Percutaneous ventricular assist devices (pVADs) are increasingly being used because of improved experience and availability. The Impella (Abiomed), a percutaneous microaxial, continuous-flow, short-term ventricular assist device, requires meticulous postimplantation management to avoid the 2 most frequent complications, namely, bleeding and hemolysis. A standardized approach to the prevention, detection, and treatment of these complications is mandatory to improve outcomes. The risk for hemolysis is mostly influenced by pump instability, resulting from patient- or device-related factors. Upfront echocardiographic assessment, frequent monitoring, and prompt intervention are essential. The precarious hemostatic balance during pVAD support results from the combination of a procoagulant state, due to critical illness and contact pathway activation, together with a variety of factors aggravating bleeding risk. Preventive strategies and appropriate management, adapted to the impact of the bleeding, are crucial. This review offers a guide to physicians to tackle these device-related complications in this critically ill pVAD-supported patient population.

2nd Department of Medicine Department of Cardiovascular Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Anaesthesia and Intensive Care Fondazione Policlinico San Matteo IRCCS Pavia Italy

Cardiac and Cardiac Surgery Intensive Care Unit IRCCS San Raffaele Scientific Institute Milan Italy

Cardiothoracic and Vascular Anesthesia and Intensive Care Azienda Ospedaliera Nazionale Santi Antonio e Biagio e Cesare Arrigo Alessandria Italy

Cardiovascular Center Onze Lieve Vrouwziekenhuis Aalst Belgium

Department of Anesthesiology and Critical Care and Burn Unit Saint Louis and Lariboisière Hospitals Paris France

Department of Cardiac Surgery University Hospitals Leuven Leuven Belgium

Department of Cardiology and Angiology University Heart Center Freiburg Bad Krozingen Faculty of Medicine University of Freiburg Freiburg Germany

Department of Cardiology and Intensive Care Medicine Jessa Ziekenhuis Hasselt Belgium

Department of Cardiology The Zena and Michael A Wiener Cardiovascular Institute Mount Sinai New York New York

Department of Cardiology University Heart and Vascular Center Hamburg Hamburg Germany

Department of Cardiovascular Diseases University Hospitals Leuven Leuven Belgium

Department of Cardiovascular Diseases University Hospitals Leuven Leuven Belgium; Departments of Cardiology and Critical Care Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust London United Kingdom

Department of Internal Medicine Cardiology Heart Center Leipzig at the University of Leipzig Leipzig Germany

Department of Laboratory Medicine University Hospitals of Leuven Leuven Belgium

Departments of Cardiology and Critical Care Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust London United Kingdom; Faculty of Medicine National Heart and Lung Institute Imperial College London London United Kingdom

Departments of Cardiology and Intensive Care Medicine Clinic Ottakring and Sigmund Freud University Medical School Vienna Austria

Faculty of Medicine National Heart and Lung Institute Imperial College London London United Kingdom; Postgraduate Medical School University of Hertfordshire Hertfordshire United Kingdom

Intensive Care Medicine University Hospitals Leuven Leuven Belgium

Intensive Care Unit Ghent University Hospital Ghent University Ghent Belgium

Interventional Cardiology Unit San Raffaele Scientific Institute Milan Italy

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