Biventricular Assist Device Implantation

What is a biventricular assist device?

A biventricular assist device (BiVAD) is an implantable pump designed to help your heart function better when both the right and left pumping chambers of your heart are failing.

When blood from your body returns to the right side of your heart, the right ventricle (one of the pumping chambers) pumps the blood into your lungs to receive oxygen. The oxygen-rich blood then goes back to the left side of your heart, where your left ventricle pumps blood out through the main artery leaving your heart.

Under extreme circumstances, a person may need assistance in pumping blood from both the right ventricle into the lungs and the left ventricle out to the body. There are two main types of ventricular assist devices: a left ventricular assist device (LVAD) and a right ventricular assist device (RVAD). When used in combination, they are called a BiVAD. A BiVAD is a battery-operated pump that helps both your right and left ventricles move blood through your heart. Your surgeon implants a BiVAD during open-heart surgery.

Why might I need a biventricular assist device?

You may need a BiVAD if you are in severe heart failure. Heart failure means your heart is too weak to function normally. A BiVAD may be necessary:

• To keep your heart working during or after heart surgery until you recover

• To keep your heart working while you wait for a heart transplant

• As a permanent treatment for heart failure

What are the risks of biventricular assist device implantation?

BiVAD surgery is major surgery that requires general anesthesia to put you to sleep. Any general anesthesia has the risk of heart or brain injury. Major surgery also increases the risk of blood clots forming during or after surgery. These clots can break free, travel to your lungs (pulmonary embolism) or your brain (stroke), and block blood flow where the clot becomes lodged. Other risks of this surgery include:

• Infection

• Bleeding

• Device failure or device malfunction

• Abnormal heart rhythm (arrhythmia)

• Infection in your heart tissue (endocarditis)

• Damage to the kidneys (renal failure)

There may be other risks, depending on your specific health problem. Discuss any concerns with your healthcare provider before the procedure.

How do I get ready for biventricular assist device implantation?

Before surgery, your medical and surgical team will evaluate you. You will likely have X-rays, blood tests, and procedures to check the health of your lungs and heart. Your health team will also do a specific heart test called an echocardiogram (echo) and cardiac catheterization. An echocardiogram is an ultrasound that uses sound waves to make images of your heart.

Cardiac catheterization is used to look at circulation through the arteries in the heart muscle and to measure the amount of pressure inside the heart chambers and the lungs.

Other preparation may include:

• Your healthcare provider will explain the procedure to you and ask you if you have any questions.

• You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.

• Follow any directions you are given for not eating or drinking before the surgery.

• If you are pregnant or suspect that you are pregnant, tell your healthcare provider

• Tell your healthcare provider if you are sensitive to or are allergic to any medicines, iodine, latex, tape, or anesthesia (local and general).

• Tell your healthcare provider about all prescription and over-the-counter medicines and herbal supplements that you are taking.

• Tell  your healthcare provider if you have a history of bleeding disorders or if you are taking any blood-thinning (anticoagulant) medicines, aspirin, or other medicines that affect blood clotting. You may need to stop some or all of these medicines before to the procedure.

• Your healthcare provider may ask you to have a blood test before the procedure to find out how long it takes your blood to clot.

• If you smoke, you should stop smoking as soon as possible before the procedure. This may improve your chances for a successful recovery from surgery. It will also help your overall health.

Based on your health condition, your healthcare provider may give you other instructions for getting ready.

What happens during biventricular assist device implantation?

The operation may take between 4 and 6 hours. Here is how the surgery usually proceeds:

• You will be asked to remove any jewelry or other objects that may interfere with the procedure.

• You will be asked to remove your clothing and will be given a gown to wear.

• You will be asked to empty your bladder before the procedure.

• An IV (intravenous) line will be started in your arm or hand. Other catheters may be inserted in your neck and wrist to monitor your heart and blood pressure. They can also be used for taking blood samples. Other sites for these catheters include under the collarbone area and the groin.

• You will be put on the operating table, lying on your back.

