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Palenzuela DL, Agarwal D, Flanders K, Coglianese E, Tsao L, D'Alessandro D, Lewis GD, Fitzsimons M, Gee D. A second chance for a new heart? The role of metabolic and bariatric surgery in patients with end-stage heart failure. J Gastrointest Surg 2024; 28:389-393. [PMID: 38583888 DOI: 10.1016/j.gassur.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/01/2024] [Accepted: 02/03/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Obesity is an independent risk factor for heart failure (HF). Substantial weight loss has been shown to reverse obesity-related cardiomyopathy. This study aimed to report our institution's experience with laparoscopic sleeve gastrectomy (LSG) in patients with morbid obesity and end-stage HF. METHODS Between 2018 and 2022, 26 patients with end-stage HF were referred for LSG. Of 26 patients, 16 underwent an operation, and 10 did not. After institutional review board approval, a retrospective electronic medical record review was performed to evaluate (i) age, (ii) preoperative weight, (iii) decrease in body mass index (BMI) score, (iv) whether the patient underwent heart transplantation, and (v) mortality. Data analysis was performed using Stata/SE (version 17.0; StataCorp). The Wilcoxon rank-sum test was used to compare continuous variables between the cohorts, and the Pearson chi-square test was used for binary variables with Bonferroni correction applied. RESULTS The LSG and non-LSG cohorts had comparable ages (P = .088) and starting BMI score (P = .918), and a proportion of patients had a ventricular assist device (P = .191). Patients who underwent LSG lost significantly more weight than the patients who did not, with an average decrease in BMI score of 8.9 kg/m2 (SD, ±6.13) and 1.1 kg/m2 (SD, ±4.10), respectively (P = .040). Of note, 6 patients (37.5%) who underwent LSG eventually underwent transplantation, compared with 2 patients (20.0%) from the matched cohort (P = .884). Of the 26 patients, there were 6 deaths: 2 (12.5%) in the LSG cohort and 4 (40.0%) in the non-LSG cohort (P = .525). CONCLUSION LSG may be safe and effective for weight loss in patients with HF. This operation may provide patients affected by obesity with end-stage HF the lifesaving opportunity to achieve transplant candidacy.
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Affiliation(s)
- Deanna L Palenzuela
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States.
| | - Divyansh Agarwal
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Karen Flanders
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Erin Coglianese
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Lana Tsao
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - David D'Alessandro
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Gregory D Lewis
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Michael Fitzsimons
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Denise Gee
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
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Do AS, Khan MA, Ross L, Ravinsky R, Milam AJ, Lee SJ, Durra O, Johnson JP. Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report. Cureus 2024; 16:e55266. [PMID: 38558610 PMCID: PMC10981535 DOI: 10.7759/cureus.55266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 04/04/2024] Open
Abstract
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.
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Affiliation(s)
- Angelique S Do
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Monis A Khan
- Department of Neurologic and Orthopedic Surgery, University of Arizona, Phoenix, USA
| | - Lindsey Ross
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Robert Ravinsky
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, USA
| | - Adam J Milam
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Seung J Lee
- Department of Neurosurgery, Mayo Clinic, Jacksonville, USA
| | - Omar Durra
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
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Place A, McCrum M, Bell T, Nirula R. EGS plus: Predicting futility in LVAD patients with emergency surgical disease. Am J Surg 2022; 224:1421-1425. [PMID: 36319484 DOI: 10.1016/j.amjsurg.2022.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 10/03/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND While emergent, non-cardiac surgery can be safely performed in LVAD patients, the inherent perioperative challenges of these rare procedures and the perception that these patients may be poor surgical candidates can contribute to reluctance to perform necessary emergency general surgery (EGS) procedures. We, therefore, sought to identify predictors of inpatient mortality to assist perioperative decision-making. METHODS The Nationwide Inpatient Sample (2010-2015Q3) was used to identify patients with previously placed LVADs with a subsequent EGS admission diagnosis. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day mortality, and a risk-adjusted probability of death was calculated for significant patient subgroups across age. Additional demographic variables were included in the regression due to clinical relevance. RESULTS There were 1805 (weighted) LVAD-EGS patients with an overall mortality rate of 11%. Independent predictors of mortality were intestinal ischemia and sepsis present on admission. Patients older than 70 with sepsis had an 80% probability of in-hospital mortality (10.6 OR, 1.70-65.5 95% CI) while those over 70 presenting with intestinal ischemia had a 38% probability of death (3.6 OR, 1.50-8.78 95% CI). Mortality risk for younger patients with sepsis was still approximately 50%. CONCLUSION Older LVAD patients presenting with either sepsis or intestinal ischemia have a substantial mortality risk while younger patients have a modest risk. These results can be used to guide treatment discussions when emergency surgery is being considered in LVAD patients.
