Perioperative Management of Patients With Left Ventricular Assist Devices Undergoing Noncardiac Surgery

Anesthetic management for non-cardiac surgery in patients with left ventricular assist devices

With the growing number of patients undergoing left ventricular assist device (LVAD) implantation and improved survival in this population, more patients with LVADs are presenting for various types of non-cardiac surgery. Therefore, anesthesiologists need to understand the physiology and adequately prepare for the perioperative management of this unique patient population. This review addresses perioperative considerations and intraoperative management for the safe and successful management of patients with an LVAD undergoing non-cardiac surgery. Understanding the basic physiology of preload dependency and afterload sensitivity in these patients is essential. The main considerations include a collaborative preoperative multidisciplinary approach, perioperative care aimed at optimizing the intravascular volume and right ventricular function, and maintaining the afterload within recommended ranges for optimal LVAD function.

Critical Care Management of Surgical Patients with Heart Failure or Left Ventricular Assist Devices: A Brief Overview

Patients with heart failure, including those with implanted left ventricular assist devices, continue to increase in number. When they require noncardiac surgery, cardiac critical care expertise may not be immediately available to assist. This review serves to provide surgeons and surgical intensivists with a brief overview of the management of this patient population and common clinical scenarios and complications.

Anesthetic Considerations in a Patient With LVAD and COVID-19 Undergoing Video-Assisted Thoracic Surgery

Increased survival with left ventricular assist devices (LVAD) has led to a large number of patients with LVADs presenting for noncardiac surgeries (NCS). With studies showing that a trained noncardiac anesthesiologist can safely manage these patients when they present for NCS, it is vital that all anesthesiologists understand the LVAD physiology and its implications in various surgeries. This is even more relevant during the current pandemic in which these complex cardiopulmonary interactions may be even more challenging in patients with coronavirus disease 2019 (COVID-19). The authors describe a case of a patient with COVID-19 with an LVAD who needed thoracoscopic decortication for recurrent complex pleural effusion and briefly discuss unique challenges presented and their management.

Anesthetic management of a patient with a continuous-flow left ventricular assist device for video-assisted thoracoscopic surgery: a case report

Background

As patients with left ventricular assist device (LVAD) have long expected survival, the incidence of noncardiac surgery in this patient population is increasing. Here, we present the anesthetic management of a patient with a continuous-flow LVAD who underwent video-assisted thoracic surgery (VATS).

Case presentation

A 37-year-old man with LVAD was scheduled to undergo VATS because of repeated spontaneous pneumothorax. Generally, patients with these devices have marginal right heart function; therefore, it is important to avoid factors that worsen pulmonary vascular resistance (PVR). However, VATS requires one-lung ventilation (OLV) and it tends to cause increase in PVR, leading to right heart failure.

In the present case, when the patient was set in a lateral decubitus position and progressive hypoxia was observed during OLV, transesophageal echocardiography demonstrated a dilated right ventricle and a temporally flattened interventricular septum, and the central venous pressure increased to approximately 20 mmHg. Because we anticipated deterioration of right heart function, dobutamine and milrinone were administered and/or respirator settings were changed to decrease PVR for maintaining LVAD performance. Finally, resection of a bulla was completed, and the patient was discharged in stable condition on postoperative day 37.

Conclusions

The anesthetic management of a patient with LVAD during VATS is challenging because the possible hemodynamic changes induced by hypoxia associated with OLV affect LVAD performance and right heart function. In our experience, VATS that requires OLV will be well tolerated in a patient with LVAD with preserved right heart function, and a multidisciplinary approach to maintain right heart function will be needed.

