This content has been generated for SALG by the Association for Cardiothoracic Anaesthesia and Critical Care

Dislodgement of the drainage cannula of a left ventricular assist device (LVAD) resulted in a major haemorrhage. The flow through the LVAD suddenly dropped then spontaneously resolved. At this point the patient was awake and moving, although not excessively. Upon investigation there was bleeding from the drainage cannula. Flow became increasingly erratic. There was no response to fluid loading. Bleeding increased and the patient became haemodynamically compromised. There was an immediate but non-sustained improvement when the LVAD drainage cannula was advanced slightly. The major haemorrhage protocol was activated and the patient was transferred to theatre with staff holding the cannula during transfer. The chest was reopened and the cannula re-sited.

Commentary

This case demonstrates the risk of haemorrhage whilst LVADs are in situ. Bleeding is the most common complication of LVAD use occurring in 30-60% of patients.¹ Bleeding can occur early or late including from cannulae, as in this case. Other potential sites include the gastrointestinal tract and intracranialbleeding.² Patients with LVADs require anticoagulation to reduce the risk of thrombosis within the LVAD system increasing the risk of bleeding. Although recent advances have allowed a reduction in the level of anticoagulation required, there is still an elevated bleeding risk.³

In this case the bleeding was identified as the cause of the reduction of flow and attempts were made to reposition the cannula on ICU. Once it was evident this was not improving the situation, the team expedited return to theatre for cannula repositioning and securing of the LVAD cannula. Early identification of bleeding in these patients is essential and early re-exploration to avoid massive transfusion as this can precipitate right heart dysfunction or failure.²

References

1. Leebeek FWG, Muslem R. Bleeding in critical care associated with left ventricular assist devices: pathophysiology, symptoms, and management. Hematology Am Soc Hematol Educ Program. 2019 Dec 6;2019(1):88-96
2. Kilic, A., Acker, M., Atluri, P. Dealing with surgical left ventricular assist device complications. J. Thorac. Dis., 2015 Dec; 7(12):2158-2164
3. Giménez-Milà M, Sandoval E, Farrero M. Let's Reduce Bleeding Complications in Patients With Left Ventricular Assist Device. JCVA, 2022, Sep; 36(9): 3435 - 3438