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. This guide does not replace local protocols or device training. Start CPR only if perfusion is inadequate or the LVAD is not functioning.

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 vital emergency procedure that restores circulation and oxygen delivery when the heart stops. It combines chest compressions and rescue breaths to maintain blood flow to vital organs until advanced care is available.

Begin by checking responsiveness and breathing. If the patient is unresponsive and not breathing normally, start CPR immediately. Place the heel of one hand on the center of the chest (between the nipples), place the other hand on top, and keep your arms straight with shoulders above your hands. Deliver compressions at a rate of 100–120 per minute, at a depth of at least 2 inches (5 cm) for adults. After 30 compressions, give 2 rescue breaths lasting about one second each, just enough to make the chest rise. Continue the 30:2 ratio until the patient shows signs of life or help arrives.

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Identifying a VAD Patient

Before starting compressions, determine if the patient has a Ventricular Assist Device (VAD). Look for external components such as a driveline cable, controller, or battery pack, or check for medical alert bracelets or cards. A surgical scar or external driveline near the abdomen or chest may also indicate the presence of a VAD. Recognizing this is critical, as CPR technique and priorities differ from standard cases.

Modifications to CPR for VAD Patients

When a VAD is present, follow the AHA 2025 guidance emphasizing perfusion assessment over pulse checks, as many LVADs produce continuous flow.

1. Assess perfusion and device function: Check for skin color, consciousness, and end-tidal CO₂. Listen for the device hum and verify power and connections.
2. Start chest compressions only if perfusion is inadequate or the LVAD is not functioning (e.g., MAP < 50 mm Hg, ETCO₂ < 20 mm Hg, no device sound).
3. Hand placement may be slightly adjusted to avoid direct pressure on the pump. Perform compressions on a firm surface, following standard rate and depth.
4. Use an AED if needed, as defibrillation is not contraindicated in LVAD patients.
5. Continue to monitor for signs of restored perfusion and follow local or device-specific protocols.

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These updates highlight that chest compressions are reasonable when circulation is absent, and early recognition of device malfunction is crucial for survival.

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How to Perform CPR on a Patient with a VAD?

Performing CPR on a patient with a Ventricular Assist Device (VAD) requires specific steps to ensure both effective resuscitation and the safety of the device. The AHA 2025 Guidelines emphasize assessing perfusion rather than relying solely on pulse checks, as many LVADs produce continuous, non-pulsatile flow.

1. Assess the Situation: If the patient is unresponsive or not breathing, perform an ultrafast LVAD/perfusion check. Start compressions if MAP < 50 mm Hg, ETCO₂ < 20 mm Hg, or if the device isn’t functioning.
2. Call for Help: Have someone immediately call emergency medical services (EMS). Professional assistance is critical in cardiac emergencies.
3. Positioning: Lay the patient flat on a firm surface, ensuring no obstacles interfere with CPR.
4. Modify Hand Placement: Avoid placing hands directly over the VAD site. Use the standard lower half of the sternum for compressions.
5. Adjust Compression Depth and Rate: Compress at least 2 inches (5 cm) deep at a rate of 100–120 compressions per minute. Allow full chest recoil after each compression.
6. Deliver Rescue Breaths with Caution: If trained, give 2 rescue breaths after every 30 compressions. Follow standard airway management; avoid excessive ventilation or gastric insufflation.
7. Continue CPR Until Help Arrives: Keep the 30:2 compression-to-breath cycle until the patient shows signs of life or EMS takes over. Reassess periodically.
8. Communicate with EMS: Inform responders that the patient has a VAD and describe actions taken. Ensure smooth transfer of care.

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. Updated according to the latest American Heart Association (AHA) 2025 CPR and ECC Guidelines.
• 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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