Noncardiac surgery in patients with a left ventricular assist device

Left ventricular assist devices are implanted in patients with chronic left heart failure refractory to maximal medical therapy. These devices were initially meant as bridge-to-transplant therapy, but with technological advances they are now also used as destination therapy. With improved survival, many patients with implanted devices need noncardiac surgery. We present three representative cases of noncardiac surgery in such patients to highlight the issues involved in their management. We also review the contemporary literature on various aspects of perioperative management. Anesthesia for noncardiac surgery in these patients was initially the domain of cardiac anesthesiologists, but with an increasing number of such patients needing surgery, general anesthesiologists are frequently tasked to provide anesthetic care. An understanding of left ventricular assist device physiology and issues unique to these patients is essential for safe management of these cases.

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.

Embracing the Future of Surgery: Gastric Cancer Resection Within One Month of Left Ventricular Assist Device Implantation

Left ventricular assist devices (LVADs) have been implanted recently, with increasing frequency, to treat advanced heart failure with good survival rates. Since heart failure is most prevalent in patients above 70 years of age, LVAD implantations are increasing particularly in this cohort. On the other hand, due to a higher incidence of malignant tumors in the elderly population, there is a significant cohort of patients having concurrent indications for LVAD implantation.

Herein, we report a case of complicated gastric malignancy that was encountered soon after the implantation of an emergent LVAD with ensuing treatment difficulties and ethical considerations.

Keeping in mind the fairly high life expectancy for both groups, there is a predisposition to the notion that simultaneous procedures can and should be applicable to a selected group of patients with end-stage heart failure.

Complications, Risk Factors, and Staffing Patterns for Noncardiac Surgery in Patients with Left Ventricular Assist Devices

BACKGROUND

Patients with left ventricular assist devices presenting for noncardiac surgery are increasingly commonplace; however, little is known about their outcomes. Accordingly, the authors sought to determine the frequency of complications, risk factors, and staffing patterns.

METHODS

The authors performed a retrospective study at their academic tertiary care center, investigating all adult left ventricular assist device patients undergoing noncardiac surgery from 2006 to 2015. The authors described perioperative profiles of noncardiac surgery cases, including patient, left ventricular assist device, surgical case, and anesthetic characteristics, as well as staffing by cardiac/noncardiac anesthesiologists. Through univariate and multivariable analyses, the authors studied acute kidney injury as a primary outcome; secondary outcomes included elevated serum lactate dehydrogenase suggestive of left ventricular assist device thrombosis, intraoperative bleeding complication, and intraoperative hypotension. The authors additionally studied major perioperative complications and mortality.

RESULTS

Two hundred and forty-six patients underwent 702 procedures. Of 607 index cases, 110 (18%) experienced postoperative acute kidney injury, and 16 (2.6%) had elevated lactate dehydrogenase. Of cases with complete blood pressure data, 176 (27%) experienced intraoperative hypotension. Bleeding complications occurred in 45 cases (6.4%). Thirteen (5.3%) patients died within 30 days of surgery. Independent risk factors associated with acute kidney injury included major surgical procedures (adjusted odds ratio, 4.4; 95% CI, 1.1 to 17.3; P = 0.03) and cases prompting invasive arterial line monitoring (adjusted odds ratio, 3.6; 95% CI, 1.3 to 10.3; P = 0.02) or preoperative fresh frozen plasma transfusion (adjusted odds ratio, 1.7; 95% CI, 1.1 to 2.8; P = 0.02).

CONCLUSIONS

Intraoperative hypotension and acute kidney injury were the most common complications in left ventricular assist device patients presenting for noncardiac surgery; perioperative management remains a challenge.

Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery

Aim:

The aim of this study was to describe our institutional experience, primarily with general anesthesiologists consulting with cardiac anesthesiologists, caring for left ventricular assist device (LVAD) patients undergoing noncardiac surgery.

Materials and Methods:

This is a retrospective review of the population of patients with LVADs at a single institution undergoing noncardiac procedures between 2009 and 2014. Demographic, perioperative, and procedural data collected included the type of procedure performed, anesthetic technique, vasopressor requirements, invasive monitors used, anesthesia provider type, blood product management, need for postoperative intubation, postoperative disposition and length of stay, and perioperative complications including mortality.

Statistical Analysis:

Descriptive statistics for categorical variables are presented as frequency distributions and percentages. Continuous variables are expressed as mean ± standard deviation and range when applicable.

