What is a left ventricular assist device (LVAD)?
A left ventricular assist device (VAD -- also called ventricular assist system or VAS) is a type of mechanical circulatory support device (MCSD). It is a mechanical pump that is implanted in patients who have heart failure to help the heart’s weakened left ventricle (major pumping chamber of the heart) pump blood throughout the body.
The LVAD can be used two ways:
- Bridge-to-transplant, which means it can help a patient survive until a donor heart becomes available for transplant. This option may be appropriate for people whose medical therapy has failed and who are hospitalized with end-stage systolic heart failure. As a bridge-to-transplant, the LVAD allows the patient to be discharged to an outpatient setting while waiting for transplant.
- Destination therapy, which is an alternative to heart transplant. Destination therapy provides long-term support in patients who are not candidates for transplant.
The LVAD may provide blood pressure support; maintain or improve other organ function by improving blood flow to the kidneys, liver, brain and other organs; and when used as destination therapy or bridge-to-transplant, improve the patient’s strength and ability to participate in activities such as cardiac rehabilitation; and allow the patient to be discharged from the hospital.
How does the LVAD work?
A LVAD does not replace the heart. The left ventricular assist device (LVAD) receives blood from the left ventricle and delivers it to the aorta. It assists the patient’s own heart to pump blood throughout the body, decreasing the work of the left ventricle.
What are the components of the VAD?
There are a few different types of LVADs available at Cleveland Clinic. The type of VAD selected will depend on each patient’s individual needs and medical condition. The components of the VAD vary, according to the specific device used. In general, the device consists of an implanted pump unit, a controller, and an energy or power supply.
Types of VADs
Reprinted with permission from HeartWare
The HeartWare Ventricular Assist Device is attached to the left ventricle. A tube goes from the device to the aorta (the large artery that takes blood from the heart to the rest of the body. It works by pumping blood by continuous flow from the left ventricle to the aorta.
A cable (also called driveline) then passes from the device through the skin on your abdomen to a controller, a small external computer. The controller runs the pump and provides messages and alarms to help you operate the system.
The controller is powered by one battery and either a second battery, or an AC adapter (plugs into the wall) or a DC adapter (plugs into car). The controller requires two power sources to be connected at all times. One battery will provide 4-5 hours of power. When the battery is low on power, it will need to be replaced. You will have extra batteries and a battery charger.
Heartmate II by Thoratec
Reprinted with permission from Thoratec Corporation.
The Thoratec Heartmate II device is attached to the left ventricle. A tube goes from the device to the aorta (the large artery that takes blood from the heart to the rest of the body). A small motor in the pump drives the rotor (similar to a propeller) that pushes the blood from the left ventricle to the aorta.
A flexible tube then passes from the device through the skin on your abdomen to a small controller outside your body. The controller runs the pump and provides messages and alarms to help you operate the system.
The controller is powered by two batteries or electricity from a wall outlet.
Who is eligible to receive a LVAD?
A LVAD is a treatment option for certain patients with end-stage heart failure. Your doctor will determine if a VAD is an appropriate treatment for you, based on your
medical condition, symptoms, age, body size and presence of other medical conditions.
A LVAD may not be the appropriate treatment choice for some patients who have blood clotting disorders, irreversible kidney failure, severe liver disease, severe lung
disease, or infections that cannot be treated with antibiotics.
What are the risks of the LVAD implantation procedure?
As with any surgical procedure, there are risks to the VAD implantation procedure. Your doctor will talk with you about the specific risks and potential benefits of this
procedure. Some of the possible risks include bleeding, development of blood clots, respiratory failure, kidney failure, stroke, infection and device failure. Special
precautions are taken to decrease these risks.
There may be other possible risks. When you meet with your doctor, please ask questions to make sure you understand why the procedure is recommended and the potential
risks of the procedure.
VAD: Bridge to Transplant
In 2008, the FDA approved the Thoratec Heartmate II device for patients awaiting heart transplant. The Heartware device received approval for bridge to transplantation in 2012.
Since that time, we have found that patients who have mechanical circulatory support while waiting transplant, have good outcomes. The VAD assists the heart and allows the patient to have better quality of life and fewer symptoms while waiting for heart transplant.
The amount of time you receive support from a VAD until heart transplantation varies and depends on your medical condition, blood type, and body size.
VAD: Destination Therapy
In 2010, the FDA approved the Thoratec Heartmate II device for patients as destination therapy for patients with heart failure who were not candidates for heart transplant surgery. It is considered only for patients when all other treatment options, such as medications, lifestyle changes and heart procedures, have been tried and not effectively managed heart failure.
