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DOI: 10.1055/s-0040-100249
Patienten mit linksventrikulären Assist Devices – Typische Notfälle versorgen
Mechanically circulatory support devices – Management of typical emergenciesPublikationsverlauf
Publikationsdatum:
29. Januar 2015 (online)
![](https://www.thieme-connect.de/media/ains/201501/lookinside/thumbnails/10.1055-s-0040-100249-1.jpg)
Zusammenfassung
Die Implantation mechanischer Herzunterstützungssysteme konnte das Überleben und die Lebensqualität von Patienten mit terminaler Herzinsuffizienz deutlich verbessern und wird in den kommenden Jahren zunehmend an Bedeutung gewinnen. Notfallmediziner werden daher häufiger mit Patienten konfrontiert werden, bei denen ein ventrikuläres Assist Device (VAD) implantiert wurde.
Die Notfallversorgung von VAD-Patienten ist bisher jedoch nicht standardisiert. Der folgende Artikel gibt einen Überblick der beiden wichtigsten, aktuell gebräuchlichen Systeme, diskutiert typische VAD-assoziierte Notfälle und gibt Handlungsempfehlungen für das Notfallteam. Dazu wird ein von den Autoren vorgeschlagener Algorithmus zur strukturierten und zügigen Evaluation des VAD-Patienten vorgestellt und Besonderheiten in der Notfallversorgung dieser Patientengruppe diskutiert.
Abstract
The use of mechanically circulatory support devices (MCS) will become increasingly important as a therapy option in patients with end-stage heart failure, and emergency physicians will more frequently encounter MCS patients in the next few years.
However, emergency management in MCS patients has not yet been standardized. In the following article, common MCS devices are presented and typical emergencies associated with MCS devices are discussed. Furthermore, we try to give recommendations for the management of MCS patients in an emergency situation and present an algorithm in order to facilitate a structured and timely efficient evaluation of the MCS patient.
Kernaussagen
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Typische Notfallbilder bei LVAD-Patienten (LVAD = linksventrikuläres Assist Device) sind niedriger Systemfluss, Blutungskomplikationen, Rechtsherzversagen, Hypotonie, Arrhythmien und neurologische Komplikationen.
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Pulsoxymetrie und nicht invasive Blutdruckmessung sind bei LVAD-Patienten nicht immer zuverlässig möglich und müssen ggf. durch eine klinische Beurteilung des Patienten ersetzt werden.
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LVAD-Systeme sind vorlastabhängig und nachlastsensibel.
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Der Ausfall eines LVAD-Systems erfordert eine zügige Evaluation des Patienten, eine Überprüfung aller Steckverbindungen und eine schnelle Kontaktaufnahme mit dem zuständigen LVAD-Zentrum.
Keywords:
ventricular assist device - artificial ventricle - emergencies - prehospital emergency care - congestive heart failure-
Literatur
- 1 DeBakey ME. Left ventricular bypass pump for cardiac assistance. Clinical experience. Am J Cardiol 1971; 27: 3-11
- 2 Slaughter MS, Rogers JG, Milano CA et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009; 361: 2241-2251
- 3 Strueber M, O'Driscoll G, Jansz P et al. Multicenter evaluation of an intrapericardial left ventricular assist system. J Am CollCardiol 2011; 57: 1375-1382
- 4 Rogers JG, Aaronson KD, Boyle AJ et al. Continuous flow left ventricular assist device improves functional capacity and quality of life of advanced heart failure patients. J Am CollCardiol 2010; 55: 1826-1834
- 5 Kirklin JK, Naftel DC, Kormos RL et al. Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant 2013; 32: 141-156
- 6 Thoratec Corporation. Gebrauchsanweisung für das Linksherzunterstützungssystem (LVAS) HeartMate II (08/2014). http://www.thoratec.com/_assets/download-tracker/HMII/106021/HM2_EU_IFU_ 106021DE-DE.F.pdf Stand 03.12.2014
- 7 HeartWare Incorporation. HeartWare Ventricular Assist System Instructions for Use (2012). http://www.heartware.com/sites/default/files/uploads/docs/ ifu00001_rev_15.pdf Stand 03.12.2014
- 8 Riebandt J, Sandner S, Mahr S et al. Minimally invasive thoratecHeartMate II implantation in the setting of severe thoracic aortic calcification. Ann ThoracSurg 2013; 96: 1094-1096
- 9 Slaughter MS, Pagani FD, Rogers JG et al. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant 2010; 29 (Suppl. 04) 1-39
- 10 Partyka C, Taylor B. Review article: Ventricular assist devices in the emergency department. Emerg Med Australas 2014; 26: 104-112
- 11 Agarwal S, High KM. Newer-generation ventricular assist devices. Best Pract Res ClinAnaesthesiol 2012; 26: 117-130
- 12 Myers TJ, Bolmers M, Gregoric ID et al. Assessment of arterial blood pressure during support with an axial flow left ventricular assist device. J Heart Lung Transplant 2009; 28: 423-427