Results:

During the study, 31 patients with LVADs underwent a total of 74 procedures. Each patient underwent an average of 2.4 procedures. Of the total number of procedures, 48 (65%) were upper or lower endoscopies. Considering all procedures, 81% were performed under monitored anesthesia care (MAC). Perioperative care was provided by faculty outside of the division of cardiac anesthesia in 62% of procedures. Invasive blood pressure monitoring was used in 27 (36%) procedures, and a central line, peripherally inserted central catheter or midline was in place preoperatively and used intraoperatively for 38 (51%) procedures. Vasopressors were not required in the majority (65; 88%) of procedures. There was one inhospital mortality secondary to multiorgan failure; 97% of patients survived to discharge after their procedure.

Conclusion:

At our institution, LVAD patients undergoing noncardiac procedures most frequently require endoscopy. These procedures can frequently be done safely under MAC, with or without consultation by a cardiac anesthesiologist.

Periprocedural Management of 172 Gastrointestinal Endoscopies in Patients with Left Ventricular Assist Devices

The number of patients with left ventricular assist devices (LVADs) continues to increase, and gastrointestinal (GI) endoscopy is commonly required in this patient population. We retrospectively reviewed the experience of a single tertiary care center in managing patients with LVADs undergoing GI endoscopy between 2006 and 2013. After hospital dismissal from the LVAD placement, 53 patients underwent 172 GI endoscopic procedures. Gastrointestinal bleeding was the indication for endoscopy in 73.8% of patients. Median age at endoscopy was 66 years, and median time from LVAD implantation to initial endoscopy was 271 days (range, 31-1681 days). Anticoagulation or antiplatelet therapy was present within 1 week before 120 of 172 endoscopies (70%) and was withheld or actively reversed in 91 of 120 cases (76%). For sedation/anesthesia during endoscopy, 63 involved care by an anesthesiology team and 109 were performed with nursing sedation protocols. Noninvasive blood pressure techniques (conventional automated cuffs or Doppler pulses) were used for hemodynamic monitoring in 84%, arterial lines in 10%, and no blood pressure recordings documented/charted as inaccurate in 6%. Six patients died within 30 days of endoscopy with one death because of aspiration of blood and multiorgan failure. Patients with LVADs may safely undergo GI endoscopy with various individualized anesthetic/sedation models. Complications after endoscopy likely represent the acuity of this patient population.

Implantable Devices: Assessment and Perioperative Management

Technology is the prominent feature of the twenty-first century, including in medicine. There are very few organs that cannot be stimulated, shocked, or infused. With more and more implantable devices being approved for clinical use, anesthesiologists have to regularly take care of patients who have these devices. An understanding of the devices, the associated comorbidities, and the perioperative risks is crucial for safe management of these patients. Cardiac devices are discussed in some detail; neurostimulators and other implantable devices are briefly described. The principles of assessment and management are similar for all patients with implanted devices.

Trends in the Management of Patients With Left Ventricular Assist Devices Presenting for Noncardiac Surgery: A 10-Year Institutional Experience

In our institution, the vast majority of patients presenting for noncardiac surgery (NCS) while supported by a left ventricular assist device (LVAD) are now cared for by noncardiac-trained anesthesiologists as the result of a decade of educational intervention to effect this transition. This represents a significant departure from the published experiences of other institutions. With institutional review board approval, we queried the database of our anesthesia record keeping system (CompuRecord) to determine various aspects of the perioperative management of these patients from July 1, 2003, through June 30, 2013, during which time 271 NCS procedures were performed on adult patients supported by LVADs. Over the entire study period (2003-2013), anesthetic care was provided by a cardiac anesthesiologist 47% of the time and by a noncardiac anesthesiologist 53% of the time. However, by the time period 2012-2013, 88% of the NCS procedures were staffed by a noncardiac anesthesiologist. Despite the prevalence of continuous flow devices in this series, the use of invasive blood pressure monitoring decreased dramatically by the later years of the study. Vasoactive and inotropic medications were rarely required intraoperatively. No intraoperative cardiac arrests, thromboembolic complications, or device malfunctions occurred. Our conclusion is that NCS procedures on LVAD-supported patients can be safely managed by educated noncardiac anesthesiologists.

