UHM 2018, Vol. 45, No.
1 – CASE: TREATING A PATIENT WITH LVAD WHILE IN THE HYPERBARIC CHAMBER
Case Report
An approach to treating a patient with a HeartMate IITM left ventricular
assist device in a multiplace hyperbaric chamber: a case report
D. Orwig, C. Logue, S. Hendriksen, B. Westgard, J. Walter, M. Pullis, T. Masters
Hennepin County Medical Center, Minneapolis, Minnesota U.S.
CORRESPONDING AUTHOR: Drue Orwig – drueorwig@gmail.com
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ABSTRACT
Introduction: Left-ventricular assist devices (LVAD) are
becoming a common therapy for end-stage heart failure.
These devices are not tested for pressurization in a hyperbaric
chamber by the manufacturer. In this article, we present
an approach to modify the power supply in order to safely
treat a patient with an LVAD.
Materials and methods: Our patient had a HeartMate IITM
LVAD and presented for hyperbaric oxygen treatments for
severe radiation cystitis. In order to modify this patient’s
equipment to be compliant with NFPA6 safety standards we
made several modifications. In brief, this included eliminating
the usage of lithium-ion batteries, modifying the cord to be
compatible with Fink chamber outlets, and enclosing the
power module in a nitrogen purge. We then used a mock cir-
culatory system to test our modifications and make sure the
LVAD continued to have appropriate flow rates. We then
conducted training for staff and developed a disaster plan
should the LVAD fail at any point.
Results: Once we felt comfortable with the modifications
and had a plan developed should any problems arise, we then
proceeded to treat our patient in the hyperbaric chamber.
He successfully underwent 44 hyperbaric treatments for
radiation cystitis without complications.
Conclusion: This case is the second reported patient
in the literature with an LVAD that was successfully treated
in a multiplace hyperbaric chamber. As LVADs become in-
creasingly popular to manage heart failure, more patients
with these devices will present for hyperbaric treatments.
With a few modifications, an LVAD patient can be safely and
successfully treated in a hyperbaric chamber.
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KEYWORDS: left-ventricular assist device; Heartmate II; hyperbaric oxygen
Copyright © 2018 Undersea & Hyperbaric Medical Society, Inc.
Introduction
Approximately 500,000 patients in the United States
are living with advanced heart failure [1]. Of these,
50,000-100,000 would benefit from a left-ventricular
assist device (LVAD) [2]. The LVAD device is a bridge
therapy to a heart transplant for many patients with
end-stage heart failure (New York Heart Association IV),
or it can also be used as a temporizing measure in
reversible cardiomyopathies. In those patients who
are not heart transplant candidates, an LVAD can also
be used as definitive management for congestive heart
failure.
There are several models of LVADs. The Heart-
Mate IITM is one of the more widely used models.
Introduced in 2008, there is a HeartMate III model
currently undergoing investigational studies. However,
to date, LVADs have not been tested for pressur-
ization by the manufacturer. Given the growing
population of patients with these devices in place, it is
imperative to know the device’s pressure tolerance in
order to ensure safety in the hyperbaric environment.
We present an LVAD patient who was successfully
treated for radiation cystitis with hyperbaric oxygen.
We highlight the necessary modifications of the power
supply to ensure safety under pressurization, present
an approach to problems should they arise, and outline
a treatment checklist to ensure safety of patient and
staff prior to initiating hyperbaric treatments.
CASE
Our patient was an 81-year-old male with a Heart-
Mate II LVAD placed in 2012 for ischemic cardio-
myopathy. Given his age, he was not a candidate for
heart transplant. In addition to end-stage congestive
heart failure (CHF), he had a history of prostate can-
cer in 2009 that was treated with 7560 cGy of radiation.
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UHM 2018, Vol. 45, No. 1 – CASE: TREATING A PATIENT WITH LVAD WHILE IN THE HYPERBARIC CHAMBER
For 12 weeks prior to the initial consult with this
patient, he had significant hematuria, clots and blood
loss anemia that required transfusion. He had also
suffered from severe bladder spasms and urinary reten-
tion. Prior treatments had included clot evacuation
and unsuccessful bladder fulguration. Subsequently the
patient had bilateral nephrostomy tubes placed to
decompress the bladder and thereby minimize the
frequency and severity of his bladder spasms. His anti-
platelet and anticoagulant medications were also
discontinued at that time. Given the severity of symp-
toms from his radiation cystitis, it was decided that the
benefits of treatment with hyperbaric oxygen to heal
the radiation injury of the bladder outweighed the
risks of placing an LVAD in the chamber.
Background
Current left-ventricular assist devices use a continuous
axial-flow rotary pump to push blood from the left
ventricle into the aorta. This pump is controlled by a
power “pocket” controller strapped to the patient’s
waist. The controller has a lithium-ion battery (11V)
inside with a 15-minute emergency backup power
supply if other power sources fail. When the patient
is ambulatory, power for the controller is supplied by
two lithium-ion batteries that are worn as holsters in
a backpack. When the patient is at home, the controller
is hooked up to a power module that can be plugged
into a standard three-pronged outlet (120V). The power
module has a nickel-metal hydride battery and is
designed to be constantly recharging while plugged in.
If this battery is removed, the power module is de-
signed to alarm continuously.
Lithium-ion batteries and the power module present
significant safety concerns in the hyperbaric environ-
ment. Since 2012 the National Fire Protection Asso-
ciation standards for health care facilities (NFPA 99 [6])
prohibits lithium and lithium ion batteries in a Class A
chamber due to the history of explosion when they
cannot be vented. Given the design of the LVAD, any
removal of the lithium-ion batteries would require that
the power module be plugged into a standard three-
pronged outlet. However, plugging in the power module
would lead to continuous recharging of its nickel met-
al hydride battery, which is also of concern given that
NFPA6 regulations also state that a battery cannot be
charging while in the hyperbaric chamber due to
fire concerns.
90
Beyond the above power and battery concerns, we
were also concerned that the LVAD pump itself might
fail while under pressure. To determine whether treat-
ing this patient was possible, we reviewed all available
literature regarding LVADs and hyperbaric chambers.
Overall there is a paucity of data relevant to this topic,
but three prior experiences have been published.
In the first study, by Churchill, et al. [3], a vented
HeartMate electric LVAS (left ventricular assist system)
was connected to a mock circulatory system and
tested in hyperbaric chamber to measure output at
various pressures. The LVAS is an older model that uses
a centrifugal pump, powered by a brushless DC motor
that pushes against a diaphragm through a one-way
chamber to propel blood in a pulsatile fashion, instead
of the newer model which delivers continuous axial-
flow using a rotary motor. The results of this study
showed that the LVAS maintained good output through
pressures of 0.85-4.0 ATA.
In the second study by Goodard, et al. [4], a
HeartMate II was connected to a mock circulatory system
and tested for flow rates at various pressure settings.
In this study, the LVAD had appropriate flow rates
through pressure ranges of 0.85-4 ATA at two different
RPM settings.
The third report, by Snyder, et al. [5], details pretreat-
ment device testing and subsequent successful treat-
ment of a patient with an LVAD at the University of
California San Diego Medical Center. The results of
that experience were presented at the 2010 meeting of
the Undersea and Hyperbaric Medical Society and
published as an abstract, but it has not been published
as a full report in any journal. The abstract and
presentation describe how a HeartMate II, with the
controller and battery supply, was connected to a mock
circulatory system and then successfully tested in the
hyperbaric chamber at 2.4 ATA, first for five minutes
and then for 110 minutes. Additionally, the battery
supply alone was tested at 7.0 ATA. There were no
visible signs of damage after the compression tests, and
everything appeared to be working properly, batteries
included. After testing of the battery-powered device
and controller, the authors successfully treated a patient
with a HeartMate II LVAD with 30 sessions of HBO2
at 2.4 ATA for 90 minutes without complications.
Of note, this patient was treated with the lithium-ion
batteries inside his device, as this was prior to the
Orwig D, Logue C, Hendriksen S, et al.
UHM 2018, Vol. 45, No. 1 – CASE: TREATING A PATIENT WITH lVAD WHIlE IN THE HYPERBARIC CHAMBER

