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When a heart is too weak to pump enough blood, a mechanical pump can be implanted to do the work. It runs continuously on battery power through a cable that comes out through the abdomen. Because the pump provides a steady flow rather than a beat, many people with one have no pulse you can feel — which changes how they must be assessed and monitored.
What the device is
A durable left ventricular assist device (LVAD) is a continuous-flow rotary pump implanted at the apex of the left ventricle, drawing blood from the ventricle and returning it to the ascending aorta. It is powered through a driveline that tunnels out through the abdominal wall to an external controller and two batteries the patient carries at all times.
Devices are implanted with one of several intentions, and knowing which applies shapes the rehabilitation goal:
- Bridge to transplant — supporting the patient until a donor heart becomes available. See Heart Transplantation.
- Destination therapy — permanent support in a patient who is not a transplant candidate. This is now a large and growing proportion.
- Bridge to candidacy — support to allow reversible contraindications, such as pulmonary hypertension or deconditioning, to improve.
- Bridge to recovery — uncommon, in potentially reversible cardiomyopathy.
Contemporary practice is dominated by fully magnetically levitated pumps, which substantially reduced pump thrombosis and stroke compared with earlier designs in the MOMENTUM 3 trial and made destination therapy a realistic long-term option.1
Why the usual observations fail
Continuous flow means many supported patients have no palpable pulse. Pulse oximetry frequently fails to register, and an automated non-invasive blood pressure cuff commonly will not read at all. Blood pressure is measured with a manual cuff and a Doppler probe, giving a mean arterial pressure. Do not interpret an absent pulse or a failed oximeter as an emergency in a conscious, well-perfused patient — and do not interpret them as reassurance either. Assess the patient, not the numbers.
| Observation | What applies with a continuous-flow device |
|---|---|
| Pulse | Often absent or barely detectable |
| Blood pressure | Doppler mean arterial pressure; a target range is set by the implanting service (commonly in the region of 70–90 mmHg) |
| Pulse oximetry | Frequently unreadable; unreliable when it does read |
| Heart rate | From electrocardiogram, not palpation. Many patients also have a defibrillator |
| Device parameters | Flow, speed, power and pulsatility index on the controller — learn to read them and know the unit's normal range for that patient |
| Perfusion | Conscious level, capillary refill, skin, urine output and exercise tolerance carry more weight than usual |
Guidance written specifically for non-specialist clinicians managing these patients is available and worth reading before a first encounter.2
The driveline
Driveline infection is the commonest long-term complication and the main cause of readmission. The exit site is stabilised with an anchoring device and dressed under a strict protocol.
- Never allow traction on the driveline. During transfers, bed mobility, dressing and exercise, the line and controller must be secured and accounted for by a named person.
- No submersion — showering only with the approved covering system.
- Report exit-site redness, discharge, pain or fever immediately.
- Abdominal exercise and trunk work are modified around the exit site; agree the limits with the ventricular assist device coordinator rather than improvising.
Other complications that shape rehabilitation
- Bleeding. Patients are anticoagulated, and acquired von Willebrand factor abnormality plus reduced pulsatility promote gastrointestinal arteriovenous malformations. Gastrointestinal bleeding is common. Falls matter more than usual.
- Stroke — both ischaemic and haemorrhagic, and a leading cause of disability in this group.
- Right ventricular failure. The device supports the left ventricle only. Rising jugular venous pressure, peripheral oedema, ascites and falling device flows suggest right heart failure, which limits exercise and is not fixed by working harder.
- Suction events. If the ventricle is underfilled — dehydration, bleeding, excessive pump speed — the inflow cannula can collapse the ventricular wall against itself, triggering alarms, low flows and arrhythmia. Sudden dizziness or an alarm during exertion should stop the session and prompt review of volume status.
- Aortic insufficiency developing over time, and pump thrombosis, which presents with power spikes and haemolysis.
- Arrhythmia. Ventricular arrhythmia is often surprisingly well tolerated because the pump continues to flow — but it still needs treating.
Cardiopulmonary resuscitation in a device-supported patient is governed by the implanting service's protocol, and historical blanket prohibitions on chest compressions have been revised in recent guidance. Know the local protocol and the emergency contact for the ventricular assist device service before you treat the patient, not during an emergency.
