Figure - available via license: Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported
Content may be subject to copyright.
Source publication
The use of mechanical circulatory support devices as a bridge to transplant or destination therapy decreases mortality, improves quality of life, and functional status. The paucity of clinical data and the challenges faced by noncardiac anesthesiologists warrant us to present the perioperative care of a patient with a HeartMate II (Thoratec Corp. P...
Similar publications
The use of long-term and short-term mechanical circulatory support in the form of ventricular assist device (VAD) has increased over the last decade. While cardiothoracic anesthesiologists care for these patients during device placement, increasingly higher numbers of general anesthesiologists are involved in the management of VAD patients during n...
A ventricular assist device (VAD) is a mechanical pump used to support heart function and blood flow in people who have weakened hearts. For selected patients who are too ill to wait for a heart transplant or are not eligible for a heart transplant because of age or other medical problems, ventricular assist devices offer life-saving therapy. This...
Citations
... Implantation in a subcutaneous pocket in a single piece similar to an implantable defibrillator without sternotomy or thoracotomy and cardiopulmonary bypass creates the premise for a greater acceptance by both doctors and patients, eliminating the need for a highly invasive intervention, as is the case of on-the-market available devices [43,44]. However, connecting the inflow cannula to the heart endovascularly is a complex intervention and limits the size of the inflow cannula which may allow only partial support of up to 3-5 L/min for an adult patient. ...
Despite evidence associating the use of mechanical circulatory support (MCS) devices with increased survival and quality of life in patients with advanced heart failure (HF), significant complications and high costs limit their clinical use. We aimed to design an innovative MCS device to address three important needs: low cost, minimally invasive implantation techniques, and low risk of infection. We used mathematical modeling to calculate the pump characteristics to deliver variable flows at different pump diameters, turbomachinery design software CFturbo (2020 R2.4 CFturbo GmbH, Dresden, Germany) to create the conceptual design of the pump, computational fluid dynamics analysis with Solidworks Flow Simulation to in silico test pump performance, Solidworks (Dassault Systèmes SolidWorks Corporation, Waltham, MA, USA) to further refine the design, 3D printing with polycarbonate filament for the initial prototype, and a stereolithography printer (Form 2, Formlabs, Somerville, MA, USA) for the second variant materialization. We present the concept, design, and early prototyping of a low-cost, minimally invasive, fully implantable in a subcutaneous pocket MCS device for long-term use and partial support in patients with advanced HF which unloads the left heart into the arterial system containing a rim-driven, hubless axial-flow pump and the wireless transmission of energy. We describe a low-cost, fully implantable, low-invasive, wireless power transmission left ventricular assist device that has the potential to address patients with advanced HF with higher impact, especially in developing countries. In vitro testing will provide input for further optimization of the device before proceeding to a completely functional prototype that can be implanted in animals.
... The first trocar was inserted using Hasson open technique via the umbilicus. Abdominal insufflation was initiated slowly and carefully because it has been reported pneumoperitoneum alters LVAD flow [3]. A pneumoperitoneum was done at a pressure of 10 mmHg, and a sufficient operative field was obtained without altering the hemodynamics. ...
... Laparoscopic surgery in patients with LVADs has been reported in various types of abdominal surgery and more recently in bariatric surgery. However, reports of laparoscopic colectomy for LVAD patients with cancer are limited [3,[5][6][7]. It has also been recognized that, in patients with LVADs, the presence of the pump and the driveline in the abdominal wall necessitates the careful positioning of the trocars during laparoscopic surgery. ...
... The risk of infection of these components is related to how close they are to the incision [10]. Previous reports do not mention the distances between the trocar insertion sites and the driveline [3,[5][6][7]. By using 3D CT imaging to measure these distances, it is possible to avoid the trocar insertion sites close to the driveline. ...
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.
... Left ventricular assist devices (LVADs) are gaining popularity as a viable treatment, and patients with LVADs survive for many years; consequently, such patients who require noncardiac surgery are becoming increasingly common [1,2]. The management of LVAD-supported patients for noncardiac surgery presents many challenges, and case reports of patients with LVADs who underwent several different types of noncardiac surgeries have been published [3][4][5][6][7][8][9][10]. However, none of these cases reported the perioperative management of video-assisted thoracic surgery (VATS). ...
... However, OLV could lead to higher PVR, induced by possible complications such as hypoxemia and hypercarbia, where the RV encounters sudden changes in afterload, preload, and contractility [14]. Therefore, based on the findings of previous studies [3][4][5][6][7][8][9][10], the management of LVAD-supported patients for VATS may be more challenging than that of LVAD-supported patients undergoing noncardiac surgeries, as there may be sudden OLVassociated, deteriorative RV function. ...
Background:
As patients with left ventricular assist device (LVAD) have long expected survival, the incidence of noncardiac surgery in this patient population is increasing. Here, we present the anesthetic management of a patient with a continuous-flow LVAD who underwent video-assisted thoracic surgery (VATS).
