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Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
INVITED COMMENTARY  
Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 257-258
Ventricular assist devices


Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India

Click here for correspondence address and email

Date of Web Publication1-Oct-2013
 

How to cite this article:
Chauhan S. Ventricular assist devices. Ann Card Anaesth 2013;16:257-8

How to cite this URL:
Chauhan S. Ventricular assist devices. Ann Card Anaesth [serial online] 2013 [cited 2020 Sep 25];16:257-8. Available from: http://www.annals.in/text.asp?2013/16/4/257/119169


Goudra and Singh have presented an excellent series of 39 patients with implanted left ventricular assist devices (LVADs) who underwent 68 endoscopy procedures for gastrointestinal bleeding. [1] The authors have used minimal monitoring - only noninvasive blood pressure and plethysmography from a pulse oximeter probe - to conduct these endoscopic procedures under conscious sedation or light intravenous anesthesia. The authors have made it appear very simple. It is in these endoscopic procedures, where airway management could be the primary concern, if the patient is being preoperatively stabilized for blood loss and hemodynamic stability. The authors found no difference in complications or outcome whether the anesthetic was administered by a cardiac anesthetist or not, and there should not be any difference if the principles of patient management for patients with implanted VAD are followed.

Consultation with the cardiologist dealing with the VAD-implanted patient and with the device technologist or nurse dealing with the device itself could be of immense help. Their presence inside the operating room (OR) would be a great support, especially for prolonged procedures, to help deal with patient transportation to the OR, to decide on powering of the LVAD device (battery or electrical power), for an emergency battery change if required, or if any device-related mishap were to occur. It is imperative to ensure that a hand crank, especially for the first-generation devices, is available in the OR. [2]

Assessment of "end-organ function," especially of the kidneys and liver, and coagulation is imperative before taking up the patient with an implanted VAD for any surgical procedure. The end-organ dysfunction could be a residual component of the congestive cardiac failure, which results in poor organ perfusion, and for which the VAD was implanted. Recovery from renal and hepatic dysfunction takes time, and an improvement in renal and hepatic function depend on the time since implantation of the VAD. Appropriate change in anesthetic management is required for any existing renal or hepatic dysfunction. [3]

A significant number of these patients also have an implanted cardiac rhythm management device (CRMD) in place, which varies from the pacing device for cardiac resynchronization therapy to an automated implantable cardioverter defibrillator (AICD) used for patients who have had a 'sudden death' episode. Such devices would require appropriate deactivation of the defibrillator or change of the pacing mode to asynchronous. If cardiopulmonary resuscitation (CPR) is required, dislodgement of the inflow or outflow cannulae is a high possibility. [4]

Infection resulting from seeding of the device or the drive line, peritoneal or the retrosternal thoracic pocket, where the device is implanted with bacteria, fungus, etc., remains one of the most important concerns in patients with an implanted VAD undergoing any surgical procedure. This concern also hold true for patients undergoing an endoscopy - either of the upper or lower gastrointestinal tract. Meticulous precautions are required to avoid infections, including use of appropriate antibiotics with doses tailored to renal or hepatic function, and strict asepsis for any procedure including intravenous, intra-arterial, or central venous line placement, intubation, or transesophageal echocardiography (TEE) probe placement. [5]

