Friday Board Review

Cardiology Board Review by Dr. Alex Hilbmann

You are asked to see a patient with a known history of Left Ventricular Assist Device (LVAD) due to end stage heart failure who presents after becoming more confused in the Emergency Department waiting room. Per family the patient was originally presenting due to feeling lightheaded/fatigued recently. The patient does not have a pulse and the automatic/manual blood pressure cuff does not determine a blood pressure. Patient cannot follow commands but localizes to pain in all four extremities. Capillary refill < 2 seconds. What should be done next?

A. Begin chest compressions

B. Auscultate heart

C. Point of care echocardiogram

D. Portable CXR

Answer: Auscultate heart

The first thing that should be done for this patient is auscultate his heart to note if an audible “whirr” is present. If it is present, this would indicate that his LVAD is in fact operating. Patients who have an LVAD do not have a palpable pulse/blood pressure therefore in this population it does not indicate that their LVAD is currently not working/they are not perfusing. An ultrasound with doppler may be used to obtain a blood pressure reading. Chest compressions should be withheld until absolutely necessary given the chance to potentially dislodge the LVAD causing dysfunction or left ventricular rupture. The chance of chest compressions causing damage to LVAD can be minimized by paying attention to positioning of compressions and avoiding unnecessarily deep compressions. It would be reasonable to begin compressions if low perfusion state suggested by exam (mental status change, skin mottling, capillary refill >2 seconds). Auscultation of the heart would be the most timely and effective method in recognizing functionality of patient’s LVAD. Given patient’s exam concerning for altered mental status without other findings for low perfusion, CPR can briefly be held until further evaluation determines concern for hypoperfusion.


Guglin, Maya (2018) “Approach to Unresponsive Patient with LVAD,” The VAD Journal: Vol. 4, Article 2.
Available at:

Tintinalli, J., Ma, O., Yealy, D., Meckler, G., Cline, D., Thomas, S. and Stapczynski, J., 2020. Tintinalli’s emergency medicine. 9th ed. [New York]: McGraw-Hill Education, pp.382

Yuzefpolskaya M, Uriel N, Flannery M, Yip N, Mody K, Cagliostro B, Takayama H, Naka Y, Jorde UP, Goswami S, Colombo PC. 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 Dec;5(8):522-526. doi: 10.1177/2048872615574107. Epub 2015 Mar 4. PMID: 25740223.

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