The goal of destination therapy is to support the patient’s heart function and improve quality of life for the rest of the patient’s life.
Your doctor will determine if destination therapy is an appropriate treatment option for you, based on your medical condition, symptoms, body size and presence of other medical conditions.
Destination therapy may not be the appropriate treatment choice for some patients who have blood clotting disorders, irreversible kidney failure, severe liver disease, severe lung disease, or infections that cannot be treated with antibiotics.
Multidisciplinary Team of Experts
To determine if an LVAD is the best treatment for you, patients are evaluated by a team from the Kaufman Center for Heart Failure. In addition, your team cares for you after you get your LVAD in the hospital as well as after you leave the hospital for outpatient appointments.
The team consists of
- Heart failure cardiologists
- Cardiac surgeons
- Nurse practitioners and physician assistants
- Social workers
- Palliative Medicine specialists
- Cardiac Rehabilitation
- And other team members as needed; for example, you may need to see a lung specialist or kidney doctor if these organs have been affected by your illness
Tests may include routine blood work, chest X-ray, electrocardiogram (EKG), echocardiogram, left and right heart catheterization or other tests. These tests may be ordered by your heart failure cardiologist or by the surgeon. Some of these tests may have been performed before and will only be repeated if they were not recently performed (within the last 6 to 12 months, depending on the type of test).
Bioethicist, Palliative Care and Social Worker Evaluation:
As part of your medical evaluation, you will meet with a bioethicist, palliative care specialist and a social worker. These professionals will talk with you and ask you questions to make sure you understand how destination therapy will affect your long-term health care decisions.
The bioethicist will meet with you to assess your understanding of device placement with associated risks, benefits and alternatives. They will discuss your thoughts about advance directives (see below) , if you have one or if you want to make any changes.
The Palliative Care specialist will meet with you to assess your needs regarding symptom management and discuss your goals of care related to the LVAD. They will discuss advance care planning as well. This may be an initial evaluation and they will be available to assist as needed following device placement if this is what is recommended.
The social worker uses counseling skills and community resources to help you and your family during the evaluation, surgery and recovery.
The social worker will assess your strengths, coping resources, and areas of concern regarding your ability to undergo the LVAD implant procedure. The social worker will conduct an evaluation to make sure the necessary resources are available for you during your recovery. He or she will also meet with your family and caregivers to provide support and resources, including information about housing and other community resources.
We encourage you to create advance directives to let your doctor and others know your wishes concerning medical treatment in the event that you become unable to communicate your wishes.
If you already have advance directives, please review these documents to make sure that they still reflect your preferences if you are e a candidate for LVAD therapy.
Under Ohio law, there are two advance directives forms you can use to make your wishes known:
- Durable power of attorney: This form allows you to appoint someone as your agent to make all health care decisions for you, should you become terminally ill and unable to communicate, or if you become permanently unable to make decisions for yourself. You may want to choose an alternate agent, in case the primary agent is unable to assist.
- Living will: This form allows you to give advance written directions about all of your health care decisions if you become terminally ill and unable to communicate, or if you are in a permanently unconscious state.
The ventricular assist device’s power supply allows it to continue pumping without regard to your medical status. There may come a time when your medical condition or quality of life warrant that the device be turned off, and a living will can communicate your preferences to your health care providers.
Please share information about your advance directives with your surgical team.
How long can I be supported with an LVAD?
Although implantation of a left ventricular assist device as destination therapy is considered permanent therapy, it is not considered a curative procedure for your heart problem.
One device and its components will not last you a lifetime. If it is not possible to repair your device, replacement may be necessary. Cleveland Clinic has some patients who have been living with the same LVAD for more than five years.
Are there other support devices: RVAD, BIVAD, TAH
There are other devices available for use. These are terms that you may hear from your doctor:
- Left ventricular assist device (LVAD): supports the left ventricle
- Right ventricular assist device (RVAD) supports the right ventricle. A right ventricular assist device (RVAD) receives blood from either the right atrium or right ventricle and delivers it to the pulmonary artery
- Biventricular assist device (BiVAD): supports both ventricles
RVAD and BiVAD devices are used in rare instances for those patients who require right side support only or they are in need of support for both the right and left side. In this situation, the patient would need to be a transplant candidate.
For patients who fit criteria and are in need of biventricular support, a total artificial heart (TAH) may be an option.
How will I know how to care for my LVAD?
To enhance quality of life, all patients with a LVAD must carefully follow the guidelines provided by their health care team.
After the implantation procedure, a detailed education program is provided to you and your caregivers to ensure safety and proper use of the device. You’ll learn how to manage the device and trouble-shoot potential emergency situations. You’ll be required to demonstrate your knowledge about the device before you are discharged from the hospital. You’ll also need to demonstrate independence with self-care activities before you are discharged.
