Left Ventricular Assist Device (LVAD)

• Patients who need permanent mechanical support because transplant is not an option for them

Not every patient with severe heart failure is a suitable candidate. Doctors weigh the risks carefully, and the procedure is generally not offered in these situations.

• Severe irreversible disease of other major organs, such as the kidneys or liver, that the improved circulation is unlikely to help
• Active, uncontrolled infection anywhere in the body
• Significant disease of the right ventricle (the other pumping chamber) that the LVAD alone cannot correct
• Blood-clotting disorders that make anticoagulation (blood-thinning treatment) too dangerous
• Body size or anatomy that does not accommodate the device physically
• Conditions that make surgery or anesthesia too high-risk, such as very advanced age combined with multiple other illnesses

• Arrhythmias (irregular heartbeats) that may need additional treatment or a defibrillator device
• Kidney or liver injury from the stress of surgery or from periods of low circulation before the device is placed
• Air embolism (air bubbles in the blood) or blood clots forming elsewhere in the body
• Wound complications including poor healing at the chest or driveline exit site
• Death, which remains a real possibility in patients with end-stage heart disease undergoing major surgery

• Nutritional assessment, because poor nutrition slows healing and increases infection risk
• Psychological and social assessment to ensure the patient and a committed caregiver understand the device and can manage it at home

In the days before surgery, adjustments to existing medications are common. Blood thinners may be paused or switched to a shorter-acting form. Some heart medicines are continued right up to the morning of surgery; others are stopped. The team will give written instructions for each drug. Smoking stops as early as possible, and alcohol is avoided in the weeks before the operation, as both impair healing and anesthesia response.

Patients are usually asked to stop eating solid food around six hours before surgery and to stop drinking clear fluids around two hours before, though the exact fasting times depend on the anesthesia team's protocol at each hospital.

On the day of surgery, the steps typically follow this sequence.

• 1. The patient is admitted and final checks are completed, including identity verification and consent review.
• 2. An intravenous (IV) line is placed, and monitoring leads for the heart, blood pressure, and oxygen are attached.
• 3. General anesthesia (medicine that puts the patient fully to sleep) is given.
• 4. The surgeon makes an incision (cut) along the centre of the chest and opens the breastbone.
• 5. The patient is connected to a cardiopulmonary bypass machine (a heart-lung machine that takes over circulation during surgery) in most cases.
• 6. The surgeon attaches the inflow cannula (a short tube) to the tip of the left ventricle and connects the outflow graft (a synthetic tube) to the aorta.
• 7. The pump is secured in position inside the chest or abdomen, depending on the device model.
• 8. The driveline cable is tunnelled under the skin and brought out through a small exit site on the abdomen.
• 9. The device is switched on, tested, and adjusted while the patient is still on bypass.
• 10. The bypass machine is weaned off and the heart and device work together.
• 11. The chest is closed, chest drainage tubes are placed to remove fluid, and the patient is moved to the intensive care unit (ICU).

• Water precautions: the driveline exit site must never be submerged in water, so bathing routines change permanently
• Power supply: the device must be plugged in overnight to charge batteries, and the patient needs a reliable electricity supply at home as well as spare batteries for outings
• Follow-up: clinic visits are frequent in the first months, then spaced to every few months if stable, with echocardiograms and blood tests at each visit
• Emergency plan: patients carry a device identification card and the care team provides a 24-hour contact number because some alarms require immediate clinical evaluation

• Post-operative medications: long-term blood thinners, heart medicines, and antibiotics used after surgery are ongoing costs that continue after discharge
• Rehabilitation and device training: some hospitals charge separately for the physiotherapy and specialist nurse training sessions that are essential before discharge
• Follow-up imaging and blood tests: regular echocardiograms and anticoagulation monitoring tests after discharge are recurring costs over months or years

Hospital packages for LVAD surgery typically cover the surgical procedure, the device itself, anesthesia, and the basic ICU and ward stay up to a defined number of days. Items that are usually billed separately include extended ICU care beyond the package limit, treatment of complications such as reoperation or dialysis, rehabilitation sessions, take-home medications, and all outpatient follow-up visits and tests after discharge.

Indonesian patients travelling abroad for an LVAD should know that BPJS Kesehatan does not cover treatment received outside Indonesia, and most Indonesian private health insurance policies also exclude overseas care. Patients generally pay entirely out of pocket or rely on international private health insurance that explicitly covers treatment abroad. Before travelling, request a detailed written cost estimate from the hospital that breaks out the device cost, the surgical fee, the expected length of stay, and what falls outside the package. This written estimate is the only reliable way to budget for a procedure where the final bill can be significantly higher than the initial quote if complications arise.