1
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Min JJ, Cho YH, Lee SM, Lee JH. Anesthetic management for non-cardiac surgery in patients with left ventricular assist devices. Korean J Anesthesiol 2024; 77:175-184. [PMID: 36912004 PMCID: PMC10982535 DOI: 10.4097/kja.23169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023] Open
Abstract
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.
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Affiliation(s)
- Jeong-Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic & Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sangmin M. Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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2
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Linganna R, Rodriguez AC, Faloye AO. Mechanical assist devices; a primer for the general anesthesiologist II: Left ventricular assist device. J Clin Anesth 2023; 85:111014. [PMID: 36528958 DOI: 10.1016/j.jclinane.2022.111014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/04/2022] [Accepted: 11/19/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Regina Linganna
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104, USA.
| | - Andrea Corujo Rodriguez
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Emory University, 1364 Clifton Rd. Suite C220, Atlanta, GA 30322, USA.
| | - Abimbola O Faloye
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Emory University, 1364 Clifton Rd. Suite C220, Atlanta, GA 30322, USA.
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3
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Trela KC. Mechanical circulatory support devices in noncardiac surgery. Int Anesthesiol Clin 2022; 60:55-63. [PMID: 35972136 DOI: 10.1097/aia.0000000000000374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kristin C Trela
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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4
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Troutman GS, Genuardi MV. Left Ventricular Assist Devices: A Primer for the Non-Mechanical Circulatory Support Provider. J Clin Med 2022; 11:jcm11092575. [PMID: 35566701 PMCID: PMC9100630 DOI: 10.3390/jcm11092575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/25/2022] [Accepted: 04/30/2022] [Indexed: 02/01/2023] Open
Abstract
Survival after implant of a left ventricular assist device (LVAD) continues to improve for patients with end-stage heart failure. Meanwhile, more patients are implanted with a destination therapy, rather than bridge-to-transplant, indication, meaning the population of patients living long-term on LVADs will continue to grow. Non-LVAD healthcare providers will encounter such patients in their scope of practice, and familiarity and comfort with the physiology and operation of these devices and common problems is essential. This review article describes the history, development, and operation of the modern LVAD. Common LVAD-related complications such as bleeding, infection, stroke, and right heart failure are reviewed and an approach to the patient with an LVAD is suggested. Nominal operating parameters and device response to various physiologic conditions, including hypo- and hypervolemia, hypertension, and device failure, are reviewed.
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Affiliation(s)
- Gregory S. Troutman
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Michael V. Genuardi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Correspondence: ; Tel.: +1-215-615-0800
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5
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Mondino M, Martinez Lopez de Arroyabe B, Nonini S. LVAD Patients in Non-Cardiac Surgery: Implications for Anesthetic Management. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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6
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Zaidi MA, Christenson CR. Critical Care Management of Surgical Patients with Heart Failure or Left Ventricular Assist Devices: A Brief Overview. Surg Clin North Am 2021; 102:85-104. [PMID: 34800391 DOI: 10.1016/j.suc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Mohsin A Zaidi
- Anesthesiology and Critical Care Medicine, Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA.
| | - Carl R Christenson
- Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, M.L. 0531, Cincinnati, OH 45267, USA
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7
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Notarianni A, Tickoo M, Bardia A. Mechanical Cardiac Circulatory Support: an Overview of the Challenges for the Anesthetist. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:421-428. [PMID: 34611458 PMCID: PMC8484296 DOI: 10.1007/s40140-021-00486-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 11/29/2022]
Abstract
Purpose of Review Owing to increased utilization of Mechanical Circulatory Support (MCS) devices, patients with these devices frequently present for surgeries requiring anesthetic support. The current article provides basics of perioperative management of these devices. Recent Findings Use of extracorporeal membrane oxygenation (ECMO) and left ventricular assist devices (LVADs) are on the rise with recently updated management guidelines. Veno-venous ECMO utilization has been widely utilized as a salvage therapy during the COVID-19 pandemic. Summary Intra-Aortic Balloon Pumps continue to be one of the most frequently used devices after acute myocardial infarction. ECMO is utilized for pulmonary or cardiopulmonary support as salvage therapy. LVADs are used in patients with end-stage heart failure as a destination therapy or bridge to transplant. Each of these devices present with their own set of management challenges. Anesthetic management of patients with MCS devices requires a thorough understanding of underlying operating and hemodynamic principles.
