# Electrical activity with LVAD



## NPO (Sep 28, 2015)

Do patients with LVAD devices have any abnormal (specific to LVAD) ECG changes? Does anyone have any examples?


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## NTXFF (Sep 28, 2015)

We've got a guy in our district with one.  I've got some 12 leads I'll snag from the station and scan in.  I remember low limb lead voltage and a ventricular abnormality.  We have to to an EKG on him every 2 months and keep them on file so that we can see any subtle changes that may appear if we are called to his house.


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## jwk (Sep 28, 2015)

NTXFF said:


> We've got a guy in our district with one.  I've got some 12 leads I'll snag from the station and scan in.  I remember low limb lead voltage and a ventricular abnormality.  We have to to an EKG on him every 2 months and keep them on file so that we can see any subtle changes that may appear if we are called to his house.


I have no experience with LVAD's and I'm kinda playing devil's advocate here, but who pays for an EMS EKG every two months?  I'd be pretty surprised if that's covered by insurance.


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## NPO (Sep 28, 2015)

NTXFF said:


> We've got a guy in our district with one.  I've got some 12 leads I'll snag from the station and scan in.  I remember low limb lead voltage and a ventricular abnormality.  We have to to an EKG on him every 2 months and keep them on file so that we can see any subtle changes that may appear if we are called to his house.


Out of curiosity, do you guys have specific resuscitation information on file for this patient? I'm told sometimes LVAD manufacturers send instructions to medical agencies in areas their patients live.


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## TransportJockey (Sep 28, 2015)

I flew an LVAD patient once with absolutely no electical activity. It can vary upon the patient.


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## NTXFF (Sep 28, 2015)

jwk said:


> I have no experience with LVAD's and I'm kinda playing devil's advocate here, but who pays for an EMS EKG every two months?  I'd be pretty surprised if that's covered by insurance.


He doesn't pay for it.  We keep it on file that way we're not behind the 8 ball.  If he has a follow up appointment he brings us a copy from his doctor as well.


NPO said:


> Out of curiosity, do you guys have specific resuscitation information on file for this patient? I'm told sometimes LVAD manufacturers send instructions to medical agencies in areas their patients live.


Yes we do. When he got it the manufacturer sent a DVD with specific resuscitation guidelines as well as treatment guidelines.  None of us had any experience with them so we used it as a learning experience and did a bunch of research in addition to the manufacturer literature.


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## TransportJockey (Sep 28, 2015)

NPO said:


> Out of curiosity, do you guys have specific resuscitation information on file for this patient? I'm told sometimes LVAD manufacturers send instructions to medical agencies in areas their patients live.


In some areas that's true. When I worked in Pecos TX, the first time, we had a rep come down to give us an inservice because we just had a guy move to town with one.


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## NPO (Sep 28, 2015)

NTXFF said:


> He doesn't pay for it.  We keep it on file that way we're not behind the 8 ball.  If he has a follow up appointment he brings us a copy from his doctor as well.
> 
> Yes we do. When he got it the manufacturer sent a DVD with specific resuscitation guidelines as well as treatment guidelines.  None of us had any experience with them so we used it as a learning experience and did a bunch of research in addition to the manufacturer literature.


You guys seem to have a great working relationship with this patient (and presumably the rest of the community). Glad to see the system working.

Just curious because I had a section on LVAD today and we noted a contraindication was CPR. Which makes sense but did start a train of thought and questions.


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## NTXFF (Sep 28, 2015)

NPO said:


> You guys seem to have a great working relationship with this patient (and presumably the rest of the community). Glad to see the system working.
> 
> Just curious because I had a section on LVAD today and we noted a contraindication was CPR. Which makes sense but did start a train of thought and questions.


We try.  We don't have a community paramedic but with two stations and building our third we're able to reach out a bit more than some systems.  We only cover 40,000 people so once that goes up hopefully we can continue doing what we're doing. I'll get those strips and a copy of the manufactures suggestions and try and get them on here soon.  I'm back on shift Thursday.


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## NPO (Sep 28, 2015)

NTXFF said:


> We try.  We don't have a community paramedic but with two stations and building our third we're able to reach out a bit more than some systems.  We only cover 40,000 people so once that goes up hopefully we can continue doing what we're doing. I'll get those strips and a copy of the manufactures suggestions and try and get them on here soon.  I'm back on shift Thursday.


Much appreciated.


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## Nova1300 (Sep 28, 2015)

VADs are generally implanted to increase cardiac output in the face of a failing heart, typically due to some form of cardiomyopathy, be it ischemic, viral, etc. Many of these patients will come to surgery with existing EKG abnormalities from these underlying diseases.  

Though the EKG is bound to experience some minute changes from the mechanical effects of implantation, overall it will remain relatively unchanged from their pre-op rhythm

 Its nice when VAD patients have a coordinated rhythm as this keeps the left ventricle relatively full of blood to suck through the VAD.  VAD flows can drop when the LV is underfilled. 