normal ambulatory LVAD setup

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modifications for LVAD setup in hyperbaric chamber

change in NFPA6 codes prohibiting the use of these
batteries in hyperbaric chambers due to the risk of
explosion.
Treatment
In our case, given that portable lithium-ion batteries
are not allowed in the chamber, we decided to use the
LVAD device’s power module for the primary power
supply. With the assistance of the biotechnology de-
partment at our hospital, we were able to design a new
power cord for the power module that was compatible
with the outlets in our Fink multiplace hyperbaric
chamber. Additionally we were able to get the latest
model of the power module with an alkaline battery that
does not automatically charge when it is in place and
the power module is plugged in. This meant that there
would be no need to remove the batteries and that the
power module would not alarm during the entire course
of treatment. We also removed the lithium-ion battery
from the power controller and placed it nearby, outside
the chamber. In the event of an emergency, such as an
electrical failure of the power module, we planned to
lock in the battery to be used as backup power in the
pocket controller, a procedure that takes approximately
15 seconds. Lastly, the power module is a high-voltage
system that can safely be operated at pressure only
in a low-oxygen environment. With the assistance of our
biotechnology department, we designed an enclosure
that could be purged with nitrogen to a safe standard
of 4% oxygen. Because the pocket controller is low-
voltage (12V), it did not need a nitrogen purge.
Prior to initiating therapy, we also felt it necessary
to come up with a contingency plan should the LVAD
fail. Although chest compressions have historically been
discouraged in LVAD patients, the recommendation
from our local LVAD institution was that chest com-

