Noncardiac Surgery in Long-Term Implantable Left Ventricular Assist-Device Recipients

Abstract

ObjectiveThe authors describe their experience with left ventricular assist-device (LVAD) recipients undergoing noncardiac surgery and delineate surgical, anesthetic, and logistic factors important in the successful intraoperative management of these patients. Summary Background DataLeft ventricular assist-devices have become part of the armamentarium in the treatment of endstage heart failure. As the numbers of patients chronically supported with long-term implantable devices grows, general surgical problems that are commonly seen in other hospitalized patients are becoming manifest. Of particular interest is the intraoperative management of patients undergoing elective noncardiac surgical procedures. MethodsThe anesthesia records and clinical charts were reviewed for eight ventricular assist-device recipients undergoing general surgical procedures between August 1, 1990 and August 31, 1994. ResultsA total of 12 procedures were performed in 6 men and 2 women averaging 52.7 years of age. Mean time elapsed from device implantation to operation was 68 ± 35 days. Conventional inhalational and intravenous anesthetic techniques were well tolerated in these patients undergoing diverse surgical procedures. No perioperative mortality was observed. Five of eight patients went on to successful cardiac transplantation. ConclusionsHemodynamic recovery after LVAD insertion has defined a new group of patients who develop noncardiac surgical problems often seen in other critically ill patients. Recognition of the unique potential problems that the LVAD recipient may encounter in the perioperative period-in particular patient positioning, device limitations, and fluid and inotropic management-will ensure an optimal surgical outcome for LVAD recipients undergoing noncardiac surgery. 203

Laparoscopic nephroureterectomy in a patient with a left ventricular assist device

“…6 Although open partial 9 and open radical nephrectomy 10 have been described, this is the first report of laparoscopic renal surgery in a patient supported with an HMII LVAD. Although there is growing interest in less invasive, nephron-sparing techniques, their efficacy is not established and nephroureterectomy continues to serve as the gold standard for the treatment of upper tract TCC.…”

Nichtkardiochirurgische operative Eingriffe bei Patienten nach Implantation eines „ventricular assist device“

“…Patienten mit einem VAD unterziehen sich in einer steigenden Anzahl von Fällen nichtkardiochirurgischen operativen Eingriffen, 4-42% der VAD-Patienten werden im Verlauf nach der initialen Implantation des VAD mit nichtkardiochirurgischen Operationsindikationen operiert [3,4,5,6,7,8]. Hieraus ergibt sich ein wichtiges und klinisch relevantes Thema für das anästhesiologische Management dieser Patienten.…”

“…Das anästhesiologische Management für nichtkardiochirurgische operative Eingriffe bei VAD-Patienten stellt eine Herausforderung dar, da diese Patienten einer Hochrisikopatientengruppe angehören und verschiedene VAD-abhängige Komplikationen zu beachten sind, wie ein erhöhtes Blutungs-und Thromboserisiko [13,14], Hypotension [5], Koagulopathie [8], Infektionen [3,8] sowie Limitationen durch das linksventrikuläre Assist-System [5,8] und Rechtsherzversagen [13].…”

“…Die geringe Mortalität bei nichtkardiochirurgischen operativen Eingriffen verdeutlicht, dass diese Maßnahmen sicher bei VAD-Patienten durchgeführt werden können [4,5,6,8,12,14,21,22].…”

“…B. ein erhöhtes Blutungs-und Thromboserisiko, hämodynamische Komplikationen, Rechtsherzinsuffizienz oder Infektionen [5,8,14,21,23,24,25]. Managementkonzepte für VAD-Patienten bei nichtkardiochirurgischen operativen Eingriffen sind in der aktuellen Literatur spärlich vorhanden und basieren i. d. R. auf Fallbeschreibungen und Fallserien.…”