Resuscitation of Durable Mechanical Circulatory Supported Patients with Acutely Altered Perfusion or Cardiac Arrest: ALS ScR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: (none applicable)

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (none applicable)

Task Force Synthesis Citation

Moskowitz, A., Pocock, H., Lagina, A., Chong-Ng, K., Scholefield, B. R., Zelop, C., Bray, J., Rossano, J., Johnson, N. J., Dunning, J., Olasveengen, T., Raymond, T., Morales, D. L. S., Carlese, A., Elias, M., Berg, K. M., Drennan, I., on behalf of the ILCOR Advanced Life Support, Basic Life Support, and Pediatric Life Support Task Forces. (Year of Publication). Resuscitation of Patients with Durable Mechanical Circulatory Support with Acutely Altered Perfusion or Cardiac Arrest: A Scoping Review. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review conducted by the ILCOR ALS, BLS, and PLS Task Force Scoping Review team. Evidence for adult and pediatric literature was sought and considered.

Scoping Review Citation

Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.

PCC, Study Design, and Time Frame

The PCC (Population, Concept, Context)

Population: Patients of any age who were receiving durable mechanical support (MCS) of any kind.

Concept: Acute impaired perfusion resulting in need for acute resuscitation.

Context: In- and Out-of-Hospital settings

Study Designs: Randomized controlled trials, non-randomized studies, and case series and reports were included in the initial search. All relevant publications in any language were included so long as there was an English language abstract.

Timeframe: All years.

Literature search updated: September 2023.

Search Strategies

The search strategy was created in coordination with a research librarian. Two databases were (PubMed and Embase) were searched initially to identify all potentially relevant publications. The full search terms can be found below. Non-peer reviewed studies, unpublished studies, conference abstracts and trial protocols (grey literature) were sought using publicly available search engines Google and Bing. We additionally searched the references of all included studies for any missed studies. Clinicaltrials.gov was searched to identify any ongoing clinical trials relevant to the scoping review.

Each identified title and abstract were reviewed by two authors and any disagreements adjudicated by consensus or a third reviewer. Full text articles were then reviewed and relevant data abstracted using a standardized form. Data abstraction was conducted by a single author and reviewed by a second author.

A total of 3,556 results were identified in the initial search conducted in September 2023. After title and abstract screening, 97 (2.7%) remained and underwent full text review. Thirty-one (0.9%) studies were included after full text review and underwent data abstraction. The primary reason for exclusion of a full text study was due to incorrect concept (42 of 66 [63.6%]), often because of a focus on patients with MCS who developed stable ventricular arrhythmias without acutely altered perfusion. A repeat search using the above search strategy was performed in May 2024 with one additional study identified. The Cochrane Database was additionally searched in September 2024 to identify any additional references—there were no reviews or other relevant studies identified.