Exercise training
Exercise capacity remains substantially reduced after implantation — the pump restores resting output far more completely than it restores exercise capacity, because peripheral muscle deconditioning, chronotropic limitation and right ventricular reserve all persist.3
The Rehab-VAD randomised trial demonstrated that supervised cardiac rehabilitation in patients with continuous-flow devices improved functional capacity and patient-reported health status, and current international guidance for mechanical circulatory support endorses structured rehabilitation.4,5
Practical prescription
- Prescribe by perceived exertion; heart rate is unreliable and blood pressure is inconvenient to measure mid-exercise.
- Progressive aerobic and resistance work, with trunk and abdominal loading agreed around the driveline site.
- Avoid prolonged Valsalva and sustained straining, which reduce preload in a preload-dependent circulation.
- Maintain hydration — hypovolaemia is a direct route to a suction event.
- Plan for the equipment. Batteries, controller, spare batteries and the emergency bag travel with the patient to every session.
- Train the carer as well as the patient. Equipment competence is part of the rehabilitation.
Role of the physiotherapist
Learn the device before the first session: type, driveline route, target mean arterial pressure, alarm meanings and the emergency contact. Assess perfusion clinically rather than through numbers that do not work. Protect the driveline absolutely. Train these patients — the evidence supports it and their limitation is largely peripheral — while watching for the specific failure modes of low preload, right ventricular failure and bleeding.
Evidence summary
Framing. Durable mechanical circulatory support has shifted from a short bridge to a long-term therapy, and a growing number of these patients live in the community for years.1,4 For physiotherapy the defining problem is that the standard cardiovascular assessment toolkit — pulse, cuff pressure, oximetry — is largely invalid, while the rehabilitation need is high and the evidence for training is favourable.
Evidence — the devicesMOMENTUM 3 established the superiority of the fully magnetically levitated centrifugal pump over the axial-flow predecessor for survival free of disabling stroke or reoperation, which is the basis of contemporary practice.1 The 2023 ISHLT guidelines for mechanical circulatory support are the reference standard for management, including rehabilitation and activity.4 Practical guidance for non-specialist providers covers the assessment problems described above.2
Evidence — exerciseRehab-VAD randomised supported patients to cardiac rehabilitation or usual care and found improved functional capacity and patient-reported health status.5 Reviews of exercise physiology in this population explain why peak oxygen uptake remains reduced despite restored resting output, and support training targeted at peripheral and ventilatory limitation rather than at pump output.3
Physiotherapy implicationsEstablish device type, target mean arterial pressure and emergency protocol before the first contact. Use Doppler for blood pressure and clinical signs for perfusion. Treat driveline security as a non-negotiable of every transfer. Prescribe by perceived exertion. Recognise suction events, right ventricular failure and gastrointestinal bleeding as distinct causes of a sudden fall in exercise tolerance, none of which respond to progression.
Evidence gapsTrials of exercise training in this population are small and single-centre, and the optimal intensity, modality and timing after implantation are undefined. There is no evidence base for abdominal and trunk loading limits around the driveline, which are set by convention. Rehabilitation models for long-term destination-therapy patients living in the community, particularly in regional settings, are largely undescribed.
References & evidence base
- Mehra MR, Uriel N, Naka Y, et al. A fully magnetically levitated left ventricular assist device — final report (MOMENTUM 3). N Engl J Med 2019;380(17):1618–1627.
- Ben Gal T, Ben Avraham B, Milicic D, et al. Guidance on the management of left ventricular assist device supported patients for the non-specialist healthcare provider: executive summary. Eur J Heart Fail 2021;23(10):1597–1609.
- Loyaga-Rendon RY, Plaisance EP, Arena R, Shah K. Exercise physiology, testing, and training in patients supported by a left ventricular assist device. J Heart Lung Transplant 2015;34(8):1005–1016.
- Saeed D, Feldman D, El Banayosy A, et al. The 2023 International Society for Heart and Lung Transplantation guidelines for mechanical circulatory support. J Heart Lung Transplant 2023;42(7):e1–e222.
- Kerrigan DJ, Williams CT, Ehrman JK, et al. Cardiac rehabilitation improves functional capacity and patient-reported health status in patients with continuous-flow left ventricular assist devices: the Rehab-VAD randomized controlled trial. JACC Heart Fail 2014;2(6):653–659.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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