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    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
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Table of Contents
ORIGINAL ARTICLE  
Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 250-256
Anesthesia for gastrointestinal endoscopy in patients with left ventricular assist devices: Initial experience with 68 procedures


1 Department of Anaesthesia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
2 Department of Anaesthesia, Post Graduate Institute of Medical Education and Research, (PGIMER), Chandigarh, India

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Date of Submission12-Apr-2013
Date of Acceptance09-Jun-2013
Date of Web Publication1-Oct-2013
 

   Abstract 

Aims and Objectives: Continuous flow left ventricular assist devices (LVAD) have emerged as a reliable treatment option for heart failure. Because of bleeding secondary to anticoagulation, these patients present frequently for gastrointestinal (GI) endoscopy. The presently available literature on perioperative management of these patients is extremely limited and is primarily based upon theoretical principles. Materials and Methods: Perioperative records of patients with LVAD undergoing (GI) endoscopy between 2008 and 2012 were reviewed. Patient, device and procedure specific information was analyzed. Results: A total of 105 LVADs were implanted, and 68 procedures were performed in 39 patients. The most common indication was GI bleed (48/68), with yearly risk of 8.57% per patient. A total of 63 procedures were performed under deep sedation, with five procedures requiring general anesthesia. Intra-procedure hypotension was managed by fluids and (or) vasopressors/inotropes (phenylephrine, ephedrine or milrinone) guided by plethysmographic waveform, non-invasive blood pressure (NIBP) and LVADs pulsatility index (for HeartMate II)/flow pulsatility (for HeartWare). No patient required invasive monitoring and both NIBP and pulse oximeter could be reliably used for monitoring (and guided management) in all patients due to the presence of native heart's pulsatile output. Conclusion: In the presence of residual heart function, with optimal device settings, non-invasive hemodynamic monitoring can be reliably used in these patients while undergoing GI endoscopy under general anesthesia or monitored anesthesia care. Transient hypotensive episodes respond well to fluids/vasopressors without the need of increasing device speed that can be detrimental.

Keywords: Anesthesia; Continuous flow left ventricular assist devices; Monitored anesthesia care; Non-cardiac surgery

How to cite this article:
Goudra BG, Singh PM. Anesthesia for gastrointestinal endoscopy in patients with left ventricular assist devices: Initial experience with 68 procedures. Ann Card Anaesth 2013;16:250-6

How to cite this URL:
Goudra BG, Singh PM. Anesthesia for gastrointestinal endoscopy in patients with left ventricular assist devices: Initial experience with 68 procedures. Ann Card Anaesth [serial online] 2013 [cited 2019 Nov 15];16:250-6. Available from: http://www.annals.in/text.asp?2013/16/4/250/119167

This article is accompanied by an invited commentary by Prof. Sandeep Chauhan



   Introduction Top


Randomized evaluation of mechanical assistance of chronic heart failure found an exceptional increase in 1 and 2 year survival rates of these patients. [1] As a result, since 2006, thousands of patients have been benefitted by these "continuous flow" cardiac assist devices. [2] The small and continuous flow second generation devices have replaced large-pulsatile flow first generation devices, thereby significantly increasing their clinical utility. Their role has extended from initial "bridge to transplant (BTT)" to actual permanent circulatory assistance as "destination therapy (DT)". HeartMate II and HeartWare are the most common second generation devices and have shown significant improvements in quality-of-life of patients with end stage heart failure. Patients with left ventricular assist device (LVAD) are subjected to anticoagulation and are at high-risk for bleeding. Implanted device acts as a foreign body, increasing the incidence of infective complications. Increased survival rates and several other factors predispose these patients to frequent non-cardiac surgeries. Perioperative anesthesia management of these patients requires consideration of their unique cardiac physiology. Cardiac output determinants differ significantly from the normal population and are primarily dependent upon LVADs function rather than conventional physiological factors alone. With only isolated reports available, anesthesia experience for these patients undergoing non-cardiac surgery presently is extremely sketchy. Lack of experience on cardiovascular responses to anesthetic drugs in these high-risk patients (mostly American society of Anesthesiologists [ASA] III, IV) with LVAD can lead to unnecessary interventions and procedural cancellations, even for minor diagnostic procedures. We present a retrospective review of anesthetic management of 68 endoscopic procedures (upper and lower gastrointestinal [GI]) performed safely in patients with second generation, continuous flow LVADs.


