15.4 Blood pressure management and heart failure medication
Many patients still suffer from volume overload after LT-MCS implantation [71, 377–384]. Therefore, most patients require diuretics after LVAD implantation. Diuretic doses must be reviewed regularly to ensure relief of fluid overload and to avoid depletion of intravascular volume, which could result in suction events, pump alarms, arrhythmias and syncope.
Hypertension leads to increased afterload for the LVAD, decreased LVAD flow and less effective left ventricular unloading [71, 377–384]. Furthermore, there is a significant association between Doppler-derived BP and a range of adverse events including intracranial haemorrhage, thromboembolic events and progressive aortic insufficiency [71, 377–385].
With CF-LVADs, conventional measurement of BP is difficult. Thus it is common practice to use a Doppler BP reading as the mean systemic BP [382]. Newer oscillometric devices show good correlation of systolic, diastolic and mean pressures in patients with a CF-LVAD in comparison with intra-arterial pressure [378].
As a therapy, angiotensin converting enzyme inhibitors or angiotensin receptor blockers are the first-line drugs for post-LT-MCS hypertension. Beta-blockers can be used in combination with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers but caution should be exercised in patients with marginal RV function. These agents may also be useful for rate control in the setting of atrial or ventricular arrhythmias (VAs). Calcium antagonists, especially the dihydropyridines, can be used as a third option. Aldosterone antagonists should be used for their potassium-sparing and antifibrotic effects.