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Affiliation(s)
- Aubrey Place
- Department of Surgery, University of Utah School of Medicine, USA; Division of General Surgery, University of Utah School of Medicine, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Marta McCrum
- Department of Surgery, University of Utah School of Medicine, USA; Division of General Surgery, University of Utah School of Medicine, 30 N 1900 East, Salt Lake City, UT, 84132, USA
| | - Teresa Bell
- Department of Surgery, University of Utah School of Medicine, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah School of Medicine, USA; Division of General Surgery, University of Utah School of Medicine, 30 N 1900 East, Salt Lake City, UT, 84132, USA
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Ng M, Rodgers B, Rehman S, Nathan SS, Bajwa KS, Shah SK, Akkanti BH, Jumean MF, Kumar S, Dressel JL, Radovancevic R, Felinski MM, Kar B, Gregoric ID. Left Ventricular Assist Device Support and Longitudinal Sleeve Gastrectomy Combined With Diet in Bridge to Heart Transplant. Tex Heart Inst J 2022; 49:478098. [PMID: 35201356 DOI: 10.14503/thij-20-7521] [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: 11/23/2022]
Abstract
Combining left ventricular assist device (LVAD) implantation and longitudinal sleeve gastrectomy may enable patients with morbid obesity to lose enough weight for heart transplant eligibility. In a retrospective study, we evaluated long-term outcomes of patients with body mass indexes ≥35 who underwent LVAD implantation and longitudinal sleeve gastrectomy during the same hospitalization (from January 2013 through July 2018) and then adhered to a dietary protocol. We included 22 patients (mean age, 49.9 ± 12.5 yr; mean preoperative body mass index, 43.3 ± 6.2). Eighteen months after gastrectomy, all 22 patients were alive, and 16 (73%) achieved a body mass index of less than 35. Myocardial recovery in 2 patients enabled LVAD removal. As of October 2020, 10 patients (45.5%) had undergone heart transplantation, 5 (22.3%) were waitlisted, 5 (22.3%) still had a body mass index ≥35, and 2 (9%) had died. With LVAD support, longitudinal sleeve gastrectomy, and dietary protocols, most of our patients with morbid obesity and advanced heart failure lost enough weight for transplant eligibility. Support from physicians and dietitians can maximize positive results in these patients.
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Affiliation(s)
- Mandy Ng
- Clinical Nutrition, Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Beverly Rodgers
- Clinical Nutrition, Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Saadiya Rehman
- Clinical Nutrition, Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Sriram S Nathan
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Kulvinder S Bajwa
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Shinil K Shah
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Bindu H Akkanti
- Division of Critical Care Medicine, University of Texas McGovern Medical School, Houston, Texas.,Division of Pulmonary and Sleep Medicine, University of Texas McGovern Medical School, Houston, Texas
| | - Marwan F Jumean
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Sachin Kumar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jennifer L Dressel
- Clinical Nutrition, Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Melissa M Felinski
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
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Clinical Outcomes, Trends in Weight, and Weight Loss Strategies in Patients With Obesity After Durable Ventricular Assist Device Implantation. Curr Heart Fail Rep 2021; 18:52-63. [PMID: 33420916 DOI: 10.1007/s11897-020-00500-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW To discuss clinical outcomes, changes in weight, and weight loss strategies of patients with obesity post left ventricular assist device (LVAD) implantation. RECENT FINDINGS Despite increased complications in patients with obesity after LVAD implantation, survival is comparable to patients without obesity. A minority of patients with obesity lose significant weight and become eligible for heart transplantation after LVAD implantation. In fact, a great majority of such patients gain weight post-implantation. Obesity by itself should not be considered prohibitive for LVAD therapy but, rather, should be incorporated into the overall risk assessment for LVAD implantation. Concerted strategies should be developed to promote sustainable weight loss in patients with obesity and LVAD to improve quality of life, eligibility, and outcomes after heart transplantation. Investigation of the long-term impact of weight loss on patients with obesity with LVAD is warranted.