   Materials and Methods Top


After ethical approval by the Institutional Review Board of the University of Pennsylvania, we used a retrospective explorative study design. Anesthesia and perioperative records of all patients with LVAD, who underwent endoscopy from 2008 to 2012 were reviewed to obtain the following patient-specific and procedure specific data: Demographic profile and comorbidities (ASA grade), indication of endoscopy, method of airway management, baseline pulse oximeter saturation, baseline hemodynamic parameters, minimal oxygen saturation, minimal/maximal - mean blood pressure and heart rate during the procedure, cardiovascular complications and total fluids/vasopressors used. All patients with LVAD or right ventricular assist device (RVAD) have some degree of functional limitation and hence were classified as ASA grade III; patients with significant hypotension or vasopressor/inotrope requirement on initial presentation were classified as ASA grade IV. Unexpected endoscope withdrawal to facilitate patient's oxygenation, duration of procedure and any procedure cancellation after start of the procedure due to anesthesia issues was also noted. Details specific to LVAD - type (model), make, date of insertion, and pre-operative evaluation of its functional status were extracted. Special attention was paid to record the need for emergency airway management and any anesthesia related immediate complication during the endoscopy.

As a routine protocol, all patients prior to GI endoscopy underwent a detailed pre-anesthetic assessment as per ASA guidelines. Prior to induction, all patients were pre-oxygenated using 100% oxygen using a tight fitting facemask. Endoscopy was performed in left lateral position and besides the routine hemodynamic monitoring; possible apnea during the procedure was monitored using end tidal carbon dioxide (CO 2 ) along with vigilant visual assessment of chest excursion. Careful examination of chest movement is important in upper GI endoscopy as end tidal CO 2 is unreliable in this setting. [3] Special attention was paid to the pulse oximeter derived plethysmograph. Non-invasive blood pressure (NIBP) at 2-3 min interval was recorded when pulsatility was present on plethysmograph. Effort was made to keep patient peripheries warm throughout the procedure.

Data analysis

The data obtained was analyzed using SPSS version 21 (IBM Inc. Chicago, USA) for Macintosh. Descriptive statistics was used for variables involving patient demography, surgical indication, airway device and LVAD related descriptors. Mean values were used for measured parametric data. For non-parametric data, Spearman's rank coefficient was derived to detect any possible relation between the variables. The difference of means, wherever reported was calculated allowing an alpha error of up to 5%.


   Results Top


Demographics

During 2008-2012, 105 patients received second generation continuous flow LVADs. Two patients received combined RVAD and LVAD, whereas 103 patients received LVAD alone. Details were analyzed for patients who underwent endoscopic procedures with these assist devices in situ. A total of 68 endoscopic procedures were recorded in 39 of the total of 105 patients. These 68 procedures were analyzed as separate events as no procedure performed previously even on same patient had any relation to the repeat procedure, i.e., previous anesthesia management did not affect management/outcome of subsequent episodes. All patients in 68 procedures had only LVAD device implanted, with 10 (14.7%) and 58 (85.3%) of procedure performed on patients with HeartWare and HeartMate II models respectively. 63.2% and 36.8% of involved patients had received LVAD as DT and BT, respectively. Ten procedures were performed on females and rest 58 on males, with the mean age and body mass index of patients being 60.50 ± 14.39 years and 27.22 ± 4.08 Kg/m 2 respectively. The mean number of days between LVAD insertion and procedures was 184.65 ± 209.02 (11-1108 days).