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Affiliation(s)
- Andrew Notarianni
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT 06515 USA
| | - Mayanka Tickoo
- Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA
| | - Amit Bardia
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT 06515 USA
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8
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Gustafsson F, Ben Avraham B, Chioncel O, Hasin T, Grupper A, Shaul A, Nalbantgil S, Hammer Y, Mullens W, Tops LF, Elliston J, Tsui S, Milicic D, Altenberger J, Abuhazira M, Winnik S, Lavee J, Piepoli MF, Hill L, Hamdan R, Ruhparwar A, Anker S, Crespo-Leiro MG, Coats AJS, Filippatos G, Metra M, Rosano G, Seferovic P, Ruschitzka F, Adamopoulos S, Barac Y, De Jonge N, Frigerio M, Goncalvesova E, Gotsman I, Itzhaki Ben Zadok O, Ponikowski P, Potena L, Ristic A, Jaarsma T, Ben Gal T. HFA of the ESC position paper on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider Part 3: at the hospital and discharge. ESC Heart Fail 2021; 8:4425-4443. [PMID: 34585525 PMCID: PMC8712918 DOI: 10.1002/ehf2.13590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/22/2021] [Accepted: 08/19/2021] [Indexed: 12/28/2022] Open
Abstract
The growing population of left ventricular assist device (LVAD)‐supported patients increases the probability of an LVAD‐ supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient‐device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD‐supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non‐cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end‐of‐life approaches are described.
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Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Binyamin Ben Avraham
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C., Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Tal Hasin
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Avishai Grupper
- Heart Failure Institute, Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aviv Shaul
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Yoav Hammer
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, University Hasselt, Hasselt, Belgium
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeremy Elliston
- Anesthesiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Steven Tsui
- Transplant Unit, Royal Papworth Hospital, Cambridge, UK
| | - Davor Milicic
- Department for Cardiovascular Diseases, Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Johann Altenberger
- SKA-Rehabilitationszentrum Großgmain, Salzburger, Straße 520, Großgmain, 5084, Austria
| | - Miriam Abuhazira
- Department of Cardiothoracic Surgery, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stephan Winnik
- Department of Cardiology, University Heart Center, University Hospital Zurich, Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Jacob Lavee
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Lorrena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Righab Hamdan
- Department of Cardiology, Beirut Cardiac Institute, Beirut, Lebanon
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Stefan Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marisa Generosa Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), CIBERCV, Instituto de Investigacion Biomedica A Coruña (INIBIC), Universidad de a Coruña (UDC), A Coruña, Spain
| | | | - Gerasimos Filippatos
- Heart Failure Unit, Attikon University Hospital, National and Kapodistrian University of Athens, Greece. School of Medicine, University of Cyprus, Nicosia, Cyprus
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Rosano
- Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK.,RCCS San Raffaele Pisana, Rome, Italy
| | - Petar Seferovic
- Serbian Academy of Sciences and Arts, Heart Failure Center, Faculty of Medicine, Belgrade University Medical Center, Belgrade, Serbia
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Stamatis Adamopoulos
- Heart Failure and Heart Transplantation Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Yaron Barac
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nicolaas De Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria Frigerio
- Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | | | - Israel Gotsman
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel
| | - Osnat Itzhaki Ben Zadok