These patients can develop arrhythmias like any other patient with heart disease.  And just like those patients, the underlying arrhythmia is treated medically, despite the fact that they may show no symptoms due to their VAD support.  


But, no specific EKG changes induced by actual VAD placement in my own experience.


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## zzyzx (Oct 1, 2015)

TransportJockey said:


> I flew an LVAD patient once with absolutely no electical activity. It can vary upon the patient.


 
That is not possible. The LVAD is simply an assist device.
The most important thing to understand about LVAD's is that the patient will be very knowledgeable about their device. These patients are all required to learn about their device. LVAD's are a big deal and the program is very expensive, so these patients don't just get sent home without careful instruction.


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## Aprz (Oct 1, 2015)

I have zero experience with LVADs. I've never transported a patient with one. I don't know how they work. I remember Alameda County, CA releasing a nice cheat sheet on different LVADs. Not sure if it is still up to to date with the latest LVADs.

http://www.acphd.org/media/373942/vad ems field guide.pdf

@zzyzx I have also been told that patients can be awake even though they have a rhythm that's non viable for life like ventricular fibrillation if they have an LVAD. Is this one of those myths like not performing spinal immobilization on a trauma patient and then they end up paralyzed by turning their head the wrong way?

Edit: Online searches seem to be showing that it is possible for the patient to be awake even if they have a rhythm that's non viable for life if they have an LVAD.

http://www.ncbi.nlm.nih.gov/pubmed/20674087


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## Nova1300 (Oct 1, 2015)

You are very unlikely to see an asystolic LVAD in the community.  These patients are almost always going to be in an ICU setting.  However, patients can in fact be asystolic and conscious with VAD support.  I actually have a patient in the ICU right now who has been on a BiVAD for months awaiting a heart transplant.  And while he occasionally has a rhythm, he also goes asystolic at times and tolerates it just fine.  

Many of these patients are well-acclimated to their low cardiac output.  And the extra few liters of output provided by the VAD can be enough to sustain vital organ perfusion, even in the face of near zero cardiac output.


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## TransportJockey (Oct 1, 2015)

zzyzx said:


> That is not possible. The LVAD is simply an assist device.
> The most important thing to understand about LVAD's is that the patient will be very knowledgeable about their device. These patients are all required to learn about their device. LVAD's are a big deal and the program is very expensive, so these patients don't just get sent home without careful instruction.


With all due respect, you're wrong. We were doing an ICU to implantation center ICU transfer. Did you notice where I said I flew this patient? He had had his LVAD for many years, as they determined that a heart transplant would not happen. He had had it so long that the heart had bascially given up on pumping on it's own at all. 
Patient's in non-viable rhythms can and do function with a VAD.


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## NTXFF (Oct 1, 2015)

I've slacked.  I haven't seen the station since this morning.  I'm actually tying this from the Medic lol.  I'll try my best to get those strips up.


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## zzyzx (Oct 1, 2015)

"Patient's in non-viable rhythms can and do function with a VAD."

Ok, my mistake. It should be made clear though that this is exceptional, and that essentially these patients are dying. These are not the patients that paramedics will typically see.

Providers unfamiliar with LVAD's may confuse them with total artificial hearts, which they are not. Also, providers should not confuse the fact that some LVAD patients will have a palpable pulse and BP, and some will not, with lack of electrical activity.

Healthcare providers who have never seen an LVAD patient may get nervous around one, but as I've said, the best thing to understand is that the patient can tell you all about how to care for his/her equipment, such as how to connect and disconnect from the power supply, what they need to take to the hospital, etc.


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## DesertMedic66 (Oct 1, 2015)

If there is a Healthcare aid with the patient we are not to separate them at any times due to them being trained in LVADs. We are also instructed to call the LVAD office and get direct input on treatment options to do for the patient. 

We still follow all ACLS guidelines for heart rhythms (defib, cardioversion, pacing) the only thing we can not do is compressions on the patient.


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## chaz90 (Oct 1, 2015)

DesertMedic66 said:


> We still follow all ACLS guidelines for heart rhythms (defib, cardioversion, pacing) the only thing we can not do is compressions on the patient.


Interesting. We recently had a con ed session with reps from LVAD manufacturers and implantation centers. We were advised that chest compressions were perfectly acceptable, particularly as the alternative consequence is pretty dire.


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## TransportJockey (Oct 1, 2015)

chaz90 said:


> Interesting. We recently had a con ed session with reps from LVAD manufacturers and implantation centers. We were advised that chest compressions were perfectly acceptable, particularly as the alternative consequence is pretty dire.


That's what I've always been told. If the LVAD is NOT running CPR is ok. The problem with CPR is it can potentially tear the connection between the LVAD and the heart itself. Or damage the device somehow


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## zzyzx (Oct 1, 2015)

The recommendation used to be not to do CPR with LVAD's, but just this year the recommendation has changed and I'm told we should do CPR. This is coming from an LVAD program director at my hospital job. I did not get a chance to ask her why the change.  Follow your own protocols if you have one related to LVAD's. 
Realistically though, if someone with a VAD is in arrest, they are dead.