Data tables

Table 1: Details of Included Studies

Study	Publication Year	Study Type	Continent	Total number of patients with acutely altered perfusion	Population	Mechanical Support Device(s)	Chest Compressions Described
Senman et al¹	2024	Case Series	North America	58	Both In-and-Out of hospital	LVAD	Yes
Senman et al¹	Case series of 58 LVAD supported patients at a single institution who suffered cardiac arrest. Of these, 24 received chest compressions and 34 received no chest compressions. Per review of the notes, the most common reason for withholding of chest compressions was a perceived contraindication to chest compressions in LVAD supported patients. There were no documented cases of device dislodgement. Survival was similar between those who did and did not receive chest compressions, but neurologic outcomes were worse in patients who received chest compressions.
Sande et al²	2023	Case Report	North America	1	In-hospital	LVAD	No
Sande et al²	Case report of a patient experiencing device alarms after undergoing an ablation procedure shortly after a percutaneous LVAD placement. A bedside echo showed a large circumferential pericardial effusion with right ventricular collapse and tamponade. The patient underwent bedside pericardiocentesis with improved physiology.
Victor et al³	2022	Case Report	North America	1	In-hospital	LVAD	No
Victor et al³	Case report of a patient experiencing increasing dyspnea and hemodynamic instability 6 days after LVAD placement. LVAD flow rate adjustments and vasopressor utilization were unsuccessful, and ultrasound identified a pericardial effusion. Successful operative management was performed.
Akin et al⁴	2022	Case Report	Europe	1	In-hospital	LVAD	No
Akin et al⁴	A case report of a patient 10 days after LVAD placement involved a research study for a sublingual microcirculatory imaging tool for microvascular circulation and perfusion. The device revealed severe failure of the microcirculation, and the patient later developed hemodynamic compromise and signs of hypoperfusion. Cardiac tamponade was identified that was subsequently surgically corrected.
Ratman et al⁵	2022	Case Report	Europe	1	Out-of-Hospital	LVAD	No
Ratman et al⁵	Case report of a patient admitted with low LVAD flows and multiple organ failure. Pump flows and evidence of organ injury improved with fluids.
Doita et al⁶	2022	Case Report	Asia	1	In-hospital	LVAD	Yes
Doita et al⁶	Case report of an LVAD thrombosis leading to left outflow obstruction. The clot was large enough to occupy the LVAD inflow and resulted in nearly no forward flow from the device. The patient suffered cardiac arrest. Chest compressions were administered but the patient could not be resuscitated.
Barssoum et a⁷l	2022	Retrospective observational cohort	North America	578	In-hospital	LVAD	No
Barssoum et a⁷l	Retrospective analysis of the National Inpatient Sample including LVAD patients who sustained cardiac arrest comparing outcomes of those who underwent chest compressions with those who did not. Of 578 patients, 226 (39.1%) survived to hospital discharge. Mortality was 74% for those receiving chest compressions vs. 61% for those who did not achieve chest compressions (p<0.01). This study was limited by potential misclassification as only administrative data was used and variables available for abstraction were limited.
Pokrajac et al⁸	2022	Retrospective observational cohort	North America	1	In-hospital; Pediatrics Included	LVAD	No
Pokrajac et al⁸	Single center, retrospective review of 54 emergency department visits in pediatric VAD patients. There were no deaths or cardiac arrests in the ED. 4 patients in the cohort died, with one experiencing cardiogenic shock and organ failure.
Esangbedo et al⁹	2022	Case Series	North America	4	In-hospital; Pediatrics Included	LVAD; BiVAD	Yes
Esangbedo et al⁹	Case series of 5 pediatric patients who underwent chest compressions with VAD in place. Patient 1 had had cardiac arrest due to tamponade and suffered severe neurologic injury. Patient 2 had RVAD disconnect and brief chest compressions. Patient 3 had cardiac tamponade and brief chest compressions prior to chest exploration. Patient 4 had brief chest compressions with tamponade. Of the 4 patients, 3 survived with good outcomes.
Oates et al¹⁰	2022	Case Report	North America	1	In-hospital	LVAD	No
Oates et al¹⁰	Case report of patient who deteriorated after attempt at VT ablation with hypoxemia from intratrial shunt.
Ziegler et al¹¹	2021	Case Report	North America	1	Out-of-Hospital	LVAD	No
Ziegler et al¹¹	Case report of an emergency repair using splicing of a transected driveline in a left ventricular assist device.
Iwashita et al¹²	2020	Case Report	Asia	1	Both In-and-Out of hospital	LVAD; ECMO	Yes
Iwashita et al¹²	Case report of cardiac arrest 2 years post LVAD placement. The device was unknown by responders and chest compressions were performed for 40 minutes. On arrival to the hospital a depleted battery was discovered and changed after 50minutes of total chest compressions. Subsequent VT was not responsive to defibrillation and VA-ECMO was initiated. A complicated course led to patient death after ECMO was discontinued.
Eyituoyo et al¹³	2020	Case Report	North America	1	Both In-and-Out of hospital	LVAD	No
Eyituoyo et al¹³	A case report of a patient with an LVAD placed 7 years earlier who developed altered mentation and hypotension. Upon EMS arrival, an irregular rhythm was noted and presumed to be artifact from LVAD. In the emergency department, VF was noted and corrected with defibrillation. The patient developed multiorgan failure and later expired.
Saito et al¹⁴	2019	Case Report	Asia	1	Out-of-Hospital	LVAD	Yes
Saito et al¹⁴	Case report of a patient who suffered from global cerebral ischemia due to LVAD pump stoppage. Chest compressions were performed by paramedics and LVAD function was restored after hospital arrival by exchanging external cables. The patient recovered without any neurological deficit.
Harper et al¹⁵	2019	Case Report	North America	1	In-hospital	LVAD	No
Harper et al¹⁵	Case report of a patient with an LVAD placed 3 years earlier presenting to the emergency department in refractory VT and experiencing chest pain, dizziness and multiple discharges of his ICD. Received medications and external shocks and LVAD flow rate was decreased to allow better ventricular filling.
Thiele et al¹⁶	2018	Case Report	Europe	1	Out-of-Hospital	LVAD	Unclear
Thiele et al¹⁶	Case report of LVAD driveline disconnect. Patient recovered with re-connecting driveline.
Ornato et al¹⁷	2018	Case Report	North America	1	Out-of-Hospital	LVAD	Yes