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Kajiwara T, Naitoh T, Suzuki Y, Kohyama A, Karasawa H, Suzuki H, Akiyama M, Saiki Y, Watanabe K, Ohnuma S, Kamei T, Unno M. Laparoscopic right hemicolectomy for an ascending colon cancer patient with an implantable left ventricular assist device: a case report. Surg Case Rep 2020; 6:282. [PMID: 33165746 PMCID: PMC7652963 DOI: 10.1186/s40792-020-01064-9] [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: 09/16/2020] [Accepted: 11/03/2020] [Indexed: 11/15/2022] Open
Abstract
Background Left ventricular assist devices (LVADs) currently play an important role in the treatment of patients with end-stage heart failure who require a bridge to heart transplantation or destination therapy. With the development and improvement of the LVADs, the morbidity and mortality rates are declining and life expectancies increasing, and the number of patients with LVADs requiring non-cardiac surgery is likely to increase. We present the case of a patient with implantable LVAD who underwent laparoscopic right hemicolectomy for ascending colon cancer. Case description The patient was a 66-year-old man who underwent LVAD implantation as a BTT 3 years prior. He suffered from severe anemia at follow-up, and a colonoscopy revealed ascending colon cancer. The LVAD pump was implanted in the epigastrium. The long C-shaped subfascial driveline tunnel was made, and driveline exit site was located on the left lateral abdominal wall. We assessed the positional relationship between the tumor and the driveline using X-ray and three-dimensional computed tomography (3D CT) images. 3D CT image allowed us to easily identify the location of the driveline, and we determined to perform laparoscopic right hemicolectomy. The port sites were decided upon carefully to avoid the driveline injury, and the driveline was marked on the skin before surgery. There were no adhesions in the abdominal cavity, and both the LVAD and the driveline were observable. The trocars were in nearly the same positions as in a standard laparoscopic right hemicolectomy. During the operation, the LVAD and the driveline did not interfere with the trocars. We successfully completed a standard laparoscopic right hemicolectomy despite hemorrhagic tendency. The patient was discharged without any bleeding complications during the postoperative course. Conclusion Laparoscopic surgery is feasible and safe for patients with LVADs with intensive preoperative simulation and perioperative prevention of infection.
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Affiliation(s)
- Taiki Kajiwara
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Takeshi Naitoh
- Department of Lower Gastrointestinal Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yusuke Suzuki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Atsushi Kohyama
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hideaki Karasawa
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hideyuki Suzuki
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Masatoshi Akiyama
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Kazuhiro Watanabe
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Shinobu Ohnuma
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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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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Is it Safe for Patients with Left Ventricular Assist Devices to Undergo Non-Cardiac Surgery? MEDICINA-LITHUANIA 2020; 56:medicina56090424. [PMID: 32842512 PMCID: PMC7559908 DOI: 10.3390/medicina56090424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 11/26/2022]
Abstract
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.
