Perioperative Care of the Patient With the Total Artificial Heart

Abstract

Advanced heart failure continues to be a leading cause of morbidity and mortality despite improvements in pharmacologic therapy. High demand for cardiac transplantation and shortage of donor organs have led to an increase in the utilization of mechanical circulatory support devices. The total artificial heart is an effective biventricular assist device that may be used as a bridge to transplant and that is being studied for destination therapy. This review discusses the history, indications, and perioperative management of the total artificial heart with emphasis on the postoperative concerns.

Chest Compressions in Pediatric Patients With Continuous-Flow Ventricular Assist Devices: Case Series and Proposed Algorithm

“…Chest compressions can be performed on all patients with VADs, with the exception of the Total Artificial Heart (TAH) (SynCardia Systems, LLC; Tucson, Arizona). Patients with a TAH have had their ventricle(s) excised at the time of implantation, and therefore do not benefit from chest compressions, defibrillation, pacing or cardioactive medications; the plastic artificial ventricle is incompressible ( 14 , 17 , 18 ). A large study of adult LVAD patients with cardiac arrest between 2010 and 2018 did show a higher mortality in those who received CPR compared to those who did not.…”

Total artificial heart system

“…TAH recipients are generally hypertensive due to vasomotor dysregulation and blood pressure support with vasopressors in the preoperative setting. They may require vasodilators to reduce systemic vascular resistance (goal systolic blood pressure between 120 and 140 mm Hg) and any impedance to forward flow from the pump 10. However, vasodilation must be appropriately balanced with vasopressors to ensure adequate venous return.…”

“…The decision to close the chest immediately after TAH implantation should consider bleeding risk. Given the high risk of postoperative mediastinal bleeding and subsequent tamponade, patients are commonly transported to the intensive care unit with an open chest if significant coagulopathy is present 10. Patients with TAH, like all other MCS devices, are at risk for thrombosis and embolic events due to activation of the coagulation system and hemolysis with the device.…”

“…The risk of infection is exacerbated by the transcutaneous cannulas, which can serve as a nidus of infection. Perioperative antibiotics should have broad coverage, and antifungal agents should be considered if chest closure is delayed 10. Early extubation, mobilization, and invasive line removal postoperatively can ameliorate infection risks.…”

“…A preinduction arterial catheter is mandatory for continuous blood pressure monitoring. 10 Induction of general anesthesia is done with caution, accounting for severe biventricular failure, labile hemodynamics, and multisystem organ dysfunction. 11 Central venous access is essential for central venous pressure (CVP) monitoring and administering fluids and medications.…”