25; time ahead would be very short

Day 2 watt 11.1

• The staff became aware of the negative impact that checking the watt value might have on the patient• He/We watching the value rise!• Reviewed the initial procedure we had in place which was

checking the device several times a day• It is possible to check the value without the patient seeing the

reading• Patients’ family also wished to know the value and he stated he

did not mind knowing the readings

Practical issues for staff• The device has an alarm which sounds when there is a power

or technical failure or if the pump stops• The pump can stop due to a mechanical failure or if a patient

dies. We were told this alarm is similar to a fire alarm as it needs to alert people quickly and effectively• Team discussed turning the alarm of pre-emptively (while

leaving the pump on) but it was decided that as we would not know if there was a power failure we should leave the alarm on. • Alarm would require turning off after/around death to maintain

patient dignity

• Turning the device off. In the event that the patient became unconscious would we then turn the pump off to allow his death?

• Day 3 watt 13

•Day 9 watt 5.4• Spontaneously the watt value began to decrease and returned

to a value of around 3. It is unknown why this happened but it is assumed that the thrombus cleared (we did not refer for any investigations as there would have been no change in management).

• The patient continues on warfarin (tinzaparin if INR <2)• On-going GI bleeding with haematemesis and maelena• Ongoing blood transfusions• Difficult to discharge patient due to uncertainty of the future • Possible long prognosis• The patient wrote an advance directive, documenting

circumstances in which he would want the device turning off and who was to assess him prior to this (2 doctors).

Advance directive• More challenging than usual advance directive• Turn off device if irreversible cause of • Unconscious• Confused

• Can we be 100% certain?• Or dying• Turning device off would definitely hasten death (has had

turned off before and became peri arrest) so this needs to be in advance directive ‘even if shortens life’

Hospice admission• Long admission• Medical problems e.g. chest infection and GI bleeding• Supportive with blood transfusions• Mostly well symptom controlled• Family very anxious about discharge

Conclusion

• LVAD can be life saving• Ethical and practical issues for staff, patient and family.• ? Some similarities can be drawn between LVAD and renal

dialysis

Update• Deteriorated this week• Ongoing GI bleed, hb 60, LFT’s/renal function also worse

• Chris....?

References

• 1. Birks, EJ. Left ventricular assist devices Heart 2010;96:63-71 • • 2. Left Ventricular Assist Device (LVAD) for Heart Failure

accessed online 21/4/14• http://www.medicinenet.com/left_ventricular_assist_device_lv

ad/article.htm• 3. British heart foundation: Focus on: Left ventricular assist

devices. accessed online 21/4/14 http://www.bhf.org.uk/heart-matters-online/march-april-2013/medical/lvads.aspx• 4. National heart, lung and blood institute.

http://www.nhlbi.nih.gov/health/health-topics/topics/vad/ accessed online 3/5/14