Ornato et al¹⁷	Case report of a patient with an LVAD who suffered cardiac arrest. Patient was intubated and ETCO2 was 0 mmHg with confirmation of tube placement. Compressions started and ETCO2 rose to 28 mmHg.
Godishala et al¹⁸	2017	Case Series	North America	4	In-hospital	LVAD	No
Godishala et al¹⁸	Case series of 4 patients suffering acute myocardial infarction while supported by continuous-flow LVADs. Patient 1 received shocks from ICD due to VT, attributed to electrolyte derangement; once corrected the patient was asymptomatic. Patient 2 also received shocks from ICD due to VT which was attributed to complete thrombotic occlusion of left circumflex artery; this was removed but the patient suffered complications and died following intracranial hemorrhage. Patient 3 experienced chest pressure, diaphoresis shortness of breath and presyncope due to coronary artery occlusion; once stented he remained symptom-free. Patient 4 experienced chest pain and shortness of breath due to large thrombus in aortic valve; this was removed but one month later the thrombus returned and the patient died.
Yuzefpolskaya et al¹⁹	2016	Case Report	North America	1	In-hospital	LVAD; ECMO	Yes
Yuzefpolskaya et al¹⁹	This paper presents an algorithm for assessment and management of hospitalized unresponsive LVAD patients. A case study is presented by way of rationale for the algorithm in which a patient who was post-operative day 8 after LVAD implantation developed acute altered perfusion. Chest compressions were not initially performed as the patient was recently post-operative and it was unclear whether cardiac arrest had occurred. Chest compressions were ultimately initiate 15 minutes into the event and the patient was placed on VA-ECMO. After transfer to the ICU, the patient was pronounced brain dead.
Bouchez et al²⁰	2016	Case Report	Europe	2	Both in and out of hospital	LVAD	No
Bouchez et al²⁰	Two case reports of patients with LVADs who went into VF and developed deteriorating RV function. The authors describe a "treatment protocol" that includes augmenting MAP, addressing wall tension, treating electrical storm, and defibrillation.
Plymen et al²¹	2015	Case Report	Europe	1	In-hospital	LVAD; RVAD	Yes
Plymen et al²¹	Case report of a patient with LVAD who developed RV failure and arrhythmia after embolism. Patient was treated with a temporary RVAD and ultimately underwent heart transplant.
Mulukutla et al²²	2015	Case Report	North America	1	Out-of-Hospital	BiVAD	No
Mulukutla et al²²	Case report of patient with BiVAD who developed sustained, unstable VT who underwent VT ablation.
Wilson et al²³	2014	Case Report	Canada	1	In-hospital	LVAD	No
Wilson et al²³	Case report of a single patient with recurrent, brief cardiac arrest and loss of consciousness iso LVAD and fused aortic valve. Underwent aortic valve replacement with improvement.
Shinar et al²⁴	2014	Case Series	North America	8	Both In-and-Out of hospital	LVAD	Yes
Shinar et al²⁴	Case series of 8 patients who had LVADs and underwent chest compressions with a focus on cannula dislodgement. Eight patient records were reviewed revealing no apparent dislodgement after receiving chest compressions. In all cases with return of effective circulation, post-arrest pump flows were reported as stable. Three patients underwent autopsy, with no device dislodgement found—including an autopsy for a patient who underwent 2.5 hours of chest compressions. 6 of 8 (75%) patients had return of effective circulation and 4 patients (50%) survived with good neurologic outcomes.
Cubillo et al²⁵	2014	Case Report	North America	1	Out-of-Hospital	LVAD	Yes
Cubillo et al²⁵	Case report of emergency repair of an LVAD driveline that was accidentally transected resulting in cardiac arrest. Chest compressions were initiated by a bystander and then continued by paramedics. Patient was taken to the emergency department where LVAD flows were restored, however patient had sustained substantial neurologic injury.
Garg et al²⁶	2014	Case Series	North America	16	In-hospital	LVAD	No
Garg et al²⁶	Case series of 16 patients with continuous-flow LVADs who suffered in-hospital cardiac arrest. 9 patients (56.3%) received chest compressions and 2 (22.2%) of those who received chest compressions survived. 4 of 9 patients (44.4%) who received chest compressions had delays of at least 2 minutes before chest compression initiation. As compared to a non-LVAD cardiac arrest cohort, time to initiation of chest compressions was substantially longer.
Haglund et al²⁷	2014	Case Report	North America	1	In-hospital	LVAD	No
Haglund et al²⁷	Case report of a patient post-operative day 7 from LVAD implantation with acute hyperactive delirium with power source disconnection from his LVAD leading to cardiac arrest. He was found unresponsive and cyanotic. LVAD power was restored with improved perfusion, though low flow alarm continued. Chest compressions were not provided.
Duff et al²⁸	2013	Case Report	North America	2	In-hospital; Pediatrics Included	LVAD; BiVAD	No
Duff et al²⁸	Case report of cardiac arrest in two pediatric patients with ventricular assist devices. Patient 1 involved LVAD failure and circulatory arrest resulting from acute pulmonary hypertension triggered by post-anesthetic hypercarbia. Patient 2 involved episodic hypoperfusion.
Schweiger et al²⁹	2012	Case Report	Europe	1	Out-of-Hospital	LVAD	Yes
Schweiger et al²⁹	Case report of 2 patients with LVADs—one of which suffered acutely altered perfusion resulting in EMS response. Paramedics unsure of whether to do CPR and wife called VAD specialist. CPR advised but patient's wife declined.
Brenyo et al³⁰	2011	Case Report	North America	1	Out-of-Hospital	LVAD	No
Brenyo et al³⁰	Case report of patient with LVAD who suffered cardiac arrest with ventricular fibrillation and was defibrillated. He was comatose and treated with therapeutic hypothermia. After rewarming, had neurological recovery other than amnesia around the arrest event.
Rottenberg et al³¹	2011	Case Report	North America	1	In-hospital	LVAD; ECMO	Yes
Rottenberg et al³¹	Case report of patient sustaining cardiac arrest during redo sternotomy for LVAD exchange. Abdominal chest compressions were performed to avoid damage to inflow cannula.
Andersen et al³²	2009	Case Series	Europe	3	Out-of-Hospital	LVAD	Yes
Andersen et al³²	Case series of 23 patients with HeartMate II LVADs describing the incidence of VT/VF during 266 total months of follow up. They noted an incidence of 52%, with external defibrillator or ICD shock in 8 patients and significant hemodynamic instability in 3 patients.