Case presentation:
A 37-year-old man with LVAD was scheduled to undergo VATS because of repeated spontaneous pneumothorax. Generally, patients with these devices have marginal right heart function; therefore, it is important to avoid factors that worsen pulmonary vascular resistance (PVR). However, VATS requires one-lung ventilation (OLV) and it tends to cause increase in PVR, leading to right heart failure. In the present case, when the patient was set in a lateral decubitus position and progressive hypoxia was observed during OLV, transesophageal echocardiography demonstrated a dilated right ventricle and a temporally flattened interventricular septum, and the central venous pressure increased to approximately 20 mmHg. Because we anticipated deterioration of right heart function, dobutamine and milrinone were administered and/or respirator settings were changed to decrease PVR for maintaining LVAD performance. Finally, resection of a bulla was completed, and the patient was discharged in stable condition on postoperative day 37.
Conclusions:
The anesthetic management of a patient with LVAD during VATS is challenging because the possible hemodynamic changes induced by hypoxia associated with OLV affect LVAD performance and right heart function. In our experience, VATS that requires OLV will be well tolerated in a patient with LVAD with preserved right heart function, and a multidisciplinary approach to maintain right heart function will be needed.
... From the first article in 2009 up until the present, 4 articles reporting 5 patients with LVAD who underwent laparoscopic colectomy were identified and included in this review [7][8][9][10]. All these patients had a laparoscopic right colectomy (Table 1). ...
... Positioning of the patient intraoperatively should be done with caution taking in mind that in a Trendelenburg position, venous return increases, while in reverse Trendelenburg position, venous return and cardiac preload reduce, lowering eventually the cardiac output and blood pressure [9]. The LVAD's pumping mechanism depends on both preload and afterload, meaning that inadequate filling leads to inadequate flow and reduced end-organ perfusion. ...
... Peritoneal insufflation should be kept to a minimum and only increased in a gradual fashion. This is because the insufflation has detrimental effects on cardiac preload, while at the same time increasing the afterload [9]. ...
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.
... Multiple studies found that the shift in LVAD design from pulsatile to continuous pump flow causes the development of acquired von Willebrand disease and platelet dysfunction. [100][101][102] These changes lead to a greater risk for bleeding than thrombosis, and as a result, require much less systemic anticoagulation. Currently, warfarin therapy with goal INR 2.0 to 3.0 in addition to aspirin and dipyridamole or clopidogrel is recommended for both HeartMate II and Hardware LVADS, while an INR of 2.5 to 3.5 is advised for other LVAD models by the International Society of Heart and Lung Transplantation latest guidelines. ...
... [104][105][106] Perioperative management of LVAD patients at present involves holding warfarin for 2 to 5 days and containing heparin bridging until the morning of the procedure. 101,104 But, due to physiologic changes in these patients, which shift the balance between thrombosis and bleeding toward higher rates of bleeding, some investigators believe that all anticoagulation can be safely held shortly before invasive procedures. In a case series of 188 LVAD patients undergoing noncardiac surgery, no thrombotic complications were observed even though only 73% of patients were on anticoagulation within 1 week of surgery. ...
Non-operating room anesthesia presents unique challenges for anesthesiologists. Limited preprocedural optimization and unfamiliarity with the location and procedure itself add to the difficulties in delivering safe care for these patients. Management of chronic oral anticoagulation can prove especially problematic since risks of bleeding for non-operating room procedures vary widely and differ from traditional surgeries. In addition, many physicians may not be familiar with the growing number of newly approved oral anticoagulants and their periprocedural management. This review will examine common non-operating procedures, their risks of bleeding, as well as pharmacokinetics of oral anticoagulants available on the market and periprocedural management options.
... [25] Bhat et al. also demonstrated that anticoagulation could be withheld preoperatively without thrombotic complications. [69] Thienopyridine antiplatelet agents should be stopped at least 5 days prior to elective surgery (Class IIb, Level of evidence: C). [7] Aspirin and warfarin may be continued perioperatively in nonemergent NCS if the risk of bleeding is low (Class I, Level of evidence: C). [7] However, if the risk of bleeding is high, warfarin may be held off and bridged with heparin infusion, subcutaneous low molecular weight heparin (LMWH), or heparin alternative which should be stopped on the morning of the planned procedure (Class I, Level of evidence: C). [3,7,[70][71][72][73] For emergency surgery, warfarin effect may be rapidly reversed with fresh frozen plasma or prothrombin complex concentrate. Vitamin K may be administered, but the onset of reversal of anticoagulation profile is slower (Class I, Level of evidence: B). [7] After the procedure, warfarin and antiplatelet therapy may be resumed when the risk of surgical bleeding is acceptable. ...
... Patients should be kept in normal sinus rhythm when possible as VA may impair the unassisted right ventricle, leading to RV dysfunction, and decreasing inflow to the LVAD. [72,108] The causes of VA include mechanical irritation from the inflow cannula, excessive ventricular offloading, altered ventricular repolarization, previous history of VA, VAD dysfunction with increased LVEDP, metabolic imbalance, effect of pharmacotherapy, and re-entry (scar related). [95,109] Higher mortality rates have been reported in patients who developed VA, 30% compared to 18% in patients without arrhythmias, and more than 50% if occurring less than a week after LVAD implantation. ...
