How to Perform CPR on a Patient with Ventricular Assist Device: Guide

Performing CPR on any individual experiencing cardiac arrest is a critical skill, but when the patient has a Ventricular Assist Device (VAD), the approach must be carefully tailored to ensure both the patient's and the device's safety. Ventricular Assist Devices are increasingly common in patients with severe heart failure, underscoring the importance of understanding how to perform CPR effectively in these situations.

What are Ventricular Assist Devices?

Ventricular Assist Devices (VADs) are mechanical pumps designed to support the functioning of a weakened heart. They are surgically implanted in patients with severe heart failure to help the heart pump blood more effectively throughout the body. Depending on the patient's condition and medical needs, these devices serve as either a temporary or long-term treatment option.

There are different types of VADs, but they generally work by assisting one or both of the heart's ventricles—the lower chambers responsible for pumping blood. Some VADs support the left ventricle (LVAD), while others support the left and right ventricles (BiVAD). VADs are commonly used in the following scenarios:

• Bridge to Transplant (BTT): Patients awaiting heart transplantation receive a VAD to support their heart function while they wait for a suitable donor organ.
• Destination Therapy: In cases where heart transplantation is not feasible or desired, VADs serve as long-term therapy to improve the patient's quality of life and prolong survival.
• Bridge to Recovery: Occasionally, patients with reversible heart failure receive a VAD temporarily to support their heart function while undergoing treatment to allow the heart to recover.

VADs improve the quality of life for patients with advanced heart failure by relieving symptoms such as shortness of breath, fatigue, and fluid retention. They prolong survival and serve as a lifesaving intervention for those who are critically ill.

Standard Procedure of CPR Overview

Cardiopulmonary Resuscitation (CPR) is a critical intervention in cardiac emergencies. It aims to restore blood flow and oxygenation to vital organs. The procedure involves a combination of chest compressions and rescue breaths, effectively mimicking the heart's pumping action and supplying oxygen to the lungs.

CPR typically begins with assessing the victim's responsiveness and breathing. If the person is unresponsive and not breathing normally, CPR should be initiated immediately.

1. The rescuer begins by placing the heel of one hand on the center of the victim's chest, between the nipples, and then places the other hand on top.
2. With straight arms and shoulders directly over the hands, the rescuer delivers compressions at a rate of about 100 to 120 per minute, aiming for a depth of at least 2 inches (5 centimeters) to 2.4 inches (6 centimeters) in adults.
3. After 30 compressions, the rescuer provides two rescue breaths, tilting the victim's head back slightly, lifting the chin, and pinching the nose shut while covering the victim's mouth with their own. Each breath should be delivered over about one second, just enough to make the chest rise visibly.
4. Compressions and breaths are then continued in a cycle, maintaining a ratio of 30 compressions to 2 breaths until the victim shows signs of life or until emergency medical services arrive.

Identifying a VAD Patient

In Cardiopulmonary Resuscitation, it is crucial to identify whether the victim has a Ventricular Assist Device (VAD) before initiating chest compressions. Recognizing a patient with a VAD is achieved through various means, including visual cues and patient history. External signs such as a surgical scar over the heart or an external driveline exiting the body are indicative of a VAD. Additionally, patients with VADs carry medical alert cards or wear bracelets indicating the device's presence. Prompt identification of a VAD patient allows responders to adapt CPR techniques to avoid potential complications.

Modifications to CPR for VAD Patients

Performing CPR on a patient with a VAD necessitates specific modifications to standard techniques to ensure both the patient's safety and the integrity of the device.

• When initiating chest compressions, the rescuer should slightly position their hands to the left or right of the device to avoid direct pressure.
• Adjusting the depth and force of compressions is crucial to maintaining circulation without dislodging the device.
• When delivering rescue breaths, the rescuer must exercise caution not to exert excessive pressure that could damage the device or dislodge its components.

These modifications help optimize the effectiveness of CPR while minimizing the risk of harm to the patient with a VAD.

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How to Perform CPR on a Patient with a VAD?

Here's a comprehensive guide and do's on how to perform CPR on a patient with a VAD:

1. Assess the Situation: Before initiating CPR, assess the patient's responsiveness and breathing. If the patient is unresponsive and not breathing normally, CPR should be started immediately.
2. Identify the Presence of a VAD: Look for external signs that indicate the presence of a VAD, such as a surgical scar over the heart or an external driveline exiting the body. Patients with VADs also carry medical alert cards or wear bracelets indicating the device's presence. Promptly identifying a VAD patient ensures appropriate modifications to CPR techniques are made.
3. Call for Help: Instruct someone to call emergency medical services (EMS) immediately if available. Time is crucial in cardiac emergencies, and professional medical assistance is necessary.
4. Positioning: Position the patient on a flat, firm surface, preferably on their back. Ensure there are no obstacles around the patient that could interfere with CPR.
5. Modify Hand Placement for Compressions: When performing chest compressions, avoid placing pressure directly over the area where the VAD is implanted. Instead, position your hands slightly to the left or right of the device. This helps prevent damage to the device while maintaining effective circulation.
6. Adjust Compression Depth and Rate: In adults, compressions should be performed at a depth of at least 2 inches (5 centimeters), with a rate of about 100 to 120 compressions per minute. Ensure that each compression allows for full chest recoil to maximize blood flow.
7. Deliver Rescue Breaths with Caution: If you are trained and comfortable providing rescue breaths, deliver them after every 30 compressions. Tilting the patient's head back slightly, lift the chin, and pinch the nose shut while covering the patient's mouth with yours. Be cautious not to exert excessive pressure that could damage the VAD or dislodge its components.
8. Continue CPR Until Help Arrives: Maintain the cycle of 30 compressions to 2 breaths until the patient shows signs of life or until EMS personnel take over. Regularly reassess the patient's condition and adjust CPR as necessary.
9. Communicate with EMS: Upon the arrival of EMS, communicate effectively with the responders, informing them of the patient's VAD and any interventions performed. Transfer care smoothly to ensure continuity of treatment.