Table 2: Studies Including Patients who Received Chest Compressions

Study	Number of Patients Receiving Chest Compressions	Device	Duration of Implantation prior to Chest Compressions	Cause of arrest	Outcome	Duration of Chest Compressions	Documentation of MCS Dislodgement or other Complication
Senman¹	24	HVAD, Heartmate 2, Heartmate 3	See reference	See reference	Hospital survival, survival with good neurologic outcome	See reference	None
Theeuwus et al³³	1	Heartmate 3	1.5 years	Unknown	ROSC obtained	2+ hours	None
Doita et al⁶	1	Heartware HVAD	1 year	Thrombosis	Expired in hospital after identification of hypoxemic ischemic encephalopathy	Not reported	None
Barssoum et al⁷	578	Unknown	Non-index admission	See reference	Hospital mortality	See reference	None
Esangbedo et al⁹	4	Patient 1 Heartmate-3; Patient 2 Jarvik 2015 LVAD & PediMag RVAD; Patient 3 HeartMate 3; Patient 4 Heartware HVAD	Patient 1 10 days; Patient 2 6 days; Patient 3 9 days; Patient 4 14-days	Patient 1 cardiac tamponade; Patient 2 accidental disconnection; Patient 3 hemorrhage; Patient 4 cardiac tamponade	Patient 1 hypoxemic ischemic encephalopathy and death; Patient 2 good neurologic outcome and transplantation; Patient 3 good neurologic outcome; Patient 4 good neurologic outcome	Patient 1 15 minutes; Patient 2 4 minutes; Patient 3 2 minutes; Patient 4 2 minutes	None
Iwashita et al¹²	1	Heartmate 2	2 years	Battery depletion	Hypoxemic ischemic encephalopathy and death	120 minutes	None
Saito et al¹⁴	1	Jarvik 2000 LVAD	401 days	Unknown	Good neurologic outcome and transplantation	Not reported	None
Ornato et al¹⁷	1	Not reported	Not reported	Not reported	Return of spontaneous circulation	Not reported	None
Yuzefpolskaya et al¹⁹	1	Heartmate 2	8 days	Unknown	Hypoxemic ischemic encephalopathy and death	30 minutes	None
Shinar et al²⁴	8	See reference					None
Cubillo et al²⁵	1	HeartWare LVAD	1.5 years	Driveline transection	Hypoxemic ischemic encephalopathy and death	Not reported	None
Garg et al²⁶	9	See reference					None
Retherford et al³⁴	1	Heartmate 2	3 years	Fractured driveline	Good neurologic outcome	30 minutes	None

Task Force Insights

1. Why this topic was reviewed.

This topic was chosen for review as 1) the prevalence of durable MCS devices, left ventricular assist devices (LVADs) in-particular, is increasing both in hospitals and the community 2) controversies regarding the optimal approach to the identification and the resuscitation of patients with acutely impaired perfusion supported by durable MCS 3) this topic has not been previously reviewed.

2. Narrative summary of evidence identified

Details of Included Studies

Of the 32 studies included, 22 (68.8%) were case reports including 2 or fewer patients, 8 (25.0%) were case series including 3-10 patients, and 2 (6.3%) were retrospective cohort studies including more than 10 patients. Eleven (34.4%) studies described a patient who suffered cardiac arrest and received chest compressions. Durable MCS in all studies was a left ventricular or biventricular assist device.

Identification of Altered Perfusion and Cardiac Arrest and Potential Delays in Resuscitation

Several studies highlighted the challenges of identifying durable MCS supported patients with acutely altered perfusion and cardiac arrest.^29,35-40 These studies documented complexity resulting from the expected pulselessness in continuous flow LVAD supported patients who do not have native heartrates. Other challenges described included the added difficulty of measuring blood pressure when electronic noninvasive blood pressure monitors are unreliable as well as challenges in determining adequate perfusion.

Delays in the initiation of chest compressions were documented in several reports.^38,41-43 In one study of hospitalized patients, 4 of 9 (44.4%) patients with LVADs who suffered cardiac arrest had delays of over two minutes prior to starting chest compressions.⁴¹ In addition, delays in chest compressions were longer for patients supported by LVADs as compared to a control cohort of cardiac arrest patients without durable MCS. In a report of 4 pediatric inpatients with durable MCS, delays in chest compressions were highlighted as a potential contributor to poor outcomes.³⁸ In the out-of-hospital settings, case reports highlighted delays in chest compressions due to paramedics being unsure of whether chest compressions can be administered to MCS supported patients.²⁹ In one study, the most common reason clinicians provided for not performing chest compressions in MCS supported patients with acutely impaired perfusion as a result of cardiac arrest was a belief that chest compressions are contra-indicated in patients with LVADs.¹

As a result of difficulty in the assessment of perfusion in durable MCS supported patients, as well as rescuer uncertainty with respect to the safety of chest compressions, a number of studies and reviews proposed algorithms for the resuscitation of patients with durable MCS.^{35,36,38,41,44}

Performance of Chest Compressions vs. No Chest Compressions with Respect to Patient Outcomes

Three studies included MCS supported patients who experienced cardiac arrest and reported outcomes in those who received chest compressions and those who did not. In the largest study leveraging the United States National Inpatient Sample, 578 patients with LVADs who had a cardiac arrest were identified.⁴⁵ Compared with patients who did not receive chest compressions, patients who received chest compressions had higher in-hospital mortality (74.3% vs 55%), and receipt of CPR was associated with worse outcomes after multivariate adjustment. While this study is the largest exploration of cardiac arrest in LVAD supported patients to date, it is limited by use of administrative, in-hospital data only which may lead to incomplete capture and misclassification of events. Risk adjustment may also be incomplete as only variables available in the database could be adjusted for in the multivariate model. Patients who received chest compressions may also have had higher illness severity at baseline, including higher sepsis rates.