One of the most important issues for the anesthetic management of VAD-supported patients for noncardiac surgery is adequate monitoring. Despite the fact that one or both ventricles can be supported by VAD devices, noncardiac surgery can be accompanied by hemodynamic disturbances due to surgical trauma, severe blood loss and fluid shifts, and rhythm disturbances such as supraventricular tachycardia and atrial fibrillation. These factors can influence the non-supported ventricle - the right ventricle in a patient with a LVAD, which is the most common form of ventricular support. Typically, in the patient with a LVAD, right ventricular dysfunction result in a decrease in blood flowing into the LVAD. Decreases in blood flowing into the LVAD also result from the creation of a capnoperitoneum during laparoscopic procedures or if body positioning influences preload of the right ventricle. For major surgery, TEE is useful for monitoring of systolic/diastolic function of the right ventricle and the volume status of the right ventricle. [6] The position of the interventricular septum should be checked using the TEE, as excessive pump flows relative to the volume status of the patient cause a suctioning effect in the left ventricle (LV) with shifting of the interventricular septum and can cause obstruction at the inflow cannula. TEE can also show VAD function [blood flow from atrium/ventricle to inflow cannula and blood flow from the outflow graft to the aorta in a LVAD or into the pulmonary artery in a RVAD]. [7]

The first-generation VAD devices provide pulsatile blood flow, and thus, standard intraoperative monitoring, including noninvasive blood pressure measurement and pulse oximetry, can be used in patients with such devices. When extensive fluid resuscitation is anticipated, a central venous catheter may be advisable for central venous pressure monitoring and for drug and volume infusions. [8]

The second- and third-generation devices provide nonpulsatile blood flow generated by rotating axial or centrifugal impellers. Because of the nonpulsatile nature of blood flow with these later generation devices, pulse oximetry is not reliable for assessing saturation. In these cases, cerebral oximetry can provide information regarding frontal cortex oxygenation. Similarly, noninvasive blood pressure measurement is not reliable because of the nonpulsatile flow state. It has been shown that a pulse pressure greater than 15 mmHg is required for aortic valve opening, which results in an ejection of blood. The occurance of an aortic ejection also depends on the interplay between the programmable parameters of the LVAD, the volume status, and afterload. Placement of an intra-arterial catheter for invasive blood pressure measurement is therefore essential in such patients. Localization of the artery can be simplified by ultrasonic and Doppler-flow technology. Avoiding hypovolemia is essential with all VADs to ensure adequate VAD function. Another cause of intraoperative hypotension is low systemic vascular resistance. In this situation, low-dose intravenous vasopressin has minimal influence on pulmonary vascular resistance, which may make it a better choice compared with norepinephrine. [9]

Goudra and Singh must, however, be congratulated for highlighting an important subset of patients i.e., with implanted VADs, whose numbers are likely to increase in the future with the increase in the incidence of patients with congestive heart failure.

 
   References Top

1.Goudra BG, Singh PM. Anaesthesia for gastro intestinal endoscopy in patients with left ventricular assist devices: Initial experience with 68 procedures. Ann Card Anaesth 2013;16:250-6.  Back to cited text no. 1
  Medknow Journal  
2.Stone ME. Current status of mechanical circulatory assistance. Semin Cardiothorac Vasc Anesth 2007;11:185-204.  Back to cited text no. 2
[PUBMED]    
3.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. 3
[PUBMED]    
4.Nicolosi AC, Pagel PS. Perioperative considerations in the patient with a left ventricular assist device. Anesthesiology 2003;98:565-70.  Back to cited text no. 4
[PUBMED]    
5.Stone ME, Apinis A. Current perioperative management of the patient with a cardiac rhythm management device. Semin Cardiothorac Vasc Anesth 2009;13:31-43.  Back to cited text no. 5
[PUBMED]    
6.Chumnanvej S, Wood MJ, MacGillivray TE, Melo MF. Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg 2007;105:583-601.  Back to cited text no. 6
[PUBMED]    
7.Oleyar M, Stone M, Neustein SM. Perioperative management of a patient with a nonpulsatile left ventricular-assist device presenting for noncardiac surgery. J Cardiothorac Vasc Anesth 2010;24:820-3.  Back to cited text no. 7
[PUBMED]    
8.Myers TJ, Bolmers M, Gregoric ID, Kar B, Frazier OH. Assessment of arterial blood pressure during support with an axial flow left ventricular assist device. J Heart Lung Transplant 2009;28:423-7.  Back to cited text no. 8
[PUBMED]    
9.