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Ventricular Assist Device Implantation and Bariatric Surgery: A Route to Transplantation in Morbidly Obese Patients with End-Stage Heart Failure. ASAIO J 2020; 67:163-168. [DOI: 10.1097/mat.0000000000001212] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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10
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Bariatric Surgery in End-Stage Heart Failure: Feasibility in Successful Attainment of a Target Body Mass Index. J Card Fail 2020; 26:944-947. [PMID: 32428670 DOI: 10.1016/j.cardfail.2020.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 04/12/2020] [Accepted: 04/21/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Orthotopic heart transplantation (OHT) is contraindicated in morbidly obese patients with end-stage heart failure (HF), for whom cardiac allograft is the only means for long-term survival. Bariatric surgery may allow them to achieve target body mass index (BMI) for OHT METHODS: From 4/2014 to 12/2018, 26 morbidly obese HF patients who did not meet BMI eligibility criteria for OHT underwent laparoscopic bariatric surgery. Outcomes of interest were median difference in BMI, number of patients achieving target BMI for OHT, and 30-day mortality. RESULTS Median age was 49 (IQR 14) years, and 13 (50%) were women. HF was mainly systolic (15 patients, 58%). The median LVEF was 27% (IQR 37%). At the time of bariatric surgery, 12 (46%) patients had mechanical circulatory support: 2 (8%) concomitant left ventricular assist device (LVAD) placements, 8 (31%) LVAD already-in-place, and 2 (8%) intra-aortic balloon pumps. There was no 30-day mortality, but one mortality on postoperative day 48. Over a median follow-up of 6 months (range 0-36 months, IQR 17), there was a significant reduction in BMI (p<0.0001). The median postoperative BMI was 36.7 (IQR 8.7), compared to preoperative median BMI of 42.7 (IQR 9.4). Target BMI of < 35 was achieved in 11 (42%) patients. Three patients (12%) have undergone OHT. CONCLUSION Bariatric surgery in end-stage HF is feasible and results in a high number of patients achieving target BMI, increasing their probability of undergoing OHT. The presence of a LVAD should not preclude these patients from undergoing a bariatric intervention.
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Abstract
PURPOSE To determine the safety and efficacy of cataract surgery in patients with left ventricular assist devices (LVADs). SETTING Duke Eye Center, Durham, North Carolina, USA. DESIGN Retrospective case series. METHODS Electronic medical records were used to collect patient demographics, preoperative planning, intraoperative details, and postoperative outcomes of patients with LVADs who underwent cataract surgery between March 2012 and August 2019. RESULTS A total of 53 cataract surgeries were identified involving 31 patients. Most patients were men (n = 27) and white (n = 25) with a mean age of 69.5 years. Preoperative biometry was unchanged from standard protocol. Femtosecond laser, intraoperative aberrometry, and/or a premium IOL was used in 25 cases (47.2%) . Patients were on warfarin, warfarin plus aspirin, and warfarin plus clopidogrel in 51.6% (n = 16), 45.2% (n = 14), and 3.2% (n = 1) of cases, respectively. Patients underwent topical anesthesia with monitored anesthesia care from an experienced LVAD team as planned with no episodes of hemodynamic instability, respiratory compromise, or intraoperative adverse events related to the LVAD. All patients were discharged the same day as surgery. There were no hospitalizations or deaths within 30 days that were attributed to the cataract procedure. At 1 month postoperatively, 61.1% of eyes were ±0.5 diopter of their predicted spherical equivalent (n = 11/18), with a high proportion of patients returning to local providers for postoperative care. CONCLUSIONS Cataract surgery was safe and feasible in patients with LVADs when performed with additional perioperative considerations and in conjunction of an experienced LVAD team. The presence of LVAD itself was not found to be a contraindication for cataract surgery.
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12
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Abo-Alhassan F, Trilling B, Sage PY, Girard E, Faucheron JL. Feasibility and safety of laparoscopic colorectal surgeries for patients with left ventricular assist device. Int J Colorectal Dis 2019; 34:1979-1982. [PMID: 31520199 DOI: 10.1007/s00384-019-03384-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE There is limited literature regarding the feasibility and safety of laparoscopic procedures in patients having mechanical circulatory support, especially colonic resections. METHODS The aim of this study is to present the case of a laparoscopic colectomy for cancer undergone in a 69-year-old patient having a HeartWare II at our institution without any postoperative major complications and to describe the perioperative management and outcome of these patients according to the literature, regarding the hemodynamic, hemorrhagic, and infectious risks and the safety of this procedure. RESULTS There was no 90-day postoperative morbidity or death. A total of six patients including ours were identified in the study. This study has a limited number of patients and relatively short follow-up time. CONCLUSION Even though the management of patients having a LVAD is challenging and needs a multidisciplinary approach, reported literatures have shown the safety and feasibility of laparoscopic interventions for colorectal surgeries.