In another study of 16 patients who experienced cardiac arrest while supported by an LVAD, 9 (56.3%) received chest compressions.⁴¹ Two of 9 (22.2%) patients who received chest compressions survived to discharge as compared to 3 of 7 (42.9%) who did not receive chest compressions. No specific comparison was made in the study between patients who did and did not receive chest compressions and adjustment for potential confounders was not performed. Both patients who received chest compressions and survived to hospital discharge had chest compressions initiated within 2 minutes of cardiac arrest, with non-survivors having longer delays to chest compressions. In a final retrospective cohort study including 58 LVAD supported patients who suffered cardiac arrest at a single center, 24 received chest compressions (41.3%). There was no difference in hospital survival (54% in those receiving chest compressions vs. 58% in those not receiving compressions), however those receiving chest compressions had longer resuscitation times and a higher rate of post-arrest neurologic injury (42% vs. 26%).¹

Outcomes Among Patients who have a Cardiac Arrest and Receive Chest Compressions

A total of 226 patients across 11 studies and two published scientific abstracts sustained cardiac arrest while supported by durable MCS and underwent chest compressions. Of this group, 173 (76.5%) were identified in a single study using the National Inpatient Sample, as detailed above.⁴⁵ Common causes of cardiac arrest resulting in need for chest compressions included device thrombus, cardiac tamponade, accidental disconnection, and driveline failure. Outcomes reported for patients who experienced cardiac arrest and received chest compressions were not standard across studies. Overall, 71 (31.4%) patients were reported as having a favorable outcome.

Device Dislodgement and Other Complications of Chest Compressions

No study reported dislodgement or other complications related to MCS device function after chest compressions. In one study, LVAD dislodgement after chest compressions was specifically considered through a combination of pump function assessment, imaging, and autopsy.³⁹ In that study including 8 patients who received chest compressions (all of whom were at least 50 days removed from LVAD implantation), no cases of dislodgement were identified. Three of the 8 patients underwent autopsy and the LVAD device was noted to be in appropriate position. This included one patient who underwent 2.5 hours of chest compressions. In one published abstract, an LVAD supported patient suffered cardiac arrest and was transported via air ambulance to an advanced care center while receiving chest compressions with a mechanical chest compression device. No dislodgement of the MCS device was identified.³³ Similarly, two patients in a case series undergoing mechanical chest compressions had no device dislodgment.¹ Five patients (4 children and 1 adult) received chest compression within 14-days of device implantation, without note of device dislodgment and all survived the initial resuscitation attempt.^38,44

3. Narrative Reporting of the task force discussions

The task force highlighted the overall thin evidence base to support recommendations regarding the optimal approach to resuscitation of MCS supported patients who experience acutely impaired perfusion. The majority of publications identified were case reports or case series. The few observational cohort studies that were identified all had significant limitations including confounding by indication, lack of generalizability, and a high risk of misclassification wherein patients with acutely impaired perfusion are designated as having a cardiac arrest but may not have actually suffered a cardiac arrest. There were no high-quality observational studies or randomized control trials identified.

The Task Force found the evidence compelling that there is low risk of device dislodgement from chest compressions. This followed from a finding of no reported device dislodgements identified in the scoping review. While a number of observational studies did find a higher risk of poor outcome when chest compressions were administered to patients with acutely impaired perfusion as a result of cardiac arrest as compared to no chest compressions, these observational studies were judged to be of low quality and at high risk for confounding.

The Task Force additionally reviewed a Scientific Statement from the American Heart Association and guidance from the British Societies LVAD Emergency Algorithm Working Group.^35,36 The Task Force generally had positive reviews of these documents. One area of discussion was around the British Societies recommendation to delay chest compressions in LVAD supported patients for up to two minutes while efforts to restart the device are made. The Task Force felt that these two minutes may be unnecessary, and efforts to restart the LVAD device could occur in parallel with chest compressions as long as multiple rescuers are available.

The scoping review did not identify a sufficient evidence base to support a systematic review or meta-analysis.

The Task Force suggested the following good practice statements:

In patients receiving durable mechanical circulatory support who develop acutely impaired perfusion because of cardiac arrest and who are not in the immediate peri-device implantation period, we suggest performing rather than withholding chest compressions.
When caring for patients with durable MCS who suffers acutely impaired perfusion as a result of cardiac arrest, we suggest minimizing delays in initiating chest compressions while simultaneously assessing for device-related reversible causes of acutely impaired perfusion.
We suggest rescuers follow an algorithmic approach to concurrently assess and respond to acutely impaired perfusion in patients receiving durable MCS.

