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Heart Transplant/Left Ventricular Assist Device (LVAD)

What is a Heart Transplant?

A heart transplant is performed for removing a diseased heart and implanting a healthy heart, which is received from a donor. This procedure is life-saving for patients with chronic heart failure and it is generally recommended when the condition of the patient doesn’t improve with medications and other procedures. However, the lack of regular availability of donor's hearts because of the lack of an adequate number of donors as compared to recipients has led to the adoption of alternative strategies and procedures, such as the left ventricular assist device (LVAD) therapy.

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What is a Left Ventricular Assist Device (LVAD)?

A left ventricular assist device (LVAD) is an implantable mechanical circulatory pump that assists the left ventricle in pumping blood to the aorta and throughout the body. The device derives its name from the fact that it is placed in the left ventricle. For patients with end-stage heart failure or chronic heart failure who are waiting for a heart transplant, the LVAD is an alternative therapy. The device is temporarily implanted and then removed during a heart transplantation procedure.

Why is it recommended?

In addition to being recommended for patients with end-stage or chronic heart failure, who are waiting for a heart transplant, the LVAD is also recommended for patients with end-stage heart failure who are inoperable because of their old age or health issues (destination therapies). This procedure is also recommended as a therapy for reviving the heart (bridge to recovery).

Procedure for Implanting an LVAD:

  • It is an open-heart surgery performed under general anaesthesia.

  • A large incision is made either on the breastbone (sternotomy) or chest wall (thoracotomy).

  • Cardiopulmonary bypass (heart-lung machine) is used in this procedure.

  • An LVAD has several external and internal components. While the internal components include a pump, which is implanted into the apex of the heart, and a tube, which is connected to the pump and carries blood from the pump to the aorta, the cable that acts as a bridge between the control system or controller, which is placed outside the body and controls the pump, and the pump are the major external components. Rechargeable batteries or an AC adapter power the device. 

What are the Advantages of LVAD?

  • It is a life-saving procedure for patients with severe heart failure.

  • The device can improve the condition of the heart to such an extent that it can start functioning on its own again during the ‘bridge to recovery’ therapy. 

  • During the “destination therapy”, the implantation of an LVAD may improve the functioning of other organs, thus improving the overall health of the patient and making them fit for a heart transplant. 

  • By assisting the patient in performing routine activities, the device improves the quality of life.

Who are the Candidates?

An LVAD is implanted in:

  1. Patients who are on inotropes with weak hearts.

  2. Patients who are witnessing a sharp deterioration in their liver, renal, or other organ function in spite of maximum medical therapies.

  3. Patients who cannot undergo heart transplants because of comorbidities/age/unavailability of heart.

  4. Patients with refractory heart failure or those who have a history of recurrent admission for heart failure despite being on medications or maximal medical therapies.

What are the Risks Associated with LVAD Implantation?

  • Cardiac arrests or strokes: Blood clots may form on the LVAD which can cause the device to stop working or slow down/block the flow of blood through the heart, thus increasing the chances of heart attacks or strokes. Due to this factor, anticoagulants or blood thinners are usually prescribed after LVAD implantation.

  • Bleeding: The risk of bleeding is quite high during or after an LVAD implantation procedure.

  • Infection: A LVAD consists of several external and internal components. A port is used for connecting the internal components that are placed inside the body and the external components that are kept outside the body. As germs may enter the port, the risk of infection is quite high. Thus, to mitigate the risks of infection, check the port frequently for signs of infection like swelling, tenderness, discharge etc.

  • Weakening of the right ventricle: A LVAD may increase the pumping of blood from the left ventricle, which may increase the burden on the right ventricle to pump more blood. This can weaken the right ventricle over a certain period of time, thus increasing the chances of right heart failure. As a result, the implantation of a right ventricular assist device (RVAD) is required in some cases.

  • Malfunctioning of device: The LVAD may not be able to function properly post-implantation in some cases.

  • Difficulty in breathing

  • Patients may exhibit allergic reactions to anaesthesia in some cases.