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## chaz90 (Oct 1, 2015)

The latest review I read on CPR in pulseless LVAD patients only had 8 patients enrolled, but reported return of neurological function in 4 of them. The device was not dislodged in any of the 8 cases. It does beg the question of how "arrested" each patient was though as that can be so difficult to assess in this population.


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## zzyzx (Oct 2, 2015)

Do you have a link? Thanks


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## Aprz (Oct 2, 2015)

If you guys check out my earlier post, I put a link from Alameda County, CA on the different types of LVADs. Some of them are OK to CPR on and some of them are not. I believe not all areas are gonna have all different types of LVAD, but maybe one or two types. There are also not that many LVAD patients either. So I imagine the hospital or agency knows how many LVAD patients there are (a handful?), who they are, and what type of LVAD they are. In your guys area, they probably have LVADs that are safe to do CPR on.

That would be my guess as to why they changed their recommendation.

http://emtlife.com/threads/electrical-activity-with-lvad.42378/#post-590780


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## chaz90 (Oct 2, 2015)

zzyzx said:


> Do you have a link? Thanks


http://www.resuscitationjournal.com/article/S0300-9572(14)00017-3/abstract


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## zzyzx (Oct 2, 2015)

That's an interesting study. I do wonder what the details of the four successful resuscitations were.


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## Seirende (Oct 4, 2015)

I had originally heard that LVADs came with hand pumps that you could use instead of chest compressions; EMCrit just told me that newer ones don't. Anyone know what the benefit of a design sans hand pump would be? Intuitively, seems like a good backup to have.


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## EMT11KDL (Oct 8, 2015)

interesting podcast speaking about LVAD 
http://emcrit.org/wee/left-ventricular-assist-devices-lvads-2/


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## evantheEMT (Oct 24, 2015)

Can't get a palpable bp or pulse. It's important to be careful of the wire that's coming out of the pt as well.


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## zzyzx (Oct 24, 2015)

evantheEMT said:


> Can't get a palpable bp or pulse. It's important to be careful of the wire that's coming out of the pt as well.



Unless it's a total artificial heart, in which case, since it's pulsatile, you will get both a BP and a pulse. However, you won't have any electrical activity since the heart has been removed (except for part of the atria). Artificial hearts are bridge devices like LVAD's, and they are becoming more common for people with heart failure waiting for a heart transplant to become available.


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## evantheEMT (Oct 24, 2015)

zzyzx said:


> Unless it's a total artificial heart, in which case, since it's pulsatile, you will get both a BP and a pulse. However, you won't have any electrical activity since the heart has been removed (except for part of the atria). Artificial hearts are bridge devices like LVAD's, and they are becoming more common for people with heart failure waiting for a heart transplant to become available.


True, but every pt is different and we may not be able to feel a pulse. Ems providers have to listen for the humming or feel for it. I've never actually had a pt with one yet but it would be interesting to do an assessment on them.


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## zzyzx (Oct 24, 2015)

LVAD: often no palpable pulse.  If you get a BP, my understanding is that it will not be accurate. ECG normal as for patient. Quiet operation, but you can auscultate the hum of the implanted pump. Defib and ALS meds ok. Most will recommend no CPR, but check local protocols. 

Total artificial heart: palpable pulse and BP, but no electrical activity; no ECG. Very loud galloping sound from external pump; you will hear it before you walk into their room. No CPR, no defib or ECG possible.


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## evantheEMT (Oct 24, 2015)

zzyzx said:


> LVAD: often no palpable pulse.  If you get a BP, my understanding is that it will not be accurate. ECG normal as for patient. Quiet operation, but you can auscultate the hum of the implanted pump. Defib and ALS meds ok. Most will recommend no CPR, but check local protocols.
> 
> Total artificial heart: palpable pulse and BP, but no electrical activity; no ECG. Very loud galloping sound from external pump; you will hear it before you walk into their room. No CPR, no defib or ECG possible.


Thank you sir


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## Bullets (Oct 28, 2015)

We had a LVAD patient in town for a few months while he was waiting for a heart transplant. The facility that did the implantation and eventual transplant came down and ran multiple educational sessions for all our EMS and PD so we would be familiar with him, his condition and best treatment. At that time we were told no compression due to the concern for tearing out the connections. He has since received his transplant and is living well, so if there has been a change in the "No Compressions" rule then thats interesting. During his time with the LVAD he began having some chest pain and we called the director and decided to fly him to the home hospital. It was notable because we have a Level II hospital in town, so its the only outgoing medevac in the towns history. 

It was a great example of the system, from heart transplant surgeon all the way down to street EMT working together for the best outcome of a patient. I really enjoyed the whole process


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