In addition, you’ll be given guidelines about your activities, including swimming, showering, bathing and resuming sexual activity; medications, diet, and when to call the doctor.
At home, you’ll need to have an accurate scale as well as a thermometer. Some patients will need to monitor their blood pressure at home. Your nurse will provide specific guidelines. You will receive information about how to reach the health care team when necessary. A medical team member is always available to answer your questions, 24 hours a day.
Can I go home after receiving the LVAD?
Yes. When you are able to go home will depend on your rate of recovery and your medical condition. Our goal is to help you go home as soon as possible. Some patients may need to stay in an intermediate care facility or rehabilitation center for a while until you are strong enough to go home. Your health care team will help you with this process. If you think you will require care at home, talk to your health care team. Our Center for Connected Care can assist with local service as well as nationwide.
If you live more than two hours away from Cleveland Clinic, you will need to stay in the local area for two weeks before you go home.
The risks of LVAD therapy on a woman’s fetus are unknown, but device implantation can potentially burden the abdominal area due to the size and position of the device. Therefore, it is very important that women of child-bearing potential use two forms of contraception (birth control) simultaneously for the duration of LVAD therapy, unless absolute abstinence is the chosen method.
You must use at least one primary contraceptive method, plus a secondary method. Primary forms of contraception include your partner’s vasectomy, intrauterine devices, birth control pills, and topical/injectable/implantable/insertable hormone birth control products. Secondary forms of contraception include diaphragms, latex condoms, and cervical caps, each used with a spermicide.
Please be advised that contraceptive techniques, other than absolute abstinence, may not be 100 percent successful in preventing pregnancy. Please talk with your gynecologist about the forms of birth control that are right for you.
It’s very important to continue making healthy lifestyle changes before and after the LVAD implant procedure, including:
- Stop using tobacco – your health care provider can refer you to a smoking cessation specialist if you need help.
- Follow your recommended nutrition guidelines – a dietitian will provide you with details.
- Stop drinking alcohol.
- Don’t use illegal drugs.
- Exercise regularly – Cardiac rehabilitation is an important program to take part in after surgery. You may have some restrictions such as swimming, contact sports and weight lifting.
If you need help making lifestyle changes, talk to your health care providers to assist with strategies or refer you to other resources.
The Cleveland Clinic Experience
For more than two decades, surgeons in the Kaufman Center for Heart Failure at Cleveland Clinic have successfully utilized ventricular assist devices (VADs) as a bridge- to-transplant for patients awaiting heart transplantation. Cleveland Clinic has one of the most experienced VAD programs in the United States. The Cleveland Clinic has access to FDA- approved ventricular assist devices, as well as new investigational devices.
The Kaufman Center is approved by the Centers for Medicare and Medicaid Services and the FDA to offer destination therapy.
Cleveland Clinic is an approved site for disease- specific care for ventricular assist devices as of December 29, 2008.
Research and Study Participation
A clinical trial, also called a research study, tests the value and safety of various interventions. Clinical trials are meant to find new and improved methods of evaluating or treating a condition or it can test a new way to prevent diseases. Such trials can involve risks, and there is no guarantee regarding a trial’s outcomes.
Cleveland Clinic is evaluating different ventricular assist devices. You may be asked to participate in a research study, but clinical trial participation is not required. If you meet the criteria for participation in our current research, more information will be provided about the specific trials, so you can make an informed decision about whether or not you would like to participate.
Important: If you do not want to participate in a clinical trial, your treatment and overall course of care will not be affected.
- For more information about clinical trials, visit the Clinical Trials website sponsored by the National Institutes of Health at www.clinicaltrials.gov.
If you need more information or would like to make an appointment with a specialist, contact us, chat online with a nurse or call the Miller Family Heart and Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
Lee S, Fukamachi K, Golding L, Moazami N, Starling RC, Left Ventricular Assist Devices: From the Bench to the Clinic, Cardiology 2013;125:1-12 , http://www.karger.com/Article/FullText/346865. Accessed 7/29/2014
Kirklin, JK, Naftel DC, Kormos RL, Stevenson LW, Pagani FD, Miller, MA, Ulisney, KL, Baldwin JT, Young, JB. Third INTERMACS Annual Report: The evolution of destination therapy in the United States, The Journal of Heart and Lung Transplantation. Volume 30, Issue 2 , Pages 115-123, February 2011. http://www.jhltonline.org/article/S1053-2498(10)00754-0/abstract. Accessed 7/29/2014