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Affiliation(s)
- Fawaz Abo-Alhassan
- Department of Colorectal Surgery, Grenoble Alps University Hospital, 38000, Grenoble, France
| | - Bertrand Trilling
- Department of Colorectal Surgery, Grenoble Alps University Hospital, 38000, Grenoble, France
- University Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, 38000, Grenoble, France
| | - Pierre-Yves Sage
- Department of Colorectal Surgery, Grenoble Alps University Hospital, 38000, Grenoble, France
| | - Edouard Girard
- Department of Colorectal Surgery, Grenoble Alps University Hospital, 38000, Grenoble, France
- University Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, 38000, Grenoble, France
| | - Jean-Luc Faucheron
- Department of Colorectal Surgery, Grenoble Alps University Hospital, 38000, Grenoble, France.
- University Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, 38000, Grenoble, France.
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13
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Extrakardiale Operationen bei Patienten mit permanentem linksventrikulärem Assist Device. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-018-0226-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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14
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Nelson JA, Mauermann WJ, Barbara DW. Left Ventricular Assist Devices and Noncardiac Surgery. Adv Anesth 2018; 36:99-123. [PMID: 30414644 DOI: 10.1016/j.aan.2018.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- James A Nelson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine & Science, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - William J Mauermann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine & Science, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Barbara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine & Science, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Chung M. Perioperative Management of the Patient With a Left Ventricular Assist Device for Noncardiac Surgery. Anesth Analg 2018; 126:1839-1850. [DOI: 10.1213/ane.0000000000002669] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Greene J, Tran T, Shope T. Sleeve Gastrectomy and Left Ventricular Assist Device for Heart Transplant. JSLS 2018; 21:JSLS.2017.00049. [PMID: 28951657 PMCID: PMC5610117 DOI: 10.4293/jsls.2017.00049] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Heart failure (HF) is a severe obesity-related comorbidity. Many patients with end-stage HF eventually require cardiac transplantation for long-term survival. These patients may be precluded from enrollment in heart transplant programs secondary to morbid obesity. We propose a pathway involving sleeve gastrectomy (SG) for patients with morbid obesity and HF to afford cardiac transplantation eligibility. METHODS Three patients with HF and morbid obesity underwent implantation of a left ventricular assist device (LVAD) and SG at an academic tertiary care institution in Washington, DC. This retrospective review from April 2012 through January 2017 examines the perioperative course of these 3 patients with regard to bariatric and cardiac indices, including ejection fraction (EF), HF classification, comorbid diseases, and percentages of total weight loss (%TWL) and excess weight loss (%EWL). RESULTS All three patients underwent LVAD placement as a bridge to transplant but were excluded from cardiac transplantation secondary to body mass index (BMI) and were referred for bariatric surgery. All have demonstrated considerable weight loss, with average decrease in BMI of 19 points, 39% TWL, and 81% EWL at a mean of 44 months after SG. Two patients have gone on to receive heart transplants, with near normalization of their EF. CONCLUSION LVAD and SG constitute a feasible pathway to cardiac transplantation in morbidly obese patients with end-stage HF. LVAD permits temporary cardiac support, whereas SG assists in efficacious weight loss. We explore SG as a durable weight loss option in patients with HF, with LVAD to improve eligibility for orthotopic cardiac transplantation.
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Affiliation(s)
| | - Tung Tran
- Section of Advanced Laparoscopic and Bariatric Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Timothy Shope
- Section of Advanced Laparoscopic and Bariatric Surgery, MedStar Washington Hospital Center, Washington, DC, USA
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Emergency abdominal surgery in patients with left ventricular assist device: short- and long-term results. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2018; 13:313-319. [PMID: 29362574 PMCID: PMC5770862 DOI: 10.5114/aic.2017.71613] [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: 06/02/2017] [Accepted: 08/19/2017] [Indexed: 11/26/2022] Open
Abstract
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.