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.
... Blood is entering on the right hand side and leaving towards the aorta on the left hand side, as indicated by the red arrows. Reprinted from [38] with permission. B: Heartware HVAD. ...
... Patient history data Age, yr, mean (SD) 58 (12) 56 (13) 59 (12) 0.05 Weight, kg, mean (SD) 92 (23) 93 (25) 92 (23) 0.53 Height, cm, mean (SD) 175 (9) 175 (10) 175 (9) 0.64 Body mass index, mean (SD) 29 perioperative challenges to the anesthesiologist. Common anesthetic concerns include management of anticoagulation, 15,16 patient monitoring limitations inherent to minimally pulsatile blood flow, 10,17,18 modified surgical access to the operative site, [19][20][21][22][23] concern for intraoperative cardiovascular and cerebrovascular events, 24-26 management of intraoperative device malfunction, 6 and postoperative complications including bleeding 15,26-28 and infection. [29][30][31][32][33][34] Currently, numerous studies have characterized the LVAD patient population presenting for NCS and have described management within the preoperative, intraoperative, and postoperative periods. ...
... [29][30][31][32][33][34] Currently, numerous studies have characterized the LVAD patient population presenting for NCS and have described management within the preoperative, intraoperative, and postoperative periods. [3][4][5][7][8][9][10][11][12][13][14]17,18,22,[35][36][37] Profiles of this patient population have been described in terms of surgical procedure type, admission status, elective versus urgent/emergent status, as well as the frequency of complications. Although complications have been described, studies have been limited in sample size, with the largest study to date comprising 271 adult cases, 13 and have been greatly underpowered when investigating adverse event frequency. ...
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.
... The device itself also depends upon several physiologic variables. The output of second-and third-generation devices is directly related to pump speed and inversely related to the pressure gradient across the pump [10,16,20]. These devices have continuously rotating impellers which continue to pump at a fixed speed regardless of their environment. ...
... Likewise, a coinciding platelet dysfunction occurs, which is more significant in nonpulsatile pumps than in their pulsatile predecessors [10]. These qualitative factors place patients at an increased risk of nonsurgical bleeding as evidenced by an increased incidence of gastrointestinal bleeding [20]. This risk is also increased due to the finding of arteriovenous malformations in the gut due to the nonpulsatile flow and decreased capillary pressure [13]. ...
... Thanks to this acquired coagulopathy, only mild levels of anticoagulation are required after implantation of second-and third-generation devices. Likewise, withholding anticoagulation perioperatively has been shown to be safe, which will be discussed further [1,20,23]. ...
The use of ventricular assist devices has expanded significantly since their approval by the Food and Drug Administration in the United States in 1994. In addition to this, the prevalence of heart failure continues to increase. We aim to provide an overview of perioperative considerations and management of these patients for non-cardiac surgery. We performed a Medline search for the words “ventricular assist device,” “Heartmate” and “HeartWare” to gain an overview of the literature surrounding these devices, and chose studies with relevance to the stated aims of this review. Patients with ventricular assist devices are presenting more frequently for surgery not related to their cardiac pathology. As the mechanically supported population grows, general anesthesiologists will be faced with managing these patients, possibly outside of the tertiary care setting. The unique challenges of this patient population can best be addressed by a thorough understanding of ventricular assist device physiology and a multidisciplinary approach to care.
... Sathishkumar ve ark. laparoskopik ileo-kolektomi uygulanan VAD'li hastada intraoperatif transözefageal EKO kullanarak transtorasik EKO ile saptanmayan atriyal septal defekti ve iki yönlü flant› belirleyebilmifllerdir (7). Oksijenasyon durumunu de¤erlendirmek için ise seri kan gaz› analizi yap›ld›. ...
Mechanical cardiac support is an alternative to medical treatment in hemodynamic disturbances in patients with chronic congestive heart failure. Mechanical ventricular assist devices are used to provide support for impaired ventricular functions and they help to regulate end-organ functions by providing sufficient cardiac output. Ventricular assist devices are used to improve myocardial functions of patients with myocarditis, or they are used for patients who are candidates for cardiac transplantation whose myocardial functions are not expected to improve such as patients with end-stage cardiomyopathy. In this case, we present the anesthetic management of a 67-year-old patient with a left ventricular assist device who was a candidate for cardiac transplantation because of dilated cardiomyopathy and who underwent noncardiac surgery due to femur fracture. As the patient had a non-pulsatile ventricular assist device and bleeding diathesis, a radial artery catheter and a jugular central venous catheter were placed with ultrasound guidance. Besides, femoral nerve block and lateral femoral cutaneous nerve block were performed with ultrasound guidance for intraoperative and postoperative analgesia.