Knowledge Gaps

ReferencesUncategorized References

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2. Sande Mathias I, Burkhoff D, Bhimaraj A. Cardiac Tamponade With a Transaortic Percutaneous Left Ventricular Assist Device: When Alarms Caused No Alarm. JACC Case Rep. 2023;19:101936. doi: 10.1016/j.jaccas.2023.101936

3. Victor S, Hayanga JWA, Bozek JS, Wendel J, Lagazzi LF, Hayanga HK. Cardiac Tamponade Causing Predominant Left Atrial and Ventricular Compression After Left Ventricular Assist Device Placement. Am J Case Rep. 2022;23:e938115. doi: 10.12659/ajcr.938115

4. Akin S, Ince C, Struijs A, Caliskan K. Case Report: Early Identification of Subclinical Cardiac Tamponade in a Patient With a Left Ventricular Assist Device by the Use of Sublingual Microcirculatory Imaging: A New Diagnostic Imaging Tool? Front Cardiovasc Med. 2022;9:818063. doi: 10.3389/fcvm.2022.818063

5. Ratman K, Biełka A, Kalinowski ME, Herdyńska-Wąs MM, Przybyłowski P, Zembala MO. Permanent cardiac arrest in a patient with a left ventricular assist device support. Kardiol Pol. 2022;80:709-710. doi: 10.33963/KP.a2022.0115

6. Doita T, Kawamura T, Inoue K, Kawamura A, Kashiyama N, Matsuura R, Saito T, Yoshioka D, Toda K, Miyagawa S. Sudden severe left ventricular assist device inflow cannula obstruction caused by huge thrombus after closure of mechanical aortic valve: case report. J Artif Organs. 2022;25:364-367. doi: 10.1007/s10047-022-01332-5

7. Barssoum K, Patel H, Rai D, Kumar A, Hassib M, Othman HF, Thakkar S, El Karyoni A, Idemudia O, Ibrahim F, et al. Outcomes of Cardiac Arrest and Cardiopulmonary Resuscitation in Patients With Left Ventricular Assist Device; an Insight From a National Inpatient Sample. Heart Lung Circ. 2022;31:246-254. doi: 10.1016/j.hlc.2021.05.096

8. Pokrajac N, Cantwell LM, Murray JM, Dykes JC. Characteristics and Outcomes of Pediatric Patients With a Ventricular Assist Device Presenting to the Emergency Department. Pediatr Emerg Care. 2022;38:e924-e928. doi: 10.1097/pec.0000000000002493

9. Esangbedo ID, Yu P. Chest Compressions in Pediatric Patients With Continuous-Flow Ventricular Assist Devices: Case Series and Proposed Algorithm. Front Pediatr. 2022;10:883320. doi: 10.3389/fped.2022.883320

10. Oates CP, Towheed A, Hadadi CA. Refractory hypoxemia from intracardiac shunting following ventricular tachycardia ablation in a patient with a left ventricular assist device. HeartRhythm Case Rep. 2022;8:760-764. doi: 10.1016/j.hrcr.2022.08.008

11. Ziegler LA, Pousatis S, Kaczorowski DJ, Madathil RJ. Emergency Splicing of Transected Ventricular Assist Device Driveline. Ann Thorac Surg. 2021;111:e329-e331. doi: 10.1016/j.athoracsur.2020.07.073

12. Iwashita Y, Ito A, Sasaki K, Suzuki K, Fujioka M, Maruyama K, Imai H. Cardiopulmonary resuscitation of a cardiac arrest patient with left ventricular assist device in an out-of-hospital setting: A case report. Medicine (Baltimore). 2020;99:e18658. doi: 10.1097/md.0000000000018658

13. Eyituoyo HO, Aben RN, Arinze NC, Vu DP, James EA. Ventricular Fibrillation 7 Years After Left Ventricular Assist Device Implantation. Am J Case Rep. 2020;21:e923711. doi: 10.12659/ajcr.923711

14. Saito S, Toda K, Miyagawa S, Yoshikawa Y, Hata H, Yoshioka D, Kainuma S, Yoshida S, Sawa Y. Therapeutic hypothermia after global cerebral ischemia due to left ventricular assist device malfunction. J Artif Organs. 2019;22:246-248. doi: 10.1007/s10047-019-01099-2

15. Harper R, Ludwig J, Morcos M, Morris S. Myocardial Irritation from a Left Ventricular Assist Device Resulting in Refractory Ventricular Tachycardia. J Emerg Med. 2019;56:87-93. doi: 10.1016/j.jemermed.2018.09.013

16. Thiele J, Matusch D, Reifferscheid F. Reanimation unter besonderen Umständen: Kreislaufstillstand bei implantiertem Linksherzassist-Device (LVAD). NOTARZT. 2018;34:188-191. doi: 10.1055/a-0581-8645

17. Ornato JP, Louka A, Grodman SW, Ferguson JD. How to determine whether to perform chest compressions on an unconscious patient with an implanted left ventricular assist device. Resuscitation. 2018;129:e12-e13. doi: 10.1016/j.resuscitation.2018.05.024

18. Godishala A, Nassif ME, Raymer DS, Hartupee J, Ewald GA, Larue SJ, Vader JM. A Case Series of Acute Myocardial Infarction in Left Ventricular Assist Device-Supported Patients. Asaio j. 2017;63:e18-e24. doi: 10.1097/mat.0000000000000401

19. Yuzefpolskaya M, Uriel N, Flannery M, Yip N, Mody K, Cagliostro B, Takayama H, Naka Y, Jorde UP, Goswami S, et al. Advanced cardiovascular life support algorithm for the management of the hospitalized unresponsive patient on continuous flow left ventricular assist device support outside the intensive care unit. Eur Heart J Acute Cardiovasc Care. 2016;5:522-526. doi: 10.1177/2048872615574107