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Outcomes of Abdominal Surgery in Patients With Mechanical Ventricular Assist Devices: A Multi-institutional Study. Ann Surg 2017; 269:774-777. [PMID: 28885501 DOI: 10.1097/sla.0000000000002513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to examine the outcomes of elective and emergent abdominal operations performed in end-stage heart failure patients supported with ventricular assist devices (VADs). SUMMARY OF BACKGROUND DATA With the growing volume of end-stage heart failure patients receiving VADs, an increasing number of these patients require surgery for noncardiac pathology. There is a paucity of studies on the safety of abdominal operations in this population. METHODS We performed a retrospective chart review across 3 hospitals of patients with VADs who underwent abdominal surgeries between 2003 and 2015. We used Chi-square, Fisher exact, and Mann-Whitney U tests for comparison of elective and emergent cases. RESULTS Fifty-seven patients underwent 63 operations, of which 23 operations were elective, 24 were emergent, and 16 were emergently performed in the same admission as VAD placement and analyzed separately. Patients undergoing elective versus emergent procedures had similar comorbidities (Charlson score 2.9 vs 3.0). 43% versus 32% of patients had VADs as a destination therapy. Although perioperative anticoagulation approach was variable, holding warfarin and starting heparin/enoxaparin/bivalirudin bridge was most common (65% vs 54%). Although 2-fold higher in the emergent group (50 vs 100 mL, P = 0.06), median estimated blood loss was low. Postoperative bleeding requiring transfusion was not very common (13% vs 8%), whereas rate of ischemic cerebrovascular accident (4% each) and venous thromboembolism was low (0% vs 13%, P = 0.23). Thirty-day mortality rate was 4% versus 17%, P = 0.19. CONCLUSION VAD patients have an acceptable risk profile for abdominal surgery.
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Kettyle SM, Chervu NL, Rao AS, Sadi S, Majure D, Sava JA, Johnson LS. Outcomes following Noncardiac Surgery in Patients with Ventricular Assist Devices: A Single-Center Experience. Am Surg 2017. [DOI: 10.1177/000313481708300833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Salaam Sadi
- MedStar Washington Hospital Center, Washington, DC
| | - David Majure
- MedStar Washington Hospital Center, Washington, DC
| | - Jack A. Sava
- MedStar Washington Hospital Center, Washington, DC
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Complications, Risk Factors, and Staffing Patterns for Noncardiac Surgery in Patients with Left Ventricular Assist Devices. Anesthesiology 2017; 126:450-460. [PMID: 28059837 DOI: 10.1097/aln.0000000000001488] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Stoicea N, Sacchet-Cardozo F, Joseph N, Kilic A, Sipes A, Essandoh M. Pro: Cardiothoracic Anesthesiologists Should Provide Anesthetic Care for Patients With Ventricular Assist Devices Undergoing Noncardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:378-381. [DOI: 10.1053/j.jvca.2016.06.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Indexed: 11/11/2022]
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Periprocedural Management of 172 Gastrointestinal Endoscopies in Patients with Left Ventricular Assist Devices. ASAIO J 2016; 61:670-5. [PMID: 26181710 DOI: 10.1097/mat.0000000000000269] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Systematic Review of Outcomes After Noncardiac Surgery in Patients with Implanted Left Ventricular Assist Devices. ASAIO J 2016; 61:648-51. [PMID: 26418202 DOI: 10.1097/mat.0000000000000278] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
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.
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Current status of the implantable LVAD. Gen Thorac Cardiovasc Surg 2016; 64:501-8. [PMID: 27270581 DOI: 10.1007/s11748-016-0671-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/29/2016] [Indexed: 10/21/2022]
Abstract
With the ongoing shortage of available organs for heart transplantation, mechanical circulatory support devices have been increasingly utilized for managing acute and chronic heart failure that is refractory to medical therapy. In particular, the introduction of the left ventricular assist devices (LVAD) has revolutionized the field. In this review, we will discuss a brief history of the LVAD, available devices, current indications, patient selection, complications, and outcomes. In addition, we will discuss recent outcomes and advancements in the field of noncardiac surgery in the LVAD patient. Finally, we will discuss several topics for surgical consideration during LVAD implantation.