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Piotr Ponikowski
- Centre for Heart Diseases, University Hospital, Wroclaw, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Luciano Potena
- Heart and Lung Transplant Program, Bologna University Hospital, Bologna, Italy
| | - Arsen Ristic
- Department of Cardiology of the Clinical Center of Serbia, Belgrade University School of Medicine, Belgrade, Serbia
| | - Tiny Jaarsma
- Department of Nursing, Faculty of Medicine and Health Sciences, University of Linköping, Linköping, Sweden
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Veronese L, Swanevelder J, Brooks A. Anaesthesia for the child with a univentricular heart: a practical approach. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2021. [DOI: 10.36303/sajaa.2021.27.3.2572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - J Swanevelder
- Red Cross War Memorial Children’s Hospital, University of Cape Town,
South Africa
| | - A Brooks
- Red Cross War Memorial Children’s Hospital, University of Cape Town,
South Africa
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10
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Mentias A, Briasoulis A, Vaughan Sarrazin MS, Alvarez PA. Trends, Perioperative Adverse Events, and Survival of Patients With Left Ventricular Assist Devices Undergoing Noncardiac Surgery. JAMA Netw Open 2020; 3:e2025118. [PMID: 33180131 PMCID: PMC7662145 DOI: 10.1001/jamanetworkopen.2020.25118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Information regarding the performance and outcomes of noncardiac surgery (NCS) in patients with left ventricular assist devices (LVADs) is scarce, with limited longitudinal follow-up data that are mostly limited to single-center reports. OBJECTIVE To examine the trends, patient characteristics, and outcomes associated with NCS among patients with LVAD. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined patients enrolled in Medicare undergoing durable LVAD implantation from January 2012 to November 2017 with follow-up through December 2017. The study included all Medicare Provider and Analysis Review Part A files for the years 2012 to 2017. Patients identified by International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision (ICD-10) procedure codes for new LVAD implantation were included. Data analysis was performed from November 2019 to February 2020. EXPOSURES NCS procedures were identified using the ICD-9-CM and ICD-10 procedural codes and divided into elective and urgent or emergent. MAIN OUTCOMES AND MEASURES The primary outcome was major adverse cardiovascular events (MACEs), defined as in-hospital or 30-day all-cause mortality, ischemic stroke, or intracerebral hemorrhage after NCS. Early (<60 days after NCS) and late (≥60 days after NCS) mortality after NCS were analyzed in both subgroups using time-varying covariate and landmark analysis using patients who did not undergo NCS as reference. RESULTS Of the 8118 patients with LVAD (mean [SD] age, 63.4 [10.8] years; 6484 men [79.9%]), 1326 (16.3%, or approximately 1 in 6) underwent NCS, of which 1000 procedures (75.4%) were emergent or urgent and 326 (24.6%) were elective. There was no difference in age between patients who underwent NCS and patients who did not (mean [SD] age, 63.6 [10.6] vs 63.4 [10.9] years). The number of NCS procedures among patients with LVAD increased from 64 in 2012 to 304 in 2017. The median (interquartile range) time from LVAD implantation to NCS was 309 (133-606) days. The most frequent type of NCS was general (613 abdominal, pelvic, and gastrointestinal procedures [46.2%]). Perioperative MACEs occurred in 169 patients (16.9%) undergoing emergent or urgent NCS and 23 patients (7.1%) undergoing elective NCS. Urgent or emergent NCS was associated with higher mortality early (adjusted hazard ratio [aHR], 8.78; 95% CI, 7.20-10.72; P < .001) and late (aHR, 1.71; 95% CI, 1.53-1.90; P < .001) after NCS compared with patients with LVAD who did not undergo NCS. Elective NCS was also associated with higher mortality early (aHR, 2.65; 95% CI, 1.74-4.03; P < .001) and late (aHR, 1.29; 95% CI, 1.07-1.56; P = .008) after NCS. CONCLUSIONS AND RELEVANCE One of 6 patients with LVAD underwent NCS. Perioperative MACEs were frequent. Higher mortality risk transcended the early postoperative period in urgent or emergent and elective surgical procedures.
