Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://cr.elmerpub.com

Review

Volume 17, Number 6, December 2026, pages 561-571

Clinically Actionable Prevention and Management of Major Complications During Durable Left Ventricular Assist Device Support: A Contemporary Narrative Review

↓ Figure 1. Four-domain surveillance and escalation framework for durable LVAD support. LVAD: left ventricular assist device.

↓ **Table 1.** Practical Framework for Prevention, Surveillance, and Escalation of Major Complications During Durable LVAD Support
Complication domain	Main mechanisms	Surveillance signals	Prevention focus	Escalation triggers
AR: aortic regurgitation; BP: blood pressure; CRP: C-reactive protein; CT: computed tomography; CVP: central venous pressure; eGFR: estimated glomerular filtration rate; FAC: fractional area change; GI: gastrointestinal; HF: heart failure; INR: international normalized ratio; LDH: lactate dehydrogenase; LV: left ventricular; LVAD: left ventricular assist device; MAP: mean arterial pressure; PAP: pulmonary artery pressure; PAPi: pulmonary artery pulsatility index; PET: positron emission tomography; PVR: pulmonary vascular resistance; RA/PCWP: right atrial/pulmonary capillary wedge pressure; RHF: right heart failure; RV: right ventricular; SAVR: surgical aortic valve replacement; TAPSE: tricuspid annular plane systolic excursion; TAVR, transcatheter aortic valve replacement; TEE: transesophageal echocardiography; TR: tricuspid regurgitation; VKA: vitamin K antagonist; WBC: white blood cell.
Right heart failure	RV preload-afterload mismatch, septal shift, pulmonary hypertension, tricuspid regurgitation	CVP or right atrial pressure, PAP/PVR, PAPi, RA/PCWP ratio, TAPSE, RV S', FAC or strain when available, TR severity, septal position, congestion, renal/hepatic indices, inotrope need	Preoperative decongestion, pulmonary vascular optimization, rhythm and ventilatory optimization, intraoperative TEE-guided pump-speed titration, planned RV support strategy in high-risk patients	Persistent low output, escalating inotropes or vasopressors, refractory venous congestion, worsening renal/hepatic function, lactate rise, need for temporary RV mechanical support
Aortic regurgitation	Reduced aortic valve opening, commissural fusion, altered aortic root flow, low pulsatility, aortic root remodeling	Symptoms, pulse pressure/MAP, aortic valve opening frequency, AR severity on echocardiography, LV size, filling pressures, pump flow/power trends	Blood pressure control, speed optimization to avoid persistent valve closure when feasible, serial valve assessment, consideration of concomitant valve intervention at implant when indicated	Hemodynamically significant recirculation, recurrent HF symptoms, repeated hospitalization, progressive LV dilation, consideration of TAVR, redo SAVR, valve repair/replacement or closure
Pump thrombosis/thromboembolism	Flow disturbance, blood-material interaction, subtherapeutic anticoagulation, infection, cannula/graft malposition, low-flow states	LDH, plasma-free hemoglobin, hemoglobinuria/dark urine, pump power or flow change, alarms, neurologic events, echo ramp response, CT for cannula/outflow graft assessment	Stable VKA-based anticoagulation, protocolized perioperative heparin transition, infection control, BP control, device-position assessment, adherence support	Rising hemolysis markers with device dysfunction, recurrent low-flow/power abnormalities, stroke/systemic embolism, refractory hemolysis, need for thrombolysis or pump exchange
Bleeding	Shear-related platelet dysfunction, acquired von Willebrand syndrome, angiodysplasia, antithrombotic exposure	Hemoglobin trend, occult/overt GI bleeding, transfusion need, INR stability, antiplatelet exposure, renal/liver dysfunction	Individualized antithrombotic intensity, anemia surveillance, BP and device optimization, avoidance of unnecessary antiplatelet therapy in selected HM3 recipients	Recurrent bleeding, hemodynamic instability, repeated anticoagulation interruption, transfusion dependence, need for endoscopy or multidisciplinary antithrombotic revision
Driveline/device infection	Percutaneous exit-site vulnerability, trauma, dressing disruption, diabetes, malnutrition, prolonged support duration	Exit-site pain, erythema diameter, warmth, induration, drainage amount/character, granulation tissue, driveline instability, DESTINE or modified Sharp Memorial score, cultures, CRP/WBC, blood cultures, ultrasound or CT/PET-CT when deep infection suspected	Driveline stabilization, standardized dressing protocol, exit-site hygiene, patient/caregiver education, early treatment of trauma or drainage, outpatient surveillance	Deep/tunnel infection, pump-pocket or pump infection, bacteremia, recurrent infection, systemic illness, transplant/device-exchange implications
Renal and end-organ dysfunction	Venous congestion, low output, perioperative injury, RHF, recurrent adverse events, nephrotoxic exposure	Creatinine/eGFR, urine output, bilirubin/transaminases, lactate, nutrition/frailty, diuretic response, congestion markers	Congestion control, RV protection, medication review, renal-dose adjustment, early complication treatment, nutritional and rehabilitation support	Progressive renal/hepatic dysfunction, refractory congestion, worsening frailty or malnutrition, transplant candidacy impact, need for higher-intensity follow-up