Anesthesia technique

The most common procedural indication was GI bleeding. Upper GI endoscopy (including enteroscopy) and (or) colonoscopy was performed for either therapeutic or diagnostic purposes. [Table 1] shows the various indications for all the procedures. Deep sedation with one of the intravenous anesthetics (with or without opioids) was safely used to perform 63 (92.6%) of these procedures. Mean procedural time was 87.87 ± 35.44 (25-196) min with upper GI, lower GI and combined upper/lower GI endoscopy accounting for 35, 27 and 6 procedures respectively. General anesthesia with endotracheal intubation was used in five procedures, three of these patients arrived pre-intubated form the intensive care unit (ICU) where they had been intubated due to hemodynamic instability associated with GI bleed. However, after adequate resuscitation, they were hemodynamically stable to undergo GI endoscopy. Two patients were electively intubated prior to initiating the procedure as one had a history of severe gastroesophageal reflux disease and another patient had poor lung functions and required tracheostomy in addition to GI endoscopy. After the procedure, all five patients were shifted with endotracheal tube in situ to the ICU, where further management (extubation) was planned on individualized basis. Despite functional limitation in all patients (ASA IV-50/68 and ASA III-18/68), all procedures were performed without any cardiorespiratory sequelae or mortality. Deep sedation was provided using propofol infusion in the majority while ketamine or etomidate was used in a small group [Table 2]. This choice was guided by preference of the anesthesiologist supervising the procedure. A specialized cardiac anesthesiologist performed 11 of 68 (16.2%) procedures and the remaining 57 (83.8%) were carried out by a small group of non-cardiac anesthesiologists. No outcome difference in any parameters could be found between the patients managed by the cardiac and non-cardiac anesthesiologist. Hypotensive episodes were treated using either fluids (if pulse oximeter plethysmograph decreased significantly in amplitude) or vasoconstrictor/inotropes (phenylephrine, occasionally ephedrine) if pulsatility index/flow pulsatility remained normal. Patients who were already on milrinone were continued on it throughout the procedure.
Table 1: Indications of endoscopies performed

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Table 2: Anesthesia techniques used

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Monitoring

Pulsatile component of blood flow was present in all patients and NIBP could be recorded and trends-followed in all patients [Figure 1]. The distribution of heart rate, NIBP and saturations recorded during the procedures are shown in [Figure 2], [Figure 3] and [Figure 4]. Lowest recorded blood pressures values [Figure 3] were transient and responded to vasopressor/fluid boluses. Transient desaturations that responded almost immediately to treatment were seen in few patients under deep sedation (median lowest recorded saturation was 85%). Prior to initiation of sedation all patients were pre-oxygenated with high flow oxygen using a well-fitting mask, any intra operative desaturation was treated using additional oxygen supplementation using a Mapleson circuit attached to nasal trumpet [Figure 5]. Total amount of fluids (crystalloid) used showed statistically significant relation with duration of procedure (Spearman's correlation coefficient of 0.386, P = 0.001), but did not show any statistically significant dependence on the degree of fall in NIBP. The mean maximal fall in blood pressure was 22.29 ± 18.02 mmHg and all patients responded adequately to fluids (crystalloids) or vasopressors (phenylephrine/ephedrine) or their combination.
Figure 1: Monitor showing pulse oximeter plethysmograph and non-invasive blood pressure measured in the patient

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Figure 2: Boxplot showing heart rate variations seen during the procedure (95 percentile values are represented by whiskers)

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Figure 3: Boxplot showing blood pressure variations seen during the procedure (95 percentile values are represented by whiskers)

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Figure 4: Boxplot showing minimal pulse oximeter saturation during the procedure (95 percentile values are represented by whiskers)

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Figure 5: Airway management of patient under monitored anesthesia care using a nasal trumpet with oxygen supplementation via Mapleson circuit

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LVAD device related findings