Management of LVAD Patients for Noncardiac Surgery: A Single-Institution Study

OBJECTIVE

To describe the experience regarding the perioperative management of patients with left ventricular assist devices (LVADs) who require anesthesia while undergoing noncardiac surgery (NCS) at a single medical center.

DESIGN

Retrospective chart review

SETTING

Academic medical center

PARTICIPANTS

Patients with LVADs

INTERVENTIONS

Medical records from April 1, 2009 through January 31, 2014 were reviewed for patients who underwent Heartmate II LVAD placement at this facility. Individual records were reviewed for NCS after LVAD placement, specifically investigating perioperative and anesthetic management.

MEASUREMENTS AND MAIN RESULTS

Seventy-one patients underwent LVAD placement during this time period. Thirty-five patients (49%) underwent a total of 101 NCS procedures. Arterial catheters were placed in 19 patients (19%), and 33 patients (33%) were intubated for their procedure. No complications or perioperative mortality occurred related to the NCS.

CONCLUSIONS

Noncardiac surgery is becoming more common in patients with LVADs. Anesthetic management of these patients outside of the cardiac operating room is limited. Patients with Heartmate II LVADs can safely undergo noncardiac surgery.

Successful Perioperative Management of a Patient with the Left Ventricular Assist Device for Brain Tumor Resection: Case Report and Review of the Literature

Heart failure is the leading cause of death in the United States. Our increasingly aged population will contribute to an increased incidence and prevalence of heart failure, thereby augmenting the need for mechanical circulatory devices. Here we present the first successful resection of a brain tumor in a left ventricular device- (LVAD-) dependent patient with increased intracranial pressure and address pertinent perioperative anesthetic considerations and management.

Anesthetic management for abdominal aortic surgery in a patient with a left ventricular assist device: a case report

Left ventricular assist devices (LVAD) are a currently established destination and bridge therapy until cardiac transplantation; hence, this patient population continues to increase. Here, we present the first report of abdominal aortic cross-clamping (ACC) in a LVAD patient undergoing emergency aneurysm repair. Anticoagulation was continued pre-and intra-operatively to avoid pump thrombosis. The pumping function of the LVAD is highly dependent on both preload and afterload. In this case, abdominal ACC, which increases the afterload, did not significantly influence circulatory dynamics. However, when the abdominal ACC was released, mean atrial pressure (MAP) fell to 42 mmHg, because preload reduction due to massive bleeding (3532 g) secondary to anticoagulation and afterload reduction by abdominal ACC release combined to cause critical hypotension. Maintenance of MAP required rapid infusion and use of an alpha-adrenergic agent. Surgical and anesthesia times were 411 and 525 min, respectively. Total blood loss was 5389 g, respectively. The patient was discharged after 25 postoperative days with no major complications. ACC release, with its accompanying decrease in preload and afterload, and massive bleeding due to anticoagulation in these patients require careful management.

The year in cardiothoracic and vascular anesthesia: selected highlights from 2013

This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs that require a precise prescription with respect to type, dose, and duration. The final theme is patient safety in the cardiac perioperative environment. A recent expert scientific statement has focused attention on this issue because most perioperative errors are preventable. It is likely that clinical research in this area will blossom because this is a major opportunity for improvement in our specialty. The patient care processes identified in these research highlights will further improve perioperative outcomes for our patients.

Perioperative management of patients with left ventricular assist devices undergoing noncardiac procedures: a survey of current practices

OBJECTIVES

To describe perioperative management of patients with left ventricular assist devices (LVAD) in noncardiac procedures.