Aftercare and Emergency Response

After performing CPR on a patient with a VAD, continue to monitor their vital signs and provide supportive care until emergency medical services arrive. Communicate effectively with paramedics or emergency responders, informing them of the patient's VAD and any interventions performed. Transfer care smoothly to ensure continuity of treatment and optimize the patient's chances of recovery.

Don'ts:

1. Don't Delay CPR: Do not delay initiating CPR while waiting to confirm the presence of a VAD. Promptly begin chest compressions if the patient is unresponsive and not breathing normally.
2. Avoid Direct Pressure on the VAD: Avoid placing direct pressure on the VAD device during chest compressions. Position your hands slightly to the side of the device to minimize the risk of damage.
3. Don't Remove or Manipulate the VAD: Do not attempt to remove or manipulate the VAD device during CPR unless specifically trained and instructed to do so by medical professionals. Improper handling causes further complications and harm to the patient.
4. Don't Exert Excessive Force During Rescue Breaths: Avoid exerting excessive force when delivering rescue breaths to prevent damage to the VAD or dislodgement of its components. Use gentle, controlled breaths to inflate the patient's lungs adequately.
5. Avoid Delay in Communicating with EMS: Do not delay communication with EMS upon their arrival. Provide clear and concise information about the patient's condition, including the presence of a VAD, to facilitate appropriate medical care.

What are the risks of performing CPR on a patient with a VAD, and how can they be mitigated?

Performing CPR on a patient with a Ventricular Assist Device (VAD) introduces risks, primarily centered around the potential for damaging the device, dislodging its components, or interfering with blood flow. To mitigate these risks, careful attention must be paid to hand placement during chest compressions, ensuring pressure is directed away from the implanted device.

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What is the Success Rate of CPR on a Patient with VAD?

The success rate of CPR on a patient with a VAD differs based on various factors such as the type of VAD, the reason CPR is needed, the immediate cause of the cardiac event, and whether CPR is administered in a hospital or out-of-hospital setting. Since patients with VADs typically have underlying heart conditions that led to the device implantation, CPR outcomes can be complicated by these pre-existing conditions.

A recent study looked at what happens to patients with implanted left ventricular assist devices (LVADs) who experience a cardiac arrest while in the hospital. They used data from a large database covering several years and identified over 93,000 hospitalizations involving LVADs, of which only 578 experienced a Cardiac Arrest. Among those who had a Cardiac Arrest, 173 received CPR.

The study found that the in-hospital mortality rate was high, with over 60% of patients with Cardiac Arrest not surviving, and this rate was even higher for those who received CPR. Certain factors like age, diabetes, heart disease, and other health conditions were linked to higher mortality rates. Interestingly, there was a decreasing trend in performing CPR for LVAD patients experiencing Cardiac Arrest over the study period.

Tips for Effective CPR on VAD Patients

• Practice Proper Hand Placement: Familiarize yourself with the location of the VAD to the patient's chest. Practice placing your hands slightly to the left or right of the device to ensure effective compressions without endangering the VAD.
• Stay Updated with Training: Regularly participate in CPR training courses that include specific instructions for performing CPR on patients with VADs. Stay informed about the latest American Heart Association guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
• Utilize Simulation Training: Incorporate simulation training scenarios involving VAD patients into your CPR training sessions. Simulation exercises help improve your confidence and proficiency in responding to real-life emergencies.
• Communicate with Healthcare Providers: Establish clear communication channels with your facility's healthcare providers and emergency responders to ensure seamless coordination during emergencies involving VAD patients. Share relevant information about the patient's condition and the presence of a VAD to facilitate optimal care delivery.
• Stay Calm and Focused: Remain calm and focused during CPR, even in high-pressure situations. Remember your training and follow established protocols to provide the best possible care to the patient while safeguarding the integrity of their VAD.

CPR Training and Certification

CPR certification is crucial to being prepared to handle cardiac emergencies effectively. Whether a healthcare professional or a concerned citizen, CPR training equips you with life-saving skills that make a difference in critical situations. However, when dealing with patients with Ventricular Assist Devices (VADs), seeking specialized training that addresses the unique considerations and modifications required for performing CPR safely on such individuals is essential. By staying informed, practicing regularly, and pursuing specialized training, you enhance your ability to respond confidently and effectively during emergencies involving VAD patients. Take the initiative to obtain CPR certification today and contribute to creating safer communities where every individual survives in cardiac emergencies.

Sources:

• American Heart Association Guidelines for Cardiovascular Emergencies
• Outcomes of Cardiac Arrest and Cardiopulmonary Resuscitation in Patients With Left Ventricular Assist Device; an Insight From a National Inpatient Sample.
• CPR and Ventricular Assist Devices: The Challenge of Prolonging Life Without Guaranteeing Health.

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