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Affiliation(s)
- Amgad Mentias
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City
| | | | - Paulino A. Alvarez
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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11
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Fegley MW, Gupta RG, Elkassabany N, Augoustides JG, Werlhof H, Gutsche JT, Kornfield ZN, Patel N, Sanders J, Fernando RJ, Morris BN. Elective Total Knee Replacement in a Patient With a Left Ventricular Assist Device-Navigating the Challenges With Spinal Anesthesia. J Cardiothorac Vasc Anesth 2020; 35:662-669. [PMID: 33183934 DOI: 10.1053/j.jvca.2020.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Mark W Fegley
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ragini G Gupta
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nabil Elkassabany
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Hazel Werlhof
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Zev N Kornfield
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nimesh Patel
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, School of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI
| | - Joseph Sanders
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, School of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI
| | - Rohesh J Fernando
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Benjamin N Morris
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
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12
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Patients with left ventricle assist devices presenting for thoracic surgery and lung resection: tips, tricks and evidence. Curr Opin Anaesthesiol 2020; 33:17-26. [PMID: 31815821 DOI: 10.1097/aco.0000000000000817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Over a thousand left ventricular-assist device (LVAD) implants were performed for heart failure destination therapy in 2017. With increasing survival, we are seeing increasing numbers of patients present for noncardiac surgery, including resections for cancer. This article will review the relevant literature and guidelines for patients with LVADs undergoing thoracic surgery, including lung resection. RECENT FINDINGS The International Society for Heart and Lung Transplant Mechanically Assisted Circulatory Support Registry has received data on more than 16 000 patients with LVADs. Four-year survival is more than 60% for centrifugal devices. There are increasing case reports, summaries and recommendations for patients with LVADs undergoing noncardiac surgery. However, data on thoracic surgery is restricted to case reports. SUMMARY Successful thoracic surgery requires understanding of the LVAD physiology. Modern devices are preload dependent and afterload sensitive. The effects of one-lung ventilation, including hypoxia and hypercapnia, may increase pulmonary vascular resistance and impair the right ventricle. Successful surgery necessitates a multidisciplinary approach, including thorough preoperative assessment; optimization and planning of intraoperative management strategies; and approaches to anticoagulation, right ventricular failure and LVAD flow optimization. This article discusses recent evidence on these topics.
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13
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Iwata S, Yokokawa S, Sato M, Ozaki M. Anesthetic management of a patient with a continuous-flow left ventricular assist device for video-assisted thoracoscopic surgery: a case report. BMC Anesthesiol 2020; 20:18. [PMID: 31959102 PMCID: PMC6972011 DOI: 10.1186/s12871-020-0933-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/07/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Shihoko Iwata
- Department of Anesthesiology, Tokyo Women's Medical University Hospital, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Sumire Yokokawa
- Department of Anesthesiology, Tokyo Women's Medical University Hospital, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Mihoshi Sato
- Department of Anesthesiology, Tokyo Women's Medical University Hospital, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Makoto Ozaki
- Department of Anesthesiology, Tokyo Women's Medical University Hospital, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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14
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Puri A, Tobin R, Bhattacharjee S, Kapoor MC. Noncardiac surgery in patients with a left ventricular assist device. Asian Cardiovasc Thorac Ann 2019; 28:15-21. [PMID: 31821765 DOI: 10.1177/0218492319895840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Archana Puri
- Max Super-Speciality Hospital, Saket, Delhi, India
| | - Raj Tobin
- Max Super-Speciality Hospital, Saket, Delhi, India
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15
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Navaratnam M, Maeda K, Hollander SA. Pediatric ventricular assist devices: Bridge to a new era of perioperative care. Paediatr Anaesth 2019; 29:506-518. [PMID: 30758099 DOI: 10.1111/pan.13609] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 01/17/2023]
Abstract
Pediatric ventricular assist devices (VADs) are evolving as a standard therapy for end stage heart failure in children. Major recent developments include the increased use of continuous flow (CF) devices in children and increased experience with congenital heart disease (CHD) and outpatient management. In the current and future era anesthesiologists will encounter more children presenting for VAD implantation, subsequent procedures and heart transplantation. Successful perioperative management requires an understanding of the interaction between the patient's physiology and the device and a framework to troubleshoot problems. This review focuses on CF devices, VAD support for CHD and perioperative management of pulsatile and CF devices in the pediatric population.
