Page 12 - VAD Guidelines
P. 12

Pediatric Ventricular Assist Device (VAD) Guidelines

               injury, should begin immediately upon return from the operating room.  Extubation should be
               considered as soon as the patient tolerates a spontaneous breathing trial.

               Ongoing ICU/Floor Management

               Anticoagulation
               The goals of chronic maintenance of anticoagulation therapy maintains goals are similar to that
               described in acute post-operative management; prevention of thrombosis while controlling bleeding.
               However, as both bleeding risk as well as stroke risk declines as time from implant increases transition
               should be considered toward chronic therapies with goals of a limited needs for acute titrations. Though
               developmental hemostasis and variable gut microbiota in young patients affect both the timing of
               transition to chronic agents as well as the choice of agents. Current practice patterns in young patients
               are to continue Bivalirudin therapy until the time of device explant or transplant , however,
               considerations should be made to low molecular weight heparin agents (Lovenox, Fondaparinux) as
               deemed appropriate through discussion amongst VAD, ICU, and hematology teams. Adolescents,
               however, possess a more predictable coagulation cascade.  These, patients should be evaluated starting
               as early as 5 days post-implant for candidacy to transition to either low molecular weight heparin agents
               (Lovenox, Fondaparinux) in younger patients or Vitamin K antagonist therapy (Coumadin) in older
               patients.

               Antiplatelet therapy is universally required in all patients undergoing VAD support, however, intensity of
               therapy is dependent on patient factors. Antiplatelet agents should be ideally initiated on post-operative
               day 3-5. Patients with developmental hemostasis and undergoing support with paracorporeal devices
               (PediMag, Berlin) characteristically require an increased antiplatelet regimen which generally includes a
               minimum of Aspirin 15 mg/kg daily and Plavix 0.8 mg/kg daily. Older patients in whom durable,
               intrapericardial devices are deployed often require only low dose Aspirin and omega fish oil.

               Details of both chronic anticoagulation and antiplatelet management can be found in Appendix 2.

               Imaging Investigations

               Echocardiographic Evaluation
                   Echocardiographic evaluation of the VAD supported patient remains a critical tool for use at all
                   stages of support.  Whether for use in diagnosis of acute post-operative complications including
                   effusion or right ventricular dysfunction, or for use in device optimization or wean trials; adequate
                   echo studies are key. Guidelines for use of echo in diagnosis and direction of management in adult
                   LVAD therapy provide an important construct from which to shape any center’s practice.[6]
               Echo Assessment
                   •  Biventricular systolic function
                   •  Interventricular septal position (graded as: -1=bowing toward RV, 0=neutral position, +1=bowing
                       toward LV),
                   •  Presence of ventricular or aortic root thrombus
                   •  AV valve function - frequency of aortic valve opening (e.g. 3 of beats open out of 10), degree of
                       aortic valve insufficiency
                   •  Presence of pericardial effusion
                   •  IVC for dilation and compressibility
                   •  Complete assessment of RV function, interventricular septal position



               Updated 3/24/2019                                                                      page 12
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