During the procedure, all LVADs were connected to external power source and a nurse trained for assessing the functioning of these devices monitored the device. No device related malfunction or any readjustments of pump speed was required in any case. "pulsatility index" and "flow pulsatility" were constantly monitored for HeartMate II and HeartWare [Figure 6] and [Figure 7]. For HeartMate II, when the left ventricle contracts, the increase in ventricular pressure causes an increase in pump flow. The magnitude of these flow pulses is measured and averaged for a 15-sec interval to produce the displayed parameter "pulsatility index." For HeartWare, the difference between the highest flow and the lowest flow over one cardiac contraction cycle is measured and is called the "flow pulsatility." Pulsatility index was maintained between 3 and 6 for HeartMate II and "flow pulsatility" was kept > 2 l/min for HeartWare. This was done by decreasing anesthetic depth, increasing fluid administration or vasopressor boluses. For all procedures, two additional backup batteries were kept standby.
Figure 6: Left ventricular assist devices monitor (upper) HeartWare and (lower) HeartMate II

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Figure 7: Chest roentogram showing left ventricular assist devices (left) HeartWare and (right) HeartMate II

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Perioperative anti-coagulation

All patients after LVAD insertion are put on maintenance doses of oral warfarin targeting an international normalized ratio (INR) of 1.5-3.0. During the elective diagnostic endoscopic procedures in our patients as no invasive intervention was planned thus warfarin was continued. In patients who underwent endoscopy due to bleeding (52/68, 76.4%) warfarin was stopped as soon as the patient presented to the hospital. Fresh frozen plasma (FFP) assisted anticoagulation reversal was initiated rarely (decided on the case by case basis due to the risk of thrombosis in the device). A total of 43 out of 52 GI bleeding episodes were seen in 1 st year, six in 2 nd year and three in 3 rd year post-LVAD insertion. Overall 27 of 105 patients (total number of LVADs inserted in 3 years) presented for at least one episode of GI bleeding within 3 years period, estimating to yearly incidence of 8.57%, with the highest likelihood of bleed in 1 st year post-insertion.


   Discussion Top


Present experience with anesthetic management of patients with ventricular assist devices is extremely limited. In this study, we describe our experience with a large cohort of 39 patients who underwent 68 minor diagnostic/therapeutic procedures primarily under deep sedation; this adds knowledge of a significant number of patients to the published literature to date. [4],[5] This report is not only the first to describe anesthetic challenges for diagnostic/therapeutic procedures, but also uses one of the largest sample size published so far in patients on LVAD presenting for non-cardiac procedures.

Gastrointestinal bleeding has been reported as the most common complication of patients with LVAD on follow-up. [6] The yearly incidences may depend upon the nature of device (pulsatile vs. continuous). Initial reports suggested that for continuous flow LVADs with flows set at more than 3 l/min, anticoagulation may not be needed. [7] However, with the increasing number of these non-pulsatile second generation devices the results are contrary to previous belief. Crow et al., in their analysis showed that continuous flow devices were associated with 9 times higher rate of bleeding than pulsatile group, although both received similar degree of anticoagulation. [8] The possible reasons for this was highlighted by Geisen et al., who later showed that an acquired form of Von Willebrand disease developed preferentially in patients with continuous flow LVADs. [9] For invasive elective surgeries, the anticoagulation may be withheld weighing risk benefit ratios guided by invasiveness of the procedure. Most of our patients (52 of 68) presented for emergency procedures due to GI bleed (48 upper GI and 4 per rectal bleed) where warfarin was stopped. Blood loss was treated with packed red cell transfusion and FFP if necessary. It was made sure that the device functioned adequately (with assisted flow > 3 l/min) and constant monitoring of device power ratings was carried out to detect any possible thrombosis at the earliest. In other (16 of 68) planned procedures, as there was no invasive intervention planned, oral warfarin was continued. With yearly bleeding rates of 8.57% noted in our study, we agree to previous studies concluding that present INR targets probably overestimate anticoagulation requirements. [10],[11] In light of recent evidence of acquired Von Willebrand disease, this may be even more valid for continuous flow (recent) devices.