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Wester T, Franklin A, Donahue BS. Perioperative Management of a Pediatric Patient with Catecholamine-Induced Cardiomyopathy Undergoing Laparoscopic Paraganglioma Excision Requiring Biventricular Assist Device Support. J Cardiothorac Vasc Anesth 2015; 29:999-1002. [DOI: 10.1053/j.jvca.2014.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Indexed: 11/11/2022]
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Evans AS, Stone ME. A patient safety model for patients with ventricular assist devices undergoing noncardiac procedures. Am J Med Qual 2015; 29:173-4. [PMID: 24589753 DOI: 10.1177/1062860613497502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Knaus WJ, Olson CH. Colo-colonic anastomosis in a continuous-flow left ventricular assist device patient. Asian J Surg 2015; 40:232-235. [PMID: 25773501 DOI: 10.1016/j.asjsur.2015.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 01/29/2015] [Indexed: 11/26/2022] Open
Abstract
Noncardiac operations are being increasingly performed on patients with left ventricular assist devices (LVADs). However, little is known on the impact of continuous-flow LVADs on the vascular supply of the colon for anastomoses. In this case, a 67-year-old male supported on an LVAD underwent four successful noncardiac operations including two intestinal anastomoses; left colon and small bowel anastomosis. To the best of our knowledge, no existing literature has reported successful colonic anastomosis on a continuous-flow LVAD. This case illustrates the plausibility of performing colonic anastomoses with appropriately selected patients supported on an LVAD. A 67-year-old male with congestive heart failure underwent LVAD placement for decompensated heart failure while awaiting orthotopic transplantation. During his recovery, he developed a stage IV sacral decubitus ulcer which required a sigmoid loop colostomy placement and a rotational flap. Subsequent stoma closure with partial sigmoid colectomy and stapled anastomosis was performed, and healed without evidence of anastomotic leak. This case illustrates the potential for colonic anastomoses for patients on continuous-flow LVAD support. Although oxygenation is known to be an important aspect of healing, this patient's outcome suggests that intestinal anastomoses can be performed on the induced pulseless environment of an LVAD. Further studies will be needed to further elucidate the success of longer segment resections and appropriate surgical candidates.
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Chaudhry UI, Kanji A, Sai-Sudhakar CB, Higgins RS, Needleman BJ. Laparoscopic sleeve gastrectomy in morbidly obese patients with end-stage heart failure and left ventricular assist device: medium-term results. Surg Obes Relat Dis 2015; 11:88-93. [DOI: 10.1016/j.soard.2014.04.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/27/2014] [Accepted: 04/06/2014] [Indexed: 01/17/2023]
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Blum FE. [Noncardiological surgical procedure for patients implanted with a ventricular assist device. Anesthesiological management concepts]. Med Klin Intensivmed Notfmed 2014; 110:197-203. [PMID: 24981063 DOI: 10.1007/s00063-014-0398-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 06/03/2014] [Accepted: 06/10/2014] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- F E Blum
- Department of Internal Medicine, Weiss Memorial Hospital, affiliate of the University of Illinois, 4646 North Marine Drive, 60640, Chicago, IL, USA,
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Eghrari AO, Rivers RJ, Alkharashi M, Rajaii F, Nyhan D, Sikder S. Cataract surgery in patients with left ventricular assist device support. J Cataract Refract Surg 2014; 40:675-8. [PMID: 24568720 DOI: 10.1016/j.jcrs.2014.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 12/14/2013] [Accepted: 12/17/2013] [Indexed: 11/17/2022]
Abstract
UNLABELLED Left ventricular assist devices (LVADs) have been increasingly used for 20 years in terminally ill patients with advanced heart failure or awaiting cardiac transplantation. Despite improvement in morbidity and mortality from use of these devices, quality of life may be limited by cataract. Access to cataract surgery in this predominantly elderly population is essential but limited by unfamiliarity with these devices. We describe phacoemulsification and intraocular lens implantation in 2 patients with LVADs. The patients had extensive preoperative cardiology evaluations and were instructed to continue warfarin through the day of surgery. Monitored sedation was used with fentanyl and midazolam. Both patients experienced significant improvement in visual acuity and quality of life. Neither experienced intraoperative hemodynamic instability. Cataract surgery may be safely performed in patients with LVAD support when adequate monitoring resources are available. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.
