Experience With Noncardiac Surgery in Destination Therapy Left Ventricular Assist Devices Patients

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Outcomes after noncardiac surgery in patients with left ventricular assist devices: a systematic review

Background

The number of patients living with left ventricular assist devices (LVADs) has gradually increased in the past decade. Non-cardiac surgery (NCS) in patients with LVAD poses a unique situation with its inherent challenges.

Aim

We conducted a comprehensive review to investigate the perioperative complications and mortality associated with emergent or elective NCS in patients with LVAD.

Method

A comprehensive literature search for any papers referring to continuous LVAD patients with NCS. All publications with at least five durable LVAD patients who had NCS were eligible for inclusion.

Result

Twenty articles matching our criteria were found and included in our study. This systematic review included 6,476 LVAD patients who underwent 6,824 NCS. There were 5-3,216 LVAD patients with NCS in each study. The median age was between 39 and 65 years, and most of the patients (78.8%) were male. Thirty-day postoperative mortality ranged from 0% to 60%. Eight studies reported no death within the 30 days of the operation. Common complications include gastrointestinal (GI) bleeding, intracranial bleeding, infection, acute kidney injury (AKI), urinary tract infection (UTI), stroke, sepsis, pneumonia, and VAD exchange. Emergent abdominal surgery had the highest (up to 60%) mortality rate, and vascular and neurological operations had the highest complication rates. Due to the diverse range of patients in each publication and the combination of outcomes presented in various publications, a meta-analysis was not conducted.

Conclusion

In LVAD patients, noncardiac surgery may be performed effectively and safely. LVAD patients who undergo non-cardiac surgery may require more transfusions due to their complex coagulopathies. However, perioperative management of LVAD patients undergoing emergent NCS should be optimized to reduce mortality.

Systematic Review Registration

https://osf.io/fetsb/.

Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report

This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.

In-hospital Outcomes of Left Ventricular Assist Devices (LVAD) Patients Undergoing Noncardiac Surgery

An increasing number of stage D heart failure patients are supported with left ventricular assist devices (LVADs), and the management of LVAD patients who require noncardiac surgery (NCS) presents unique challenges. Using the 2010-2014 National Inpatient Sample, we identified all adult cases of LVAD patients undergoing noncardiac surgeries using ICD-9-CM codes. We estimated inpatient mortality, bleeding complications, stroke, length of stay (LOS), and cost of hospitalization of the admissions related to NCS using mixed effects logistic and linear mixed regressions, respectively. A total of 30,323 patients with LVADs underwent 3,216 noncardiac surgeries (73.5% urgent) during the study period. LVAD recipients undergoing NCS had higher burden of certain comorbidities such as history of end-stage renal disease, pulmonary circulation disorders, peripheral vascular disease, and obesity. The most frequent NCS were general surgery, which included breast, endocrine, skin/burn, noncardiac transplantation, and abdominal surgeries (47.9%). In-hospital mortality was 7.7% with the highest rates observed among cases of neurologic surgeries. Vascular surgeries had the highest rates of ischemic stroke and gastrointestinal bleeding. Patients who underwent NCS had higher LOS and cost of hospitalization compared with LVAD recipients admitted to reasons other than NCS. Although bleeding complication trends have decreased, ischemic stroke and in-hospital mortality rates have increased overall during the study period. Urgent or emergency surgery was an independent predictor of mortality (OR 3.1, 95% CI 1.9-5). A significant burden of complications occurs after noncardiac surgeries in LVAD recipients.

Trends, Perioperative Adverse Events, and Survival of Patients With Left Ventricular Assist Devices Undergoing Noncardiac Surgery

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.

Is it Safe for Patients with Left Ventricular Assist Devices to Undergo Non-Cardiac Surgery?