Previous reports based on the physiology of LVADs suggest that these patients may not have enough pulsatile component of blood flow; thus, conventional monitoring of NIBP and pulse oximetry may not work in them. [7] As per standard recommendations, the LVAD pump speed settings in our patients at the time of insertion had been set between 8000 rpm and 9600 rpm. This pump speed targets to allow the opening and closing of aortic valve with each cardiac contraction simultaneously keeping the flow at maximum possible value without altering the shape of the left ventricle at the end of diastole that may occur as a result of excessive blood pumped out. [12] Thus these settings allow preservation of pulsatility of blood flow as a result of some residual pumping effect of native heart. We were able to record good plethysmographic trace and measure NIBP in all our patients [Figure 1]. For optimal functioning of these conventional, non-invasive monitors pulsatile nature of blood flow is necessary. A pulsatility index target of 3-6 for HeartMate II and flow pulsatility of > 2 l/min for HeartWare) not only helped us to quantify fluid requirements, but maintaining this adequate pulsatile flow (higher the "pulsatility index/flow pulsatility" higher is the pulsatile nature of blood flow) validated the use of NIBP and pulse oximeter. Isolated reports of use of NIBP measurement methods like oscillometry or Doppler guidance exist and suggest to avoid invasive lines in minor procedures (where no major hemodynamic changes are expected). [5] A low pulse volume or a flat plethysmograph indicate severely compromised ventricular function and cerebral oximetry should be used replacing pulse oximeter. [12] In addition, in such cases use of non-invasive cardiac output using velocimetric methods may be useful. In such patients, NIBP measurement may fail and thus they require the use of invasive arterial monitoring even for minor procedures.

Patients with LVAD often have associated right ventricular dysfunction as well. Increasing LVAD pump speed to treat hypotension can lead to increased venous return causing clinically significant right ventricular failure. [13] In situations of decreased preload causing hypotension, increasing LVAD pump speed can generate negative pressure in left ventricular cavity causing interventricular septum bowing. [14] It is thus advised not to alter pump speed to treat transient hypotension in these patients. [12] These concerns are more practical for patients receiving anesthetic drugs, all of which cause some degree of hypotension. Prior to shifting to the operating room, all our patients (even ones bleeding) received adequate fluids. Three patients in our study were on inotropic support (milrinone) when presented in the operating room. From experience and previous reports, it was realized that pulse volume corresponds well to preload in these patients. [15] Changes in pulse oximeter amplitude also correspond well with changing pulsatility index of the device. Since no invasive lines were planned for our minimally invasive procedures, we used pulse oximeter trace coupled with pulsatility index/flow pulsatility values as a surrogate guide to pulse volume (thus the patient preload status). [16],[17] A good amplitude waveform with adequate pulsatility index when associated with hypotension indicated adequate preload, wherein vasopressor boluses were preferentially used over fluids. In hypotension episodes associated with fall of plethysmographic waveform amplitude associated with falling pulsatility index/flow pulsatility, fluids were preferentially used over vasopressors. With this approach, no patient showed refractory hypotension. Due to continually changing nature of fluid versus vasopressor requirements, the degree of fall of blood pressure did not show statistical correlation with the amount of fluid administered (Spearman's correlation coefficient = −0.065, P = 0.6). Airway complications like obstruction and apnea under deep sedation are known to be primarily dependent upon the depth of anesthesia rather than patient physical status alone. [18],[19] As all our patients were in lateral position, the chances of upper airway obstruction due to tongue fall were less; in case of transient desaturation, most patients responded to increased oxygen supplementation in addition to dose readjustments, with saturations returning to baseline. In patients with LVAD, if oxygen saturation does not respond to the above measures, a possibility of right ventricular dysfunction must be considered. [20] Use of milrinone is recommended in such patients to augment right heart output. [12],[21] Milrinone by its inotropic properties in such patients not only augments the native left ventricular output, but also improves right ventricular function and thus mitigates a possible failure of right heart. Three of our patients were continued on milrinone infusion during the procedure.

A practical limitation of our study was non-availability of LVAD related parameters for data analysis. Currently, anesthesia charts and electronic vital charting systems are not equipped to record LVAD specific factors like (pulsatility index, pump speed and power consumed by the pump). These factors are important in any non-cardiac surgery performed on these patients. Due to this limitation in recording systems we were not able to make time based comparisons between LVAD variables and rate of fluid/vasopressor administration.