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Affiliation(s)
- Allen O Eghrari
- From the Department of Ophthalmology (Eghrari, Alkharashi, Rajaii, Sikder) and the Department of Anesthesia and Critical Care (Rivers, Nyhan), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard J Rivers
- From the Department of Ophthalmology (Eghrari, Alkharashi, Rajaii, Sikder) and the Department of Anesthesia and Critical Care (Rivers, Nyhan), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Majed Alkharashi
- From the Department of Ophthalmology (Eghrari, Alkharashi, Rajaii, Sikder) and the Department of Anesthesia and Critical Care (Rivers, Nyhan), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fatemeh Rajaii
- From the Department of Ophthalmology (Eghrari, Alkharashi, Rajaii, Sikder) and the Department of Anesthesia and Critical Care (Rivers, Nyhan), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel Nyhan
- From the Department of Ophthalmology (Eghrari, Alkharashi, Rajaii, Sikder) and the Department of Anesthesia and Critical Care (Rivers, Nyhan), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shameema Sikder
- From the Department of Ophthalmology (Eghrari, Alkharashi, Rajaii, Sikder) and the Department of Anesthesia and Critical Care (Rivers, Nyhan), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Rodriguez LE, Suarez EE, Loebe M, Bruckner BA. General Surgery Considerations in the Era of Mechanical Circulatory Assist Devices. Surg Clin North Am 2013; 93:1343-57. [DOI: 10.1016/j.suc.2013.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hessel EA. Management of patients with implanted ventricular assist devices for noncardiac surgery: a clinical review. Semin Cardiothorac Vasc Anesth 2013; 18:57-70. [PMID: 24132353 DOI: 10.1177/1089253213506788] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Eugene A Hessel
- 1University of Kentucky College of Medicine, Lexington, KY, USA
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Barbara DW, Wetzel DR, Pulido JN, Pershing BS, Park SJ, Stulak JM, Zietlow SP, Morris DS, Boilson BA, Mauermann WJ. The perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery. Mayo Clin Proc 2013; 88:674-82. [PMID: 23809318 DOI: 10.1016/j.mayocp.2013.03.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 03/27/2013] [Accepted: 03/28/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the perioperative management of patients with left ventricular assist devices (LVADs) who require general anesthesia while undergoing noncardiac surgery (NCS) at a single, large tertiary referral center. PATIENTS AND METHODS Electronic medical records from September 2, 2005, through May 31, 2012, were retrospectively reviewed to evaluate the perioperative management and outcomes in LVAD patients undergoing NCS. Patients were included only if they required a general anesthetic and had previously been discharged from the hospital after initial LVAD implantation. RESULTS Thirty-three patients with LVADs underwent general anesthesia for 67 noncardiac operations. The mean ± SD time from LVAD implantation to NCS was 317 ± 349 days. All but 1 patient had axial flow LVADs. Anticoagulation or antiplatelet agents were present within 7 days before NCS in 49 procedures (73%) and reversed in 32 of 49 (65%). No perioperative thrombotic complications related to anticoagulation or antiplatelet reversal were noted. Red blood cell, fresh frozen plasma, and platelet transfusions were administered during 10, 6, and 4 operations, respectively. The only intraoperative complication was surgical bleeding. Postoperative complications were present in 12 patients after NCS and were mainly composed of bleeding. Three patients died within 30 days of NCS, with the causes of death not attributed to NCS. CONCLUSION Patients with LVAD safely underwent NCS in a multidisciplinary setting that included preoperative optimization by cardiologists familiar with LVADs when feasible. Anticoagulation or antiplatelet agents were present preoperatively in most patients with LVADs and were safely reversed when necessary for NCS. The relatively high occurrence of postoperative bleeding is consistent with previous series.
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