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21. Plymen C, Pettit SJ, Tsui S, Lewis C. Right ventricular failure due to late embolic RV infarction during continuous flow LVAD support. BMJ Case Rep. 2015;2015. doi: 10.1136/bcr-2015-212174

22. Mulukutla V, Lam W, Simpson L, Mathuria N. Successful catheter ablation of hemodynamically significant ventricular tachycardia in a patient with biventricular assist device support. HeartRhythm Case Rep. 2015;1:209-212. doi: 10.1016/j.hrcr.2015.02.015

23. Wilson W, Goldraich L, Parry D, Cusimano R, Rao V, Horlick E. Cardiac arrest secondary to sudden LVAD failure in the setting of aortic valve fusion successfully managed with emergent transcatheter aortic valve replacement. Int J Cardiol. 2014;171:e40-41. doi: 10.1016/j.ijcard.2013.11.117

24. Shinar Z, Bellezzo J, Stahovich M, Cheskes S, Chillcott S, Dembitsky W. Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs). Resuscitation. 2014;85:702-704. doi: 10.1016/j.resuscitation.2014.01.003

25. Cubillo EIt, Weis RA, Ramakrishna H. Emergent reconnection of a transected left ventricular assist device driveline. J Emerg Med. 2014;47:546-551. doi: 10.1016/j.jemermed.2014.07.028

26. Garg S, Ayers CR, Fitzsimmons C, Meyer D, Peltz M, Bethea B, Cornwell W, Araj F, Thibodeau J, Drazner MH. In-hospital cardiopulmonary arrests in patients with left ventricular assist devices. J Card Fail. 2014;20:899-904. doi: 10.1016/j.cardfail.2014.10.007

27. Haglund NA, Schlendorf K, Keebler M, Gupta C, Maltais S, Ely EW, Lenihan D. Is a palpable pulse always restored during cardiopulmonary resuscitation in a patient with a left ventricular assist device? Am J Med Sci. 2014;347:322-327. doi: 10.1097/maj.0000000000000219

28. Duff JP, Decaen A, Guerra GG, Lequier L, Buchholz H. Diagnosis and management of circulatory arrest in pediatric ventricular assist device patients: presentation of two cases and suggested guidelines. Resuscitation. 2013;84:702-705. doi: 10.1016/j.resuscitation.2012.09.032

29. Schweiger M, Vierecke J, Stiegler P, Prenner G, Tscheliessnigg KH, Wasler A. Prehospital care of left ventricular assist device patients by emergency medical services. Prehosp Emerg Care. 2012;16:560-563. doi: 10.3109/10903127.2012.702192

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32. Andersen M, Videbaek R, Boesgaard S, Sander K, Hansen PB, Gustafsson F. 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. doi: 10.1016/j.healun.2009.03.011

33. Theeuwes C, Frost M, Vierecke J. (813) Prolonged Cardiopulmonary Resuscitation with Lucas Device in a Patient with Left Ventricular Assist Device. The Journal of Heart and Lung Transplantation. 2023;42:S356. doi: 10.1016/j.healun.2023.02.826

34. Retherford L, Miller S, Takayama H, Sladen R. 1222: RESUSCITATION OF A 46 YEAR OLD WOMAN WITH HEARTMATE II LVAD: TWO RESUSCITATIONS, TWO OUTCOMES. Critical Care Medicine. 2012;40:1-328. doi: 10.1097/01.ccm.0000425434.69410.a9

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EMBASE

Search #1

‘Heart-Assist Devices’/exp/mj OR ‘left ventricular assist device’/de OR ‘LVAD’:ti,ab OR ‘right ventricular assist device’:ti,ab OR ‘RVAD’:ti,ab OR ‘biventricular assist device’:ti,ab OR ‘BiVAD’:ti,ab OR ‘mechanical circulatory support’:ti,ab OR ‘assisted circulation’:ti,ab OR ‘assist device’:ti,ab OR ‘VAD’:ti,ab OR ‘Duraheart’:ti,ab OR ‘Jarvik’:ti,ab OR ‘Ventrassist’:ti,ab OR ‘Evaheart’:ti,ab OR ‘heartmate ii’:ti,ab OR ‘hm ii’:ti,ab OR ‘heartmate iii’:ti,ab OR ‘hm iii’:ti,ab OR ‘Heartware’:ti,ab

Search #2

‘Heart Arrest’/exp/mj OR ‘life support care’/de OR ‘life support’:ti,ab OR ‘cardiopulmonary resuscitation’:ti,ab OR ‘CPR’:ti,ab OR ‘chest compressions’:ti,ab OR ‘cardiac arrest’:ti,ab OR ‘heart arrest’:ti,ab OR ‘Shock’:ti,ab OR ‘Hypotension’:ti,ab OR ‘Unresponsiveness’:ti,ab OR ‘return of spontaneous circulation’:ti,ab OR ‘ROSC’:ti,ab OR ‘OHCA’:ti,ab OR ‘IHCA’:ti,ab OR ‘heart massage’:ti,ab OR ‘basic life support’:ti,ab OR ‘BLS’:ti,ab OR ‘advanced life support’:ti,ab OR ‘advanced cardiac life support’:ti,ab OR ‘ALS’:ti,ab OR ‘ACLS’:ti,ab OR ‘Asystole’:ti,ab OR ‘pulseless electrical activity’:ti,ab OR ‘PEA’:ti,ab OR ‘ventricular fibrillation’:ti,ab OR ‘Vfib’:ti,ab OR ‘ventricular tachycardia’:ti,ab OR ‘Vtach’:ti,ab OR ‘cardiovascular collapse’:ti,ab