To conclude, we realize that a lot needs to be learnt by anesthesiologists to meet the future challenges of patients presenting with these modern artificial hearts. Non-invasive hemodynamic monitoring (NIBP and pulse oximetry) in conjunction with LVAD specific parameters pulsatility index/flow pulsatility, power can be used to guide perioperative fluid and vasopressor requirements, avoiding invasive lines/interventions for endoscopic procedures. Increasing experience suggests that anticoagulation targets may need revision, especially in continuous flow LVADs in view of high incidence of bleeding episodes.


   Acknowledgement Top


Mr. Divakara Gouda, Cherry East High School, NJ, USA.

 
   References Top

1.Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435-43.  Back to cited text no. 1
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2.Parides MK, Moskowitz AJ, Ascheim DD, Rose EA, Gelijns AC. Progress versus precision: Challenges in clinical trial design for left ventricular assist devices. Ann Thorac Surg 2006;82:1140-6.  Back to cited text no. 2
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3.Goudra BG, Penugonda LC, Speck RM, Sinha AC. Comparison of acoustic respiration rate, impedance pneumography and capnometry monitors for respiration rate accuracy and apnea detection during GI endoscopy anesthesia. Open J Anesthesiol 2013;3:74-9.  Back to cited text no. 3
    
4.Morgan JA, Paone G, Nemeh HW, Henry SE, Gerlach B, Williams CT, et al. Non-cardiac surgery in patients on long-term left ventricular assist device support. J Heart Lung Transplant 2012;31:757-63.  Back to cited text no. 4
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5.Ahmed M, Le H, Aranda JM Jr, Klodell CT. Elective noncardiac surgery in patients with left ventricular assist devices. J Card Surg 2012;27:639-42.  Back to cited text no. 5
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6.Sheikh FH, Russell SD. HeartMate ® II continuous-flow left ventricular assist system. Expert Rev Med Devices 2011;8:11-21.  Back to cited text no. 6
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7.Stone ME, Soong W, Krol M, Reich DL. The anesthetic considerations in patients with ventricular assist devices presenting for noncardiac surgery: A review of eight cases. Anesth Analg 2002;95:42-9.  Back to cited text no. 7
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8.Crow S, John R, Boyle A, Shumway S, Liao K, Colvin-Adams M, et al. Gastrointestinal bleeding rates in recipients of nonpulsatile and pulsatile left ventricular assist devices. J Thorac Cardiovasc Surg 2009;137:208-15.  Back to cited text no. 8
    
9.Geisen U, Heilmann C, Beyersdorf F, Benk C, Berchtold-Herz M, Schlensak C, et al. Non-surgical bleeding in patients with ventricular assist devices could be explained by acquired von Willebrand disease. Eur J Cardiothorac Surg 2008;33:679-84.  Back to cited text no. 9
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10.John R, Kamdar F, Liao K, Colvin-Adams M, Miller L, Joyce L, et al. Low thromboembolic risk for patients with the Heartmate II left ventricular assist device. J Thorac Cardiovasc Surg 2008;136:1318-23.  Back to cited text no. 10
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11.John R, Kamdar F, Liao K, Colvin-Adams M, Boyle A, Joyce L. Improved survival and decreasing incidence of adverse events with the HeartMate II left ventricular assist device as bridge-to-transplant therapy. Ann Thorac Surg 2008;86:1227-34.  Back to cited text no. 11
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19.Goudra BG, Singh PM, Sinha AC. Outpatient endoscopic retrograde cholangiopancreatography: Safety and efficacy of anesthetic management with a natural airway in 653 consecutive procedures. Saudi J Anaesth 2013;7:259-65.  Back to cited text no. 19
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21.Kihara S, Kawai A, Fukuda T, Yamamoto N, Aomi S, Nishida H, et al. Effects of milrinone for right ventricular failure after left ventricular assist device implantation. Heart Vessels 2002;16:69-71.  Back to cited text no. 21
    

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Correspondence Address:
Basavana G Goudra
Perelman School of Medicine, University of Pennsylvania, Philadelphia
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.119167

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]

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