• The anesthesiologist will give you some medicine to help you relax and fall asleep. They will monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated, a breathing tube will be put through your throat into your lungs. You will be connected to a breathing machine (ventilator). It will breathe for you during the surgery.

• A catheter will be put into your bladder to drain urine.

• The skin over the surgical site will be cleansed with an antiseptic solution.

• The surgeon will make a cut (incision) in the front of your chest, down through your chest wall to reach your heart. They will put tubes into your heart, so that a cardiopulmonary machine can keep your blood moving during the surgery.

• The surgeon will put a tube into your right atrium or ventricle. The tube is attached to a pump. Anohter tube from the pump will be attached to your pulmonary artery. The pump will circulate blood in the right side of your heart, through the pump and out the pulmonary artery to your lungs, to get oxygen.

• For the left side of your heart, your surgeon will put a tube into your left ventricle and attach it to a second pump. They will then connect another outflow tube to the pump and attach it to your aorta. This pump will circulate blood in the left side of your heart, through the pump, and out the aorta to the rest of your body.

• With inflow and outflow tubes for each side of your heart attached to their own pump, your surgeon will implant the two pumps either inside your upper belly or on the outside of your skin.

• A cable that comes out through your skin connects the pumps to a power source and a system controller that you will wear on the outside of your body.

• After all of the attachments have been completed, the pumps will be turned on to restore blood flow through your heart, lungs, and aorta.

• Once the procedure has been completed, the blood circulating through the bypass machine will be allowed to reenter your heart and the tubes to the bypass machine will be removed. 

• The incisions will be closed with sutures or surgical staples.

• Tubes will be inserted into your chest to drain blood and other fluids from around the heart. These tubes will be connected to a suction device to drain fluids away from the heart.

• A tube will be inserted through your mouth or nose into your stomach to drain stomach fluids.

• A sterile bandage or dressing will be applied to the incisions.

What happens after biventricular assist device implantation?

In the hospital 

The length of time you stay in the hospital will depend on your overall condition after surgery. 

• For the first few days, you will be in intensive care (ICU) where you can be monitored closely until your vital signs have stabilized. 

• As you recover, the tubes that give you nourishment, help you breathe, and drain fluids from your body will gradually be removed. 

• You may have temporary pacing wires that are placed during the surgery. These wires will be removed once it is determined that your heart rhythm is stable and you no longer need them.

• Physical rehabilitation (cardiac rehab or physical therapy) and pulmonary rehabilitation are important for your long term recovery. You will begin a step-wise program of increasing time and intensity of activity in preparation for going home. 

• You will be given an incentive spirometer (IS) device to use often to help expand your lungs and prevent pneumonia after the surgery. 

Caregivers will help you care for your incision, provide pain relief measures, and get you up walking.

Before you leave the hospital, you will be taught how to care for the BiVAD. You will learn how it works and what to do if its alarm goes off, or there is a power loss. You will also learn how to travel with your BiVAD and keep your battery and controller dry when you bathe.

At home

Once your healthcare providers feel that you have recovered enough, you will be discharged home. Follow all your instructions for medicines, pain control, diet, activity, bathing, and wound care. Make sure to keep all of your follow-up appointments. If you are waiting for a heart transplant, make sure to keep in close contact with your transplant center.

Other common instructions after surgery include:

• Walk every day, or as advised by your healthcare provider.

• Don't do any heavy lifting.

• Gradually resume normal activities as much as possible (ask your healthcare provider about driving, working, and sexual activity). You maybe asked not drive a car for a period after the surgery to allow for healing of the breastbone (sternum) and muscles of the chest wall.

• Check your wounds for any sign of swelling, redness, bleeding, or discharge and report these to your medical and surgical team.

• Let your healthcare provider know about any increasing pain, fever, chest pain, or shortness of breath.

• Eat a heart-healthy diet and maintain a healthy weight. Eat foods that are low in salt, cholesterol and fat. Try to eat fruits, vegetables and lean meats.

• Don't smoke and stay away from secondhand smoke. Don't use any tobacco products, including electronic cigarettes.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how you will get the results

• Who to call after the test or procedure if you have questions or problems

• How much you will have to pay for the test or procedure