Department of Critical Care Unit, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou (HEGP), Université Paris-Descartes, Paris, France.
Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France.
Blood Purif. 2018;46(4):292-300. doi: 10.1159/000491872. Epub 2018 Jul 26.
BACKGROUND/AIMS: Long-term mechanical assist devices are now commonly used in the treatment of severe heart failure to unload the failing ventricle, maintain sufficient end-organ perfusion and improve functional capacity. Depending on the assisted ventricles, 3 categories of long-term assist devices are available: left ventricular assist device (LVAD), biventricular assist device and total artificial heart. Improvements in technology, especially the advent of smaller, durable continuous flow pumps, have led to the use of LVADs in a much broader population of patients in the last 10 years. Both the number of patients living with LVADs and the life expectancy of these patients are increasing. Regarding this growing number of patients with LVAD, intensivists need to understand the physiology of the devices, their functioning, potential complications and their management.
We performed a narrative review of relevant medical literature regarding the physiology of patients with LVAD and management of common complications relevant to the critical care physicians.
The most frequent complications occurring in the LVAD patients after the post-operative period are bleeding, driveline infections, thrombosis, device malfunction, right ventricular failure and arrhythmias. Bleeding is the most frequent adverse event in LVAD due to a combination of anticoagulation and acquired von Willebrand disease secondary to shear stress produced within the pump. Their management includes antiplatelet therapy arrest, reduction of the anticoagulation regimen and specific therapy if feasible. Infection is the second most common cause of death after cardiac failure in LVAD patients. All infections must be aggressively treated to avoid seeding the device. Device thrombosis can develop even when patients are adequately anticoagulated and taking antiplatelet therapy because the LVAD is responsible for a chronic hypercoagulable state.
Management of these unique patients in the ICU is best accomplished with a multidisciplinary team that includes specialists in advanced heart failure, LVAD nurse coordinators and intensivists.
背景/目的：长期机械辅助装置现在常用于治疗严重心力衰竭以减轻衰竭心室的负荷，维持足够的终末器官灌注并改善功能能力。根据辅助心室的不同，有 3 类长期辅助装置：左心室辅助装置（LVAD）、双心室辅助装置和全人工心脏。技术的进步，特别是更小、更耐用的连续流泵的出现，导致在过去 10 年中 LVAD 在更广泛的患者群体中得到应用。使用 LVAD 的患者数量和这些患者的预期寿命都在增加。对于越来越多的 LVAD 患者，重症监护医师需要了解设备的生理学、功能、潜在并发症及其管理。
我们对有关 LVAD 患者生理学和与重症监护医师相关的常见并发症管理的相关医学文献进行了叙述性综述。
LVAD 患者在术后最常发生的并发症是出血、导线感染、血栓形成、设备故障、右心室衰竭和心律失常。出血是 LVAD 最常见的不良事件，原因是抗凝和剪切应力引起的获得性血管性血友病，这两者共同作用于泵内。其管理包括血小板治疗停药、减少抗凝方案以及在可行的情况下进行特定治疗。感染是 LVAD 患者心力衰竭后第二大常见死亡原因。所有感染都必须积极治疗，以避免感染设备。即使患者充分抗凝并服用抗血小板药物，LVAD 也会导致慢性高凝状态，因此仍可能发生设备血栓形成。
重症监护病房中这些特殊患者的管理最好由一个多学科团队完成，该团队包括心力衰竭、LVAD 护士协调员和重症监护医师方面的专家。