DESIGN

Survey of (1) respondent demographic characteristics, (2) anesthetic practices for LVAD patients having endoscopies, and (3) low-risk surgeries requiring general anesthesia.

SETTING

Internet-based.

PARTICIPANTS

Society of Cardiovascular Anesthesiologists membership.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Inpatient endoscopic procedures were done mainly in the endoscopy suite (71.7%) by a solo practitioner or 1:1 staffing ratio 59% of the time. LVAD-specific support personnel were present in more than 80% of all procedures. Both endoscopy and surgical patients used post-anesthesia recovery units and intensive care units for recovery; however, compared with endoscopy patients, surgical patients recovered in the ICU more frequently (45.5% v 29.1%, p<0.001). In addition, 18% of endoscopy patients recovered on site. Regarding patient monitoring, more than 90% of responders used electrocardiogram, pulse oximetry, end-tidal CO2, and blood pressure monitors on LVAD patients. Responders reported using arterial catheters to monitor blood pressure in 49% of endoscopy cases and 71% of surgical patients. The reported use of invasive monitors by individual clinicians was related inversely to institutional LVAD volume (p = 0.04 and p = 0.01 in endoscopy and surgical procedures, respectively).

CONCLUSIONS

This survey found heterogeneity in hospital resource utilization for noncardiac LVAD procedures. There was a decrease in the use of invasive monitors with increased institutional LVAD volume in both endoscopy and surgical procedures.

Dangerous surgical scavenger hunt: the complicated course of a patient with left ventricular assist device and end-stage renal disease undergoing reconstructive flap surgery

Patients with left ventricular assist devices (LVADs) who develop stage IV sacral pressure sores (SPS) have an increased procedural risk. We present the complications, including severe intra- and postoperative bleeding, diarrhea with metabolic acidosis, volume loss and acute on chronic renal failure, flap dehiscence and late LVAD outflow cannula thrombosis, in a 54-year-old male who underwent diverting ileostomy (DI) and subsequent fasciocutaneous flap (FCF) surgery for stage IV SPS while supported with an LVAD. Our experience suggests that, despite continuous heparinization, life-threatening thrombotic complications, such as device clotting, can occur. Therefore, the benefit of intervention has to outweigh the risk of bleeding, which should be managed with meticulous surgical technique and substitution of red blood cells rather than the reversal of heparinization or the substitution of clotting factors. Continuation of double anti-platelet therapy should also be considered.

[Noncardiological surgical procedure for patients implanted with a ventricular assist device. Anesthesiological management concepts]

BACKGROUND

The implantation of a ventricular assist device (VAD) is more frequently used as destination therapy of end-stage heart failure compared to the use of the device as bridge-to-transplantation, this results in an increasing number of noncardiac surgical procedures for patients implanted with a VAD.

OBJECTIVE

For these procedures, the anesthesia provider faces various device-related complications, such as an increased risk for bleeding complications, thromboembolism, hypotension, infections, mechanical device limitations, and right heart failure. Anesthesia care is challenging in this high-risk patient population and has significant implications on patient outcome.

CONCLUSION

More research is needed to determine specific guidelines for the anesthesiological management of VAD patients undergoing noncardiac surgical procedures. In this manuscript, device-related perioperative complications and concepts of anesthesia care for noncardiac procedures in patients implanted with a VAD are briefly reviewed.

Management of patients with implanted ventricular assist devices for noncardiac surgery: a clinical review

While originally primarily used as bridge to cardiac transplantation and bridge to recovery, more commonly ventricular assist devices (VADs) are being inserted as destination therapy. These patients are being discharged from transplant and mechanical assist centers, living as outpatients, and thus the pool of community-dwelling patients with VADs continues to expand. Not infrequently they present for surgical procedures either directly related to the device itself or more often incidental to the fact that they have a VAD. This scenario may be more common in patients with VADs placed for destination therapy because these patients tend to be older and have more comorbidities and are living longer with their device. Thus, it is important for all anesthesiologists to be aware of the special anesthesia needs of patients with VADs requiring noncardiac surgery.