↓ Table 1. Practical Framework for Prevention, Surveillance, and Escalation of Major Complications During Durable LVAD Support

Complication domain

Main mechanisms

Surveillance signals

Prevention focus

Escalation triggers

AR: aortic regurgitation; BP: blood pressure; CRP: C-reactive protein; CT: computed tomography; CVP: central venous pressure; eGFR: estimated glomerular filtration rate; FAC: fractional area change; GI: gastrointestinal; HF: heart failure; INR: international normalized ratio; LDH: lactate dehydrogenase; LV: left ventricular; LVAD: left ventricular assist device; MAP: mean arterial pressure; PAP: pulmonary artery pressure; PAPi: pulmonary artery pulsatility index; PET: positron emission tomography; PVR: pulmonary vascular resistance; RA/PCWP: right atrial/pulmonary capillary wedge pressure; RHF: right heart failure; RV: right ventricular; SAVR: surgical aortic valve replacement; TAPSE: tricuspid annular plane systolic excursion; TAVR, transcatheter aortic valve replacement; TEE: transesophageal echocardiography; TR: tricuspid regurgitation; VKA: vitamin K antagonist; WBC: white blood cell.

Right heart failure

RV preload-afterload mismatch, septal shift, pulmonary hypertension, tricuspid regurgitation

CVP or right atrial pressure, PAP/PVR, PAPi, RA/PCWP ratio, TAPSE, RV S', FAC or strain when available, TR severity, septal position, congestion, renal/hepatic indices, inotrope need

Preoperative decongestion, pulmonary vascular optimization, rhythm and ventilatory optimization, intraoperative TEE-guided pump-speed titration, planned RV support strategy in high-risk patients

Persistent low output, escalating inotropes or vasopressors, refractory venous congestion, worsening renal/hepatic function, lactate rise, need for temporary RV mechanical support

Aortic regurgitation

Reduced aortic valve opening, commissural fusion, altered aortic root flow, low pulsatility, aortic root remodeling

Symptoms, pulse pressure/MAP, aortic valve opening frequency, AR severity on echocardiography, LV size, filling pressures, pump flow/power trends

Blood pressure control, speed optimization to avoid persistent valve closure when feasible, serial valve assessment, consideration of concomitant valve intervention at implant when indicated

Hemodynamically significant recirculation, recurrent HF symptoms, repeated hospitalization, progressive LV dilation, consideration of TAVR, redo SAVR, valve repair/replacement or closure

Pump thrombosis/thromboembolism

Flow disturbance, blood-material interaction, subtherapeutic anticoagulation, infection, cannula/graft malposition, low-flow states

LDH, plasma-free hemoglobin, hemoglobinuria/dark urine, pump power or flow change, alarms, neurologic events, echo ramp response, CT for cannula/outflow graft assessment

Stable VKA-based anticoagulation, protocolized perioperative heparin transition, infection control, BP control, device-position assessment, adherence support

Rising hemolysis markers with device dysfunction, recurrent low-flow/power abnormalities, stroke/systemic embolism, refractory hemolysis, need for thrombolysis or pump exchange

Bleeding

Shear-related platelet dysfunction, acquired von Willebrand syndrome, angiodysplasia, antithrombotic exposure

Hemoglobin trend, occult/overt GI bleeding, transfusion need, INR stability, antiplatelet exposure, renal/liver dysfunction

Individualized antithrombotic intensity, anemia surveillance, BP and device optimization, avoidance of unnecessary antiplatelet therapy in selected HM3 recipients

Recurrent bleeding, hemodynamic instability, repeated anticoagulation interruption, transfusion dependence, need for endoscopy or multidisciplinary antithrombotic revision

Driveline/device infection

Percutaneous exit-site vulnerability, trauma, dressing disruption, diabetes, malnutrition, prolonged support duration

Exit-site pain, erythema diameter, warmth, induration, drainage amount/character, granulation tissue, driveline instability, DESTINE or modified Sharp Memorial score, cultures, CRP/WBC, blood cultures, ultrasound or CT/PET-CT when deep infection suspected

Driveline stabilization, standardized dressing protocol, exit-site hygiene, patient/caregiver education, early treatment of trauma or drainage, outpatient surveillance

Deep/tunnel infection, pump-pocket or pump infection, bacteremia, recurrent infection, systemic illness, transplant/device-exchange implications

Renal and end-organ dysfunction

Venous congestion, low output, perioperative injury, RHF, recurrent adverse events, nephrotoxic exposure

Creatinine/eGFR, urine output, bilirubin/transaminases, lactate, nutrition/frailty, diuretic response, congestion markers

Congestion control, RV protection, medication review, renal-dose adjustment, early complication treatment, nutritional and rehabilitation support

Progressive renal/hepatic dysfunction, refractory congestion, worsening frailty or malnutrition, transplant candidacy impact, need for higher-intensity follow-up

