Exchange techniques for implantable ventricular assist devices.

Implantable left ventricular assist devices (LVADs) are being used to support patients for longer periods because of longer transplant waiting times and the application of LVADs for destination therapy. With longer implant times comes LVAD exchange for component failure or serious device-related infection that cannot be treated medically. LVAD exchange should be performed promptly and planned in accordance with the patient's condition, the type of device previously implanted, and the type used for exchange, as well as whether total system or individual component replacement is required. Most patients who experience pump failure after extended support are in good condition. Preoperatively, patients must be stabilized using standard inotropic and vasoactive medications and undergo a complete workup, including echocardiography. Coagulation abnormalities should be corrected preoperatively. Intraoperatively, continuous transesophageal echocardiography and standard hemodynamic monitoring should be utilized. After opening the chest, LVAD support should be minimized to prevent air entry. Detailed descriptions of the following exchange procedures are presented: Jarvik 2000 to Jarvik 2000, HeartMate (VE or XVE) to HeartMate (VE or XVE), HeartMate (VE or XVE) to HeartMate II, and HeartMate II to HeartMate II. Although more reliable systems may offer longer support times, the need for exchange procedures will likely continue to increase.