ACLS and Chest Compressions in Patients with Durable LVADs

Abstract

Introduction Durable left ventricular assist devices (LVADs) are increasingly used to improve longevity in patients with advanced heart failure; however, optimal management of end-of-life issues including cardiopulmonary arrest remains uncertain for this relatively new population. We aim to assess the safety and efficacy of Advanced Cardiovascular Life Support (ALCS) including chest compressions in patients with LVADs. Methods We performed a retrospective chart review of all LVAD patients that received ACLS and chest compressions for in-hospital cardiopulmonary arrest at a single academic medical center between 2011 and 2017. We evaluated post-arrest survival, LVAD parameters/function, imaging studies, and autopsy results to assess for (1) structural issues such as LVAD dislodgment, aortic dissection/rupture, or pericardial effusion, and (2) LVAD mechanical issues such as hardware or software failure. Results Durable LVADs were implanted in 191 patients during the study period, of which 18 patients (9%) suffered in-hospital cardiopulmonary arrest necessitating ACLS (median of 22.5 days, range from 1 to 1323 days from implant). Of the patients requiring ACLS 11 (61%) survived the arrest with 7 (39%) surviving to hospital discharge. Ten patients (56%) received manual external chest compressions, and 7 (39%) received defibrillator shocks. Of the patients who received chest compressions and/or defibrillator shocks, no significant changes to LVAD parameters/function was noted after the arrest. Five autopsies were completed, all of which reported the LVAD in its proper position without evidence structural or mechanical LVAD complications. Two of the surviving patients were taken emergently to the operating room for treatment of cardiac tamponade; during the procedure the LVAD anastomoses were inspected, and no bleeding was noted in either case. Two echocardiograms were performed following chest compressions without evidence of LVAD dysfunction. There were no iatrogenic sequelae identified in any of the patients following ACLS. Conclusion While cardiopulmonary arrest in patients with LVADs is associated with high mortality, ACLS with chest compressions appears to be safe. Larger studies are warranted to identify patterns of post ALCS complications and define potential population-specific management.