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Affiliation(s)
- Manchula Navaratnam
- Pediatric Anesthesia, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California
| | - Katsuhide Maeda
- Pediatric Cardiac Surgery, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California
| | - Seth A Hollander
- Pediatric Cardiology, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California
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16
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Duhachek-Stapelman AL, Roberts EK, Schulte TE, Shillcutt SK. The Cardiothoracic Anesthesiologist as a Perioperative Consultant—Echocardiography and Beyond. J Cardiothorac Vasc Anesth 2019; 33:744-754. [DOI: 10.1053/j.jvca.2018.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Indexed: 11/11/2022]
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17
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Bobes AA, Salcedo MC, Gómez-Limón ER, Álvarez Avello JM, González Román AI, Fernández MV, Gil AF, Gómez-Bueno M, Cubero JS, Fernández JG. Experience in anaesthetic management of non-cardiac surgery in patients with ventricular assist devices. ACTA ACUST UNITED AC 2018; 66:37-45. [PMID: 30153991 DOI: 10.1016/j.redar.2018.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022]
Abstract
Heart failure (HF) is a syndromic condition with a high incidence in current medicine. When the symptoms of HF progress, and become refractory, cardiac transplant is the best therapeutic option. However, due to the shortage of donors and the long waiting lists, many of those patients are candidates for implantation of ventricular assist devices as a bridge to the cardiac transplant, or when this is not an option, as a definitive therapy. A series of four clinical cases of patients with ventricular assist devices that required surgical intervention, is presented. Three of them were assisted with long-term care: two EXCOR (pulsatile and para-corporeal) and one HEARTWARE (non-pulsatile and intra-corporeal), and the last one with short-term assistance; CentriMag biventricular Levitronix. There is no significant literature on the peri-operative implications of these patients when they undergo urgent or scheduled surgery. The experience in our centre leads us to raise the need to determine a series of aspects: operation of each device, emphasising the correct placement of the cannulas during the surgery; the proper management of any medication, emphasising the importance of anticoagulant and anti-platelet therapies; the Pathophysiological changes at cardiopulmonary level due to the implantation of these devices; and the importance of the administration of a correct antibiotic therapy. Given the complexity of these cases, the limited experience in this field, and the few cases that exist in these situations, it is recommended to create protocols to ensure their proper management.
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Affiliation(s)
- A Albajar Bobes
- Servicio de Anestesia y Reanimación, Hospital Puerta de Hierro, Majadahonda, Madrid, España.
| | - M Casado Salcedo
- Servicio de Anestesia y Reanimación, Hospital Puerta de Hierro, Majadahonda, Madrid, España
| | - E Rincón Gómez-Limón
- Servicio de Anestesia y Reanimación, Hospital Puerta de Hierro, Majadahonda, Madrid, España
| | - J M Álvarez Avello
- Servicio de Anestesia y Reanimación, Hospital Puerta de Hierro, Majadahonda, Madrid, España
| | - A I González Román
- Servicio de Anestesia y Reanimación, Hospital Puerta de Hierro, Majadahonda, Madrid, España
| | - M Vidal Fernández
- Servicio de Anestesia y Reanimación, Hospital Puerta de Hierro, Majadahonda, Madrid, España
| | - A Forteza Gil
- Servicio de Cirugía Cardiaca, Hospital Puerta de Hierro, Majadahonda , Madrid, España
| | - M Gómez-Bueno
- Servicio de Cardiología, Hospital Puerta de Hierro, Majadahonda, Madrid, España
| | - J Segovia Cubero
- Servicio de Cardiología, Hospital Puerta de Hierro, Majadahonda, Madrid, España
| | - J García Fernández
- Servicio de Anestesia y Reanimación, Hospital Puerta de Hierro, Majadahonda, Madrid, España
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18
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Essandoh M, Essandoh G, Stallkamp ED, Perez WJ. Spectral Doppler Analysis of the HeartMate 3 Left Ventricular Assist Device Inflow: New Challenges Presented by the Artificial Pulse Technology. J Cardiothorac Vasc Anesth 2018; 32:e4-e5. [PMID: 30108022 DOI: 10.1053/j.jvca.2018.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Michael Essandoh
- Department of Anesthesiology, Wexner Medical Center, Ohio State University, Columbus, OH
| | - Grace Essandoh
- Department of Internal Medicine, Healthnet Airport Medical Center, Accra, Ghana
| | - Eric D Stallkamp
- Department of Perfusion, Wexner Medical Center, Ohio State University, Columbus, OH
| | - William J Perez
- Department of Anesthesiology, Wexner Medical Center, Ohio State University, Columbus, OH
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19
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Essandoh M, Hussain N, Cronin B. Anesthesia Care of Patients With Left Ventricular Assist Devices Undergoing Minor Noncardiac Surgery: Training General Anesthesiologists May Expedite Patient Care Without Negative Outcomes. J Cardiothorac Vasc Anesth 2018; 32:2109-2111. [PMID: 29631943 DOI: 10.1053/j.jvca.2018.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Essandoh
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Nasir Hussain
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Brett Cronin
- Department of Anesthesiology, University of California, San Diego, CA
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