↓ **Table 2.** Phase-Based Surveillance Checklist for Durable LVAD Recipients
Care phase	Core clinical questions	Minimum surveillance elements	Common action points
AR: aortic regurgitation; AV: aortic valve; BP: blood pressure; CT: computed tomography; FAC: fractional area change; INR: international normalized ratio; LDH: lactate dehydrogenase; LV: left ventricular; LVAD: left ventricular assist device; MAP: mean arterial pressure; PAP: pulmonary artery pressure; PAPi: pulmonary artery pulsatility index; PVR: pulmonary vascular resistance; RA/PCWP: right atrial/pulmonary capillary wedge pressure; RV: right ventricular; SAVR: surgical aortic valve replacement; TAPSE: tricuspid annular plane systolic excursion; TAVR: transcatheter aortic valve replacement;TEE: transesophageal echocardiography; TR: tricuspid regurgitation.
Preoperative/candidacy	Is the patient likely to tolerate LV unloading and long-term support?	RV function, TAPSE/RV S'/FAC or strain, TR severity, RA pressure, PAP/PVR, PCWP, PAPi, RA/PCWP ratio, renal/hepatic function, nutrition/frailty, infection risk, psychosocial support	Optimize congestion, treat reversible pulmonary hypertension, plan RV support strategy, address infection/nutrition, educate patient and caregivers
Early postoperative	Is effective forward flow achieved without RV failure, bleeding, or major hemocompatibility disturbance?	Hemodynamics, echo/TEE, septal position, LV size, AV opening, volume status, chest tube output, coagulation profile, renal/liver tests, lactate, urine output, LDH/plasma-free hemoglobin, device trends	Adjust pump speed, titrate inotropes/vasodilators, restart heparin only after bleeding control, stabilize anticoagulation, escalate RV support when needed
Stable outpatient follow-up	Is the patient stable across flow, hemocompatibility, infection, and end-organ domains?	Symptoms, MAP/BP, INR and adherence, hemoglobin, LDH, renal/liver function, driveline score/site findings, alarms and device log, interval echo including AV opening and AR severity	Reinforce education, adjust BP/anticoagulation, investigate anemia/hemolysis, standardize driveline care, adjust follow-up intensity by risk
Deterioration/recurrent admission	Which complication is driving instability, and has the escalation threshold been crossed?	Focused echo or ramp study when stable, device log review, hemolysis panel, cultures and inflammatory markers, CT when cannula/outflow/deep infection suspected, neurologic assessment, renal/hepatic trend	Multidisciplinary review, intensify surveillance, treat driver complication, consider TAVR/SAVR, RV support, device exchange, transplant pathway, or palliative goals when appropriate

↓ Table 2. Phase-Based Surveillance Checklist for Durable LVAD Recipients

Care phase

Core clinical questions

Minimum surveillance elements

Common action points

AR: aortic regurgitation; AV: aortic valve; BP: blood pressure; CT: computed tomography; FAC: fractional area change; INR: international normalized ratio; LDH: lactate dehydrogenase; LV: left ventricular; LVAD: left ventricular assist device; MAP: mean arterial pressure; PAP: pulmonary artery pressure; PAPi: pulmonary artery pulsatility index; PVR: pulmonary vascular resistance; RA/PCWP: right atrial/pulmonary capillary wedge pressure; RV: right ventricular; SAVR: surgical aortic valve replacement; TAPSE: tricuspid annular plane systolic excursion; TAVR: transcatheter aortic valve replacement;TEE: transesophageal echocardiography; TR: tricuspid regurgitation.

Preoperative/candidacy

Is the patient likely to tolerate LV unloading and long-term support?

RV function, TAPSE/RV S'/FAC or strain, TR severity, RA pressure, PAP/PVR, PCWP, PAPi, RA/PCWP ratio, renal/hepatic function, nutrition/frailty, infection risk, psychosocial support

Optimize congestion, treat reversible pulmonary hypertension, plan RV support strategy, address infection/nutrition, educate patient and caregivers

Early postoperative

Is effective forward flow achieved without RV failure, bleeding, or major hemocompatibility disturbance?

Hemodynamics, echo/TEE, septal position, LV size, AV opening, volume status, chest tube output, coagulation profile, renal/liver tests, lactate, urine output, LDH/plasma-free hemoglobin, device trends

Adjust pump speed, titrate inotropes/vasodilators, restart heparin only after bleeding control, stabilize anticoagulation, escalate RV support when needed

Stable outpatient follow-up

Is the patient stable across flow, hemocompatibility, infection, and end-organ domains?

Symptoms, MAP/BP, INR and adherence, hemoglobin, LDH, renal/liver function, driveline score/site findings, alarms and device log, interval echo including AV opening and AR severity

Reinforce education, adjust BP/anticoagulation, investigate anemia/hemolysis, standardize driveline care, adjust follow-up intensity by risk

Deterioration/recurrent admission

Which complication is driving instability, and has the escalation threshold been crossed?

Focused echo or ramp study when stable, device log review, hemolysis panel, cultures and inflammatory markers, CT when cannula/outflow/deep infection suspected, neurologic assessment, renal/hepatic trend

Multidisciplinary review, intensify surveillance, treat driver complication, consider TAVR/SAVR, RV support, device exchange, transplant pathway, or palliative goals when appropriate