**7. LVAD complications and emergency situations**

Strokes, infections, bleeding, right heart failure and device dysfunctions account for most of the long term complications that arise in LVAD patients. Neurologic complications appeared to have the most significant effect on survival with recurring events being detrimental to morbidity and mortality [44]. Patients with high or low INR (>3 or < 1.6), low albumin, or previous stroke seem to be at a much higher risk for post-LVAD strokes. Post-hemorrhagic management is with initiation of aspirin and an individualized approach to determine the safety of further anticoagulation. On the other hand, pump thrombosis leads to embolic stroke, noted mostly in HeartMate II. With the transition to HeartMateIII rates of pump thrombosis have declined [45]. A retrospective study noted the relationship between pre-LVAD cognitive assessment score and 900 day postoperative survival and neurological events [46]. Further evaluation of cognition may be beneficial in improving patient selection and outcomes.

Patients with LVADs are susceptible to postoperative infections, including infections that are unrelated to the LVAD. Infections in patients with LVADs have a significant effect on mortality [47]. After the post-operative course, infection of the driveline is the most dreaded, but almost inevitable complication. Despite attempts at innumerable educational sessions and sterile techniques, driveline infections will frequently occur. Once infected, it is a pathway to LVAD pocket infection as well. The only true treatment for the disastrous development of a device infection is explantation. Patients with controlled infections have been transplanted without a notable increase in mortality risk, but patients rejected due to multidrug resistant infections were not included in this assessment [48]. Most efforts have focused on preventing infection with some benefit to the silicone-to-skin interface at the driveline exit site. Progress in this area is lacking and may partly be due to non-standardized driveline implantation during surgery. Various studies using different antibiotics or horizontal orientation of the driveline have been attempted without significant differences [49].

Gastrointestinal bleeding is a notable comorbidity affecting 24–31% of LVAD recipients. There are no confirmed treatments that reduce its incidence. Some studies noted GDMT to decrease bleeding, however, no association was found during an INTERMACS registry analysis [50]. Acquired von Willebrand Syndrome had a notable increase in the post-LVAD population. Various factors from area of shear stress, to age, CRP, sex, blood type, and time with LVAD did not change prevalence. The effect of this syndrome was investigated in bleeding complications and no association was noted [51]. The typical approach to an LVAD patient with a GI bleed should start with an endoscopy plus colonoscopy, and push enteroscopy if negative. If the source is not found, capsule endoscopy is warranted. In patients with no visible source of bleeding then hemolysis, anemia of chronic disease, or arteriovenous malformations (AVMs) are expected etiologies. In patients with AVMs, antiangiogenic medications can be considered [52].
