Assessment of continuous flow VAD performance begins with evaluation of the four basic

distinct VAD parameters:

 Rotor speed—an adjustable parameter (in rotations per minute) that regulates the forward
flow of the VAD

 Power—directly measured (in watts) by the VAD

 Flow—unmeasured; rather, calculated parameter of output based on algorithm

incorporated rotor speed and power

 Pulsatility—reflects the dynamic nature of the pressure gradient between the left ventricle
and aorta during the cardiac cycle

The speed of the rotor regulates the forward flow of the VAD and is the sole adjustable
parameter of the VAD. Inadequate rotor speed can result in low, absent, or even retrograde VAD
flow. Excessive rotor speed can lead to high negative pressure in the left ventricle, resulting in a
small, overly decompressed left ventricle with a leftward septal shift. In extreme cases, the left
ventricle wall can be sucked into the inlet cannula, resulting in ventricular arrhythmias and low
VAD flow (commonly referred to as “suction events”).

Additionally, the septal shift may distort the geometry of the right ventricle as well and adversely
affect performance by both chamber dilation and annular dilation (causing increase in tricuspid
insufficiency). Real-time invasive hemodynamic data and echocardiographic data can be used to
select an optimum rotor speed that maximizes cardiac output while maintaining an appropriate
left ventricle size.

The frequency of the aortic valve on echocardiography is also used to determine the optimal
rotor speed. Opening of the aortic valve with each cardiac cycle suggests inadequate rotor speed.
Intermittent opening of the aortic valve is generally recommended, but not achievable in some
patients due to surgical closure of the aortic valve, aortic stenosis, or severely reduced native left
ventricle contractility.

Flow is also dependent upon the pressure gradient between the aorta and the left ventricle and the
structural integrity of the VAD. Because the VAD circuit must pump against the gradient
between the left ventricle and aorta, greater differences between aortic and left ventricle
pressures (due to high Doppler pressures or low left ventricle preload) results in reduced flow. A
diminished difference between aortic and left ventricle pressures (due to lower Doppler pressures
or higher left ventricle preload) will result in an increase in VAD flow.

In the presence of normal VAD function, increases in power correlate with increases in actual
flow (cardiac output). However, estimates of flow are not validated at extremely high or low
pump powers, so some interrogators will merely report flow as (– – –) or (+++) at extreme power
levels. Furthermore, there are situations (such as VAD rotor thrombus) in which a resultant
increase in power does not correlate with increase in actual flow (if anything, there will be a
decrease in actual flow). VADs cannot detect this and will report a misleading high flow state.

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Thus, the calculated flow should be taken into clinical context, rather than be interpreted
independently.

The degree of pulsatility is the last major parameter of continuous flow VADs. Pulsatility is
displayed differently by various VAD manufacturers. It can be displayed visually or quantified
as an indexed average between the peak and nadir of flow (pulsatility index).

Pulsatility is directly related to the degree of left ventricle contractility and inversely related to
the degree of assistance by the VAD. When VAD flow is high, left ventricle preload and left
ventricle contractility (by Frank–Starling mechanism) decrease. This results in a low pulsatility.

Conversely, low relative VAD flow or high left ventricle contractility will result in high
pulsatility. Lack of pulsatility suggests excessive VAD speeds or low left ventricle preload (due
to right ventricle dysfunction, dehydration, etc.). High pulsatility suggests that VAD speeds can
be increased or that left ventricle contractility has improved.

Abnormalities in the components of the VAD itself may present as abnormalities in VAD
parameters (Table IV). The inflow cannula, outflow cannula, and the pump itself can be
compromised by thrombus, kinking, and pannus ingrowth. Obstruction involving either the
inflow or outflow cannula presents with a decrease in flow and power.
Abnormalities of ventricular assist device function

Abnormality Presentation Comments

Outflow/inflow
Lower power and flow Echo and CT imaging helpful for diagnosis
cannula obstruction
The VAD reports flow as high, while true
VAD rotor malfunction High power and flow cardiac output is reduced. CT and echo may
be helpful
Sudden, transient drops Treatment options include increasing LV
Suction event
in power and flow preload or decreasing VAD rotor speed
Low flow, power, and May be due to low volume status, RV
Low LV filling/preload
pulsatility dysfunction, or excessive VAD rotor speed