Noncardiac surgery in patients with a left ventricular assist device

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.

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

“…Despite these limitations, our study highlights that surgical intervention can be performed safely in this demanding group of patients. Our findings are supported by those of existing studies investigating the outcomes of NCS while on mechanical circulatory support [ 2 , 3 , 8 , 13 , 18 , 21 ]. The prevalence of NCS in LVAD recipients is still increasing, with a growing demand for management of LVAD recipients outside the implanting center and without access to a cardiac surgical team on standby.…”

“…Ventricular assist devices (VADs, Table 1 ) were originally introduced in 1990s as bridge to recovery and bridge to cardiac transplantation [ 1 ]. As a consequence of technological advances, left ventricular assist devices (LVADs) are now commonly utilized in patients with chronic left heart failure refractory to maximal medical management as destination therapy [ 2 ]. LVADs have evolved from pulsatile and extracorporeal devices to those implanted within the body to support the circulation with continuous flow provided by an axial (HeartMate II, Abbot, Chicago, IL, USA) or centrifugal (HeartWare HVAD, Medtronic, Dublin, Ireland and HeartMate III, Abbot, Chicago, IL, USA) pump [ 1 ].…”

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

“…In the event of decreased venous return, strategies of placing the patient in a slight Trendelenburg position, judicious fluid loading, and adjusting ventilatory settings are advisable until the recovery of pump preload or vascular tone. [14] Possible hemodynamic effects of intraoperative patient positioning should be considered. Preload can be reduced if the surgical approach requires other than supine position such as reverse Trendelenburg, beach chair, lateral decubitus with one-lung ventilation, or prone positions.…”

“…Anesthetic considerations and preparations may vary depending on the type of non-cardiac surgery scheduled for the patient with an LVAD. Because LVADs only function effectively when the left ventricle is adequately filled by the right ventricle, preoperative assessment of right ventricular function, the presence of ventricular tachyarrhythmia, and the degree of pulmonary hypertension are crucial for identifying patients who need invasive monitoring (e.g., central venous catheters, pulmonary artery catheters, or transesophageal echocardiography [TEE]), early initiation of inotropic therapy, or other right ventricular optimization strategies (e.g., judicious volume therapy or ventilator setting adjustments) [ 12 – 14 ]. To facilitate awareness of any patient-specific or device-specific problems, preoperative discussions with knowledgeable clinicians (e.g., a specialized VAD team, if available) is important [ 12 , 15 ].…”

“…Factors critical to preload include intravascular volume status, patient positioning, surgical approach (laparoscopic vs. open), arrhythmias, and right ventricular function or afterload. In the event of decreased venous return, strategies for placing the patient in a slight Trendelenburg position, initiating judicious fluid loading, and adjusting ventilatory settings are advisable until recovery of the pump preload or vascular tone [ 14 ]. Possible hemodynamic effects of intraoperative patient positioning should also be considered.…”