  • The device can cause heart failure, multiorgan failure, or haemorrhagic stroke, which can, in turn, cause death. 

How to Prepare for LVAD Implantation?

Before the implantation, the patient will get an overview of the procedure along with the risks associated with it from the doctor. The doctor will give a detailed explanation about the way the device will be implanted inside the body, its mechanism of action, the safety precautions to take, how to contact an emergency if the device breaks or doesn’t work properly, and other issues like recharging the batteries and how to shower and travel while wearing the device. The patient will be asked if they are taking any supplements, medications, or herbs and if they are allergic to any injections or medications. The patient will also be asked if they have any underlying medical conditions like hypertension and diabetes and if they have undergone any surgeries in the past. The patient will be asked to not wear makeup, jewellery, heavy makeup etc. on the day of the surgery and they can also ask the doctor about exercise, medication, lifestyle changes, and diets that they must follow after the procedure.

Things to Expect Before Procedure:

The patient may be expected to be in the hospital a few days before the surgery for undergoing some treatments for their weakened heart and preparations for the surgery. The patient’s overall health will be evaluated to ensure that they are fit to undergo the procedure.

Many investigations and tests will be performed, such as:

  • ECG (Electrocardiogram): It will be performed to know the duration and timing of the heart’s electrical activity.

  • Blood investigations: The patient will be asked to submit their blood sample so that the functioning of their kidney, thyroid, liver, heart, etc. can be checked. 

  • Echocardiogram: With the help of an echocardiogram, the pumping function of the patient’s heart is measured.

  • Chest X-ray: It is conducted to view the shape and size of the patient’s lungs.

  • Cardiac catheterization: A catheter (a thin and flexible tube) is inserted through a large artery or vein in the patient’s neck, leg, or arm into the heart for measuring the pressure of the blood flow in the heart. 

During the procedure:

On the day of the implantation, the patient’s chest area is shaved and sterilized with iodine, alcohol, or an antiseptic solution. A urinary catheter is inserted into the bladder to collect urine inside a bag during the procedure while the patient is under anaesthesia. An experienced multidisciplinary team of nurses, technicians, anesthesiologists, and cardiac surgeons work together while performing the operation. The patient will be put on a cardiopulmonary bypass machine and their cardiac output and blood pressure will be controlled by the anesthesiologist with the help of some medications. Open-heart surgery is performed to implant the LVAD inside the body and the procedure can take 4-6 hours.

After the procedure:

After the surgery, the patient will be shifted to the recovery room. After regaining consciousness, they will be shifted to the intensive care unit (ICU) where their vitals will be constantly monitored. The patient will be given antibiotics, nutrition, fluids, painkillers, and other medications via intravenous (IV) lines. The patient may be placed on a ventilator until they can breathe on their own. Once their condition is stable, they will be moved to a hospital room, where they will be encouraged to sit, take a walk, and do some breathing exercises for strengthening the lungs. Before getting discharged, the patient will be given detailed instructions on how to operate the device, charge the batteries, care for the wound and also on lifestyle and diet modifications. Antibiotics will be prescribed for preventing infections while blood thinners will be given to prevent blood clots and other complications.

FAQs

A person can easily live for 5-7 years post-LVAD implantation. In some cases, patients have lived for 13 years after the implantation.

Exercising is generally recommended for people post-LVAD implantation. The patient can do low-intensity exercises like yoga and walk, depending on their condition and doctor’s approval. The patient is advised to avoid strenuous exercises.

A shower can be taken with an LVAD but some precautions must be followed. The batteries should be fully charged and then switched off before bathing. The device can be put in a shower bag and put around the neck while showering. It can be removed after showering and put in the regular carrier.

LVAD is recommended for patients with end-stage heart failure who are waiting for a transplant (bridge to transplant). In such instances, the device is implanted temporarily and removed during the transplant. The device is also recommended for patients with end-stage heart failure who are inoperable because of their age or comorbidities (destination therapy). It can also be recommended as a therapy to revive the heart (bridge to recovery).

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