Background and Objectives: Since the first use of ventricular assist devices (VADs) as bridge to recovery and bridge to cardiac transplantation in the early 1990s, significant technological advances have transformed VAD implantation into a routine destination therapy. With improved survival, many patients present for cardiac surgery for conditions not directly related to their permanent mechanical circulatory support. The aim of this study was to analyze the indications and outcomes of non-cardiac surgeries (NCSs) of left ventricular assist device (LVAD) patients in tertiary center. Material and Methods: We present a single-center experience after 151 LVAD implantations in 138 consecutive patients between 2012–2019 who had to undergo NCS during a follow-up period of 37 +/− 23.4 months on left ventricular assist device (LVAD). Results: A total of 105 procedures was performed in 63 LVAD recipients, resulting in peri-operative mortality of 3.8%. Twenty-five (39.7%) of patients underwent multiple surgeries. We found no significant difference in cumulative survival associated with the performed surgical interventions (p = 0.469). Conclusion: We demonstrated good overall clinical outcomes in LVAD patients undergoing NCS. With acceptable peri-operative mortality, NCS can be safely performed in LVAD patients on long-term support.

Abdominal Surgery in Patients with Ventricular Assist Devices: a Single-Center Report

This study was performed to evaluate the incidence and outcome of patients with ventricular assist devices (VADs) undergoing abdominal surgery at our institution. A total of 604 adult patients who underwent VAD implantation between February 2004 and February 2018 were analyzed retrospectively with a median follow-up time of 66 (6-174) months. Thirty-nine patients (6.5%) underwent abdominal surgery. Elective surgical procedures were performed in 22 patients (56.4%), mainly for abdominal wall hernia repairs, partial colectomies, and cholecystectomies. Early after elective abdominal surgery no patient died, resulting in a median survival of 23 (1-78) months. Emergency surgery was performed in 17 patients (43.6%). The most common emergency indications were intestinal ischemia and/or perforation. Eight patients undergoing emergent surgery (44.4%) died within the first 30 days after primary abdominal operation, mainly due to sepsis and consecutive multiple organ failure, resulting in a dismal median survival of one month (0-52). Patients undergoing abdominal surgery had significantly lower rates of realized heart-transplantation (p = 0.031) and a significantly higher rate of VAD exchange, before or after abdominal surgery, due to thromboses or infections (p = 0.037). Nonetheless, overall survival after primary VAD implantation in these patients (median 38 months; 0-107) was not significantly impaired when compared to all other patients undergoing VAD implantation (median 30 months; 0-171). In summary, elective abdominal surgery can be performed safely when well planned by an experienced multidisciplinary team. Abdominal complications in VAD patients requiring emergent surgery, however, lead to a significant increase in short-term morbidity and a high 30-day mortality rate.

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.

Emergency abdominal surgery in patients with left ventricular assist device: short- and long-term results

Introduction

Emergency abdominal surgery (EAS) in patients with long-term mechanical circulatory support and strong anticoagulation is very difficult.

Aim

To present our experiences regarding the short- and long-term results of patients with a left ventricular assist device (LVAD) who underwent emergency abdominal surgery under general anesthesia at a large tertiary healthcare center.

Material and methods

The electronic medical records of 7 patients with LVAD who underwent EAS between January 1, 2010 and December 31, 2016 were retrospectively investigated in order to evaluate perioperative management and outcomes. The patients were divided into two groups based on the need for EAS procedures.

Results

Seven (9.2%) of 76 patients with LVAD underwent EAS an average of 79.1 ±79.4 days after implantation. No statistically significant differences were found between the groups with and without EAS with regard to demographic characteristics, type of device, and rate of perioperative mortality (p > 0.05). The indications for surgery, retroperitoneal hematoma in 2 patients and in 5 other patients; ileus, iatrogenic splenic injury associated with thoracentesis, splenic abscess, acute abdominal pain and rectal cancer surgery was a pelvic abscess in a patient who is connected to the stump. In all cases laparotomy was performed with median incision. The perioperative mortality rate was 28.6% (n = 2). Two patients underwent orthotopic heart transplant during long-term follow-up.

Conclusions

The EAS is not rare during LVAD treatment but is a rather complex procedure. General surgeons will be increasingly likely to encounter such patients as their numbers rise and their life expectancies are prolonged.