Orwig D, Logue C, Hendriksen S, et al. 91

UHM 2018, Vol. 45, No. 1 – CASE: TREATING A PATIENT WITH LVAD WHILE IN THE HYPERBARIC CHAMBER
pressions were acceptable in the event of cardiac arrest.
Additionally it was deemed acceptable to use a defibril-
lator as well as any vasoactive drugs. Typically most
LVADs have some innate forward flow due to an intact
aortic valve that, in the event of device failure should
allow some time for staff to abort treatment and bring the
patient safely to surface pressure. As mentioned above,
the contingency plan also necessitated that the lithium-
ion battery for the pocket controller, with 15 minutes of
backup power, be available near the chamber so that it
could be locked-in and placed into the pocket controller
in the event of an electrical failure of the power module.
Once we had made the necessary modifications to the
power source for safety and fire code adherence and had
a contingency plan in place, we then completed test-
ing on a mock circulatory system. We conducted two
compression tests to 2.8 ATA to ascertain performance
beyond the pressure of our typical routine treatments
at 2.4 ATA (U.S. Navy Table 9). The device appeared to
be working appropriately during the compression test-
ing, and there was no damage noted to the equipment
after these tests. To test performance under other pos-
sible treatment pressures, we then attempted to take the
system to 6 ATA. At 3.8 ATA, the alarms on the system
controller went off. Though the device continued to
function properly (based on continued flow in the
circulatory system and no alarms indicating malfunc-
tion), on examination after the test, the buttons were
noted to be pressed in. The device functioned normally
after this test.
After pressure testing was complete, we held a meet-
ing with all of our staff to review our patient’s case and
the LVAD device. We reviewed the process of changing
the device’s power supply from the lithium-ion battery
system to the power module. We also reviewed the
contingency plan in the event of a device or an electri-
cal failure. Given the complexity of this patient’s con-
dition and the possible complications that could occur
during treatment, we decided to use a one-to-one in-
side attendant during his treatments. This was initially
done with a nurse as inside attendant, but as his treat-
ments continued, and the staff felt more comfortable
with the process, we did allow a hyperbaric tech to act as
inside attendant during the patient’s treatments.
92
The patient began treatment on December 19, 2016.
Prior to each treatment we (1) plugged the power mod-
ule into the wall using the modified power cord within
the nitrogen-purge system that we designed for use
with this patient. We then (2) exchanged the power
supply from the lithium-ion batteries to the power
module and (3) removed the lithium-ion battery from
the pocket controller. These steps typically took 10 min-
utes to complete prior to the patient’s treatment.
The patient’s LVAD pump and controller functioned
properly during all of his treatments, and we experi-
enced no malfunctions of the device or the electrical
setup during his treatments. He completed 44 treat-
ments with hyperbaric oxygen at 2.4 ATA for 90 min-
utes including pressurization and depressurization. His
nephrostomy tubes were removed after 38 hyperbaric
treatments. A urinalysis was performed two days after
nephrostomy tube removal. Results showed no gross
blood but had 25-50 microscopic RBCs. We then
continued therapy for an additional four treatments
and repeated a urinalysis that showed no microscopic
hematuria. At this point, we felt that this patient
had successfully completed treatment of radiation
cystitis with hyperbaric oxygen.
Conclusion
This is the second reported patient with an LVAD in
place who was successfully treated with a course of
hyperbaric oxygen, and it is the first case reported since
lithium-ion batteries were prohibited in the hyper-
baric environment. Although the HeartMate II LVAD
has not been pressure-tested by the manufacturer,
our site, along with the three other sites mentioned
previously [3-5] was able to successfully test the device
to treatment depths without any malfunctioning of the
device and its controller, the electrical power supply,
or the pump flow rate. With a few modifications of the
power supply, the device can be made compliant with
NFPA 996 guidelines, markedly diminishing any fire
risks. Additionally, by developing a contingency plan
for equipment or power failure prior to initiating
hyperbaric treatments, it is possible to further improve
the margin of safety for patients and comfort level for
the staff.
n
The authors declare that no conflicts of interest exist
with this submission.
Orwig D, Logue C, Hendriksen S, et al.
UHM 2018, Vol. 45, No. 1 – CASE: TREATING A PATIENT WITH LVAD WHILE IN THE HYPERBARIC CHAMBER

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