Assisting the failing heart

Facilitating noncardiac surgery for the patient with left ventricular assist device: A guide for the anesthesiologist

The introduction of left ventricular assist device (LVAD) has improved survival rates for patients with end-stage heart failure. Two categories of VADs exist: one generates pulsatile flow and the other produces nonpulsatile continuous flow. Survival is better for patients with continuous-flow LVADs. With improved survival, more of such patients now present for noncardiac surgery (NCS). This review, written for the general anesthesiologists, addresses the perioperative considerations when the patient undergoes NCS. For best outcomes, a multidisciplinary approach is essential in perioperative management of the patient.

Ventricular assist devices and non-cardiac surgery

The use of ventricular assist devices has expanded significantly since their approval by the Food and Drug Administration in the United States in 1994. In addition to this, the prevalence of heart failure continues to increase. We aim to provide an overview of perioperative considerations and management of these patients for non-cardiac surgery. We performed a Medline search for the words “ventricular assist device,” “Heartmate” and “HeartWare” to gain an overview of the literature surrounding these devices, and chose studies with relevance to the stated aims of this review. Patients with ventricular assist devices are presenting more frequently for surgery not related to their cardiac pathology. As the mechanically supported population grows, general anesthesiologists will be faced with managing these patients, possibly outside of the tertiary care setting. The unique challenges of this patient population can best be addressed by a thorough understanding of ventricular assist device physiology and a multidisciplinary approach to care.

Anesthetic Management for Cardiopulmonary Bypass

Cardiopulmonary bypass has revolutionized the practice of cardiac surgery and allows safe conduct of increasingly complex cardiac surgery. A brief review of the bypass circuit is undertaken in this review. A more thorough review of the anesthetic management is accomplished including choice of anesthetic medications and their effects. The inflammatory response to cardiopulmonary bypass is reviewed along with interventions that may help ameliorate the inflammation.

Use of the Impella 2.5 in high-risk percutaneous coronary intervention

The Impella 2.5 is a percutaneously placed partial circulatory assist device that is increasingly being used in high-risk coronary interventional procedures to provide hemodynamic support. The Impella 2.5 is able to unload the left ventricle rapidly and effectively and increase cardiac output more than an intra-aortic balloon catheter can. Potential complications include bleeding, limb ischemia, hemolysis, and infection. One community hospital's approach to establishing a multidisciplinary program for use of the Impella 2.5 is described.