Outcomes following Noncardiac Surgery in Patients with Ventricular Assist Devices: A Single-Center Experience

The Prevalence of ventricular assist devices (VADs) is increasing as advanced cardiac therapies progress. These patients commonly require non-cardiac surgical procedures (NCS), although data are scant regarding the safety, timing, and operations that may safely be performed. We aim to describe our experience with VAD patients undergoing NCS. We retrospectively reviewed records on patients who underwent NCS after VAD implantation between 2013 and 2015 at a single Joint Commission–accredited VAD institution. Data collection included demographics, ischemic cardiomyopathy or nonischemic cardiomyopathy, operative details, and perioperative anticoagulation management and outcomes. Seventy-two NCS were performed by general surgeons, thoracic surgeons, plastic surgeons, urologists, vascular surgeons, ENTs, and other services. Procedures were similarly varied, including video-assisted thoracoscopy with decortications or lung biopsy, tracheostomies, percutaneous endoscopic gastrostomies, exploratory laparotomies, and wound debridements and/or closures. The ten deaths in the study group were judged not to be directly related to NCS. Eleven cases had postoperative bleeding and two cases had postoperative thrombosis, including one pump thrombosis. Based on our results, VAD is not an absolute contraindication to NCS, and a variety of NCS procedures can safely be performed. Further study should focus on quantifying and mitigating the risk that VADs bring to NCS.

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.

Non-cardiac surgery in patients with continuous-flow left ventricular assist devices: a single institutional experience

With improvements in life expectancy for patients with continuous-flow left ventricular assist devices (LVADs), non-cardiac surgeons will increasingly encounter surgical problems in this population. 209 patients underwent LVAD placement between 10/1/2007 and 6/1/2015 at a single institution. Survival was compared between patients who had non-cardiac surgery (NCS) during the initial LVAD implantation hospitalization (n=36) and those who had NCS only in subsequent hospitalizations (n=33). Postoperative complication rates were examined. Index admission NCS was associated with lower 5-year survival compared with subsequent admission NCS (27.1% vs 39.4%, p=0.017). In subsequent admissions, the risks of bleeding and infectious complications were the same for elective or urgent NCS, but the risk of death was higher in the urgent surgery group. We conclude that elective NCS can be performed with low risk of death or LVAD dysfunction after sufficient recovery of patients from LVAD implantation.

Systematic Review of Outcomes After Noncardiac Surgery in Patients with Implanted Left Ventricular Assist Devices

The number of patients supported with left ventricular assist devices (LVADs) is rising rapidly, and noncardiac surgery (NCS) in these patients presents unique challenges. Given the controversy regarding the safety and timing of elective NCS, we performed a systematic review examining the perioperative morbidity and mortality of NCS in stable patients with LVADs. The published literature was searched using strategies created by a medical librarian. All reports involving five or more patients with implanted LVAD undergoing NCS were eligible for inclusion. One hundred and sixty one patients who underwent 252 surgeries were included from seven studies. Cohort size ranged from 8 to 47 patients undergoing 12 to 67 NCS. Median age ranged from 50.1 to 68 years and 75 to 100% were male. Thirty day postoperative mortality ranged from 6.4 to 16.7%, although four studies reported no deaths. Due to the small number of included studies with relative few patients and widely heterogeneous reporting of outcomes a formal quantitative meta-analysis was not performed. Noncardiac surgery in patients with LVADs appears to be safe and feasible in select patients. Future studies should use standard study design and reporting parameters to facilitate the systematic examination of safety and outcomes for elective NCS in LVAD patients.

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.

Pan-Cardiac Cycle Fixed Mitral Valve Opening in an LVAD Patient Presenting with Hemorrhagic Shock

We present the case of a patient with a HeartMate II left ventricular assist device (LVAD) who underwent an elective cholecystectomy and abruptly decompensated on postoperative day 9. We highlight the uncommon echocardiogram finding of mitral valve leaflets fixed widely open throughout the cardiac cycle during an LVAD suction event. Bedside echocardiographic confirmation of a suction event enabled the rapid diagnosis and intervention for hemorrhagic shock before blood tests and radiographic results were available. Acoustic image quality can be limited in LVAD patients, and awareness of this uncommon finding may increase specificity for the echocardiographic diagnosis of LVAD suction events.

[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.