- 13 Bennett MK, Roberts CA, Dordunoo D et al. Ideal methodology to assess systemic blood pressure in patients with continuous-flow left ventricular assist devices. J Heart Lung Transplant 2010; 29: 593-594
- 14 Pistono M, Corrà U, Gnemmi M et al. How to face emergencies in heart failure patients with ventricular assist device. Int J Cardiol 2013; 168: 5143-5148
- 15 Aggarwal A, Kurien S, Coyle L et al. Evaluation and management of emergencies in patients with mechanical circulatory support devices. Prog Transplant 2013; 23: 119-126
- 16 Birks EJ. Left ventricular assist devices. Heart 2010; 96: 63-71
- 17 Allen SJ, Sidebotham D. Postoperative care and complications after ventricular assist device implantation. Best Pract Res ClinAnaesthesiol 2012; 26: 231-246
- 18 Vollkron M, Voitl P, Ta J et al. Suction events during left ventricular support and ventricular arrhythmias. J Heart Lung Transplant 2007; 26: 819-825
- 19 Starling RC, Moazami N, Silvestry SC et al. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med 2014; 370: 33-40
- 20 Tigges-Limmer K, Schönbrodt M, Roefe D et al. Suicide after ventricular assist device implantation. J Heart Lung Transplant 2010; 29: 692-694
- 21 Potapov EV, Stepanenko A, Krabatsch T et al. Managing long-term complications of left ventricular assist device therapy. CurrOpinCardiol 2011; 26: 237-244
- 22 Sarsam SH, Meyers DE, Civitello AB et al. Trauma in patients with continuous-flow left ventricular assist devices. Am J Cardiol 2013; 112: 1520-1522
- 23 Klotz S, Barbone A, Reiken S et al. Left ventricular assist device support normalizes left and right ventricular beta-adrenergic pathway properties. J Am CollCardiol 2005; 45: 668-676
- 24 Refaat M, Chemaly E, Lebeche D et al. Ventricular arrhythmias after left ventricular assist device implantation. PacingClinElectrophysiol 2008; 31: 1246-1252
- 25 Raasch H, Jensen BC, Chang PP et al. Epidemiology, management, and outcomes of sustained ventricular arrhythmias after continuous-flow left ventricular assist device implantation. Am Heart J 2012; 164: 373-378
- 26 Andersen M, Videbaek R, Boesgaard S et al. Incidence of ventricular arrhythmias in patients on long-term support with a continuous-flow assist device (HeartMate II). J Heart Lung Transplant 2009; 28: 733-735
- 27 Bedi M, Kormos R, Winowich S et al. Ventricular arrhythmias during left ventricular assist device support. Am J Cardiol 2007; 99: 1151-1153
- 28 Busch MC, Haap M, Kristen A et al. Asymptomatic sustained ventricular fibrillation in a patient with left ventricular assist device. Ann Emerg Med 2011; 57: 25-28
- 29 Patel P, Williams JG, Brice JH. Sustained ventricular fibrillation in an alert patient: preserved hemodynamics with a left ventricular assist device. PrehospEmerg Care 2011; 15: 533-536
- 30 Sims DB, Rosner G, Uriel N et al. Twelve hours of sustained ventricular fibrillation supported by a continuous-flow left ventricular assist device. PacingClinElectrophysiol 2012; 35
- 31 Feldman D, Pamboukian SV, Teuteberg JJ et al. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: Executive summary. J Heart Lung Transplant 2013; 32: 157-187
- 32 Shinar Z, Bellezzo J, Stahovich M et al. Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs). Resuscitation 2014; 85: 702-704
- 33 Boyle AJ, Russell SD, Teuteberg JJ et al. Low thromboembolism and pump thrombosis with the HeartMate II left ventricular assist device: analysis of outpatient anti-coagulation. J Heart Lung Transplant 2009; 28: 881-887
- 34 Geisen U, Heilmann C, Beyersdorf F et al. Non-surgical bleeding in patients with ventricular assist devices could be explained by acquired von Willebrand disease. Eur J CardiothoracSurg 2008; 33: 679-684
- 35 Meyer AL, Malehsa D, Bara C et al. Acquired von Willebrand syndrome in patients with an axial flow left ventricular assist device. Circ Heart Fail 2010; 3: 675-681
- 36 Kormos RL, Teuteberg JJ, Pagani FD et al. Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J ThoracCardiovascSurg 2010; 139: 1316-1324
- 37 Morgan JA, Paone G, Nemeh HW et al. Impact of continuous-flow left ventricular assist device support on right ventricular function. J Heart Lung Transplant 2013; 32: 398-403
- 38 Rich JD. Right ventricular failure in patients with left ventricular assist devices. CardiolClin 2012; 30: 291-302
- 39 Van Rensburg Meineri M, Adriaan E, Vegas A. Right ventricular failure after LVAD implantation: prevention and treatment. Best Pract Res ClinAnaesthesiol 2012; 26: 217-229
- 40 Lalonde SD, Alba AC, Rigobon A et al. Clinical differences between continuous flow ventricular assist devices: a comparison between HeartMate II and HeartWare HVAD. J Card Surg 2013; 28: 604-610
- 41 Kato TS, Ota T, Schulze PC et al. Asymmetric pattern of cerebrovascular lesions in patients after left ventricular assist device implantation. Stroke 2012; 43: 872-874
- 42 Slininger KA, Haddadin AS, Mangi AA. Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery. J CardiothoracVascAnesth 2013; 27: 752-759