Search #3

‘Extracorporeal Membrane Oxygenation’/exp/mj OR ‘ECMO’:ti,ab OR ‘Impella’:ti,ab OR ‘Roaflow’:ti,ab OR ‘CentriMag’:ti,ab OR ‘CardioHelp’:ti,ab

Search #4

Combined search results for #1 and #2 and excluded #3

#1 AND #2 NOT #3

Search #5

Applied Human as a filter to exclude animal studies

Applied filter for article type of: article/letter/article in press/editorial/preprint

Search #6

Retrieved only records in Embase by clicking on the Embase section in pie chart under sources

PubMed

("Heart-Assist Devices"[Mesh] OR "left ventricular assist device"[Title/Abstract] OR "LVAD"[Title/Abstract] OR "right ventricular assist device"[Title/Abstract] OR "RVAD"[Title/Abstract] OR "biventricular assist device"[Title/Abstract] OR "BiVAD"[Title/Abstract] OR "mechanical circulatory support"[Title/Abstract] OR "assisted circulation"[Title/Abstract] OR "assist device"[Title/Abstract] OR "VAD"[Title/Abstract] OR "Duraheart"[Title/Abstract] OR "Jarvik"[Title/Abstract] OR "Ventrassist"[Title/Abstract] OR "Evaheart"[Title/Abstract] OR "heartmate ii"[Title/Abstract] OR "hm ii"[Title/Abstract] OR "heartmate iii"[Title/Abstract] OR "hm iii"[Title/Abstract] OR "Heartware"[Title/Abstract])

AND

(“Heart Arrest"[Mesh] OR "life support care"[Title/Abstract] OR "life support"[Title/Abstract] OR "cardiopulmonary resuscitation"[Title/Abstract] OR "CPR"[Title/Abstract] OR "chest compressions"[Title/Abstract] OR "cardiac arrest"[Title/Abstract] OR "heart arrest"[Title/Abstract] OR "Shock"[Title/Abstract] OR "Hypotension"[Title/Abstract] OR "Unresponsive"[Title/Abstract] OR “unconscious”[title/abstract] OR "return of spontaneous circulation"[Title/Abstract] OR "ROSC"[Title/Abstract] OR "OHCA"[Title/Abstract] OR "IHCA"[Title/Abstract] OR "heart massage"[Title/Abstract] OR "basic life support"[Title/Abstract] OR "BLS"[Title/Abstract] OR "advanced life support"[Title/Abstract] OR "advanced cardiac life support"[Title/Abstract] OR "ALS"[Title/Abstract] OR "ACLS"[Title/Abstract] OR "Asystole"[Title/Abstract] OR "pulseless electrical activity"[Title/Abstract] OR "PEA"[Title/Abstract] OR "ventricular fibrillation"[Title/Abstract] OR "Vfib"[Title/Abstract] OR "ventricular tachycardia"[Title/Abstract] OR "Vtach"[Title/Abstract] OR "cardiovascular collapse"[Title/Abstract])

NOT

("Extracorporeal Membrane Oxygenation"[Mesh] OR “ECMO”[Title/Abstract] OR “Impella”[Title/Abstract] OR ”Rotaflow”[Title/Abstract] OR “CentriMag”[Title/Abstract] OR ”CardioHelp”[Title/Abstract])

Filters: Humans

Cochrane Review

("Heart-Assist Devices" OR "left ventricular assist device" OR "LVAD" OR "right ventricular assist device" OR "RVAD" OR "biventricular assist device" OR "BiVAD" OR "mechanical circulatory support" OR "assisted circulation" OR "assist device" OR "VAD" OR "Duraheart" OR "Jarvik" OR "Ventrassist" OR "Evaheart" OR "heartmate ii" OR "hm ii" OR "heartmate iii" OR "hm iii" OR "Heartware") AND ("Heart Arrest" OR "life support care" OR "life support" OR "cardiopulmonary resuscitation" OR "CPR" OR "chest compressions" OR "cardiac arrest" OR "heart arrest" OR "Shock" OR "Hypotension" OR "Unresponsive" OR "unconscious" OR "return of spontaneous circulation" OR "ROSC" OR "OHCA" OR "IHCA" OR "heart massage" OR "basic life support" OR "BLS" OR "advanced life support" OR "advanced cardiac life support" OR "ALS" OR "ACLS" OR "Asystole" OR "pulseless electrical activity" OR "PEA" OR "ventricular fibrillation" OR "Vfib" OR "ventricular tachycardia" OR "Vtach" OR "cardiovascular collapse") NOT ("Extracorporeal Membrane Oxygenation" OR "ECMO" OR "Impella" OR "Rotaflow" OR "CentriMag" OR "CardioHelp")

Resuscitation of Durable Mechanical Circulatory Supported Patients with Acutely Altered Perfusion or Cardiac Arrest: ALS ScR

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