Pharmacotherapy considerations for long-term management of patients with left ventricular assist devices

Current guidelines and research pertaining to pharmacotherapy considerations for management of patients with left ventricular assist devices (LVADs) are reviewed.

LVADs are being used more frequently to sustain patients with end-stage heart failure who are on a waitlist or ineligible for heart transplantation. The devices significantly impact patient physiology leading to unique medical complications and pharmacotherapy considerations. Pharmacists can play a vital role in understanding and relaying relevant medication concerns to the interdisciplinary healthcare team. Although optimal treatment regimens for some complications are still unclear, evolving research provides key information to incorporate into decisions. The introduction of an LVAD requires antithrombotic therapy in the absence of contraindications to prevent thrombosis. Warfarin with a device-dependent International Normalized Ratio (INR) goal is preferred. The baseline INR goal is usually 2-3 but can be adjusted for recurrent thrombosis or refractory bleeding. When infection is suspected, cultures should be obtained, covering likely pathogens with consideration of resistance in long-standing infections. Chronic antimicrobial suppression may be warranted. Elimination rate constant and volume of distribution may be altered. LVAD implantation may improve glycemic control. Doppler probe is preferred to monitor blood pressure, with a goal mean arterial pressure of ≤80 mm Hg.

Many pharmacotherapy considerations are necessary for the long-term management of patients with an LVAD. Awareness of LVAD structure, pathophysiologic alterations after LVAD implantation, and pharmacologic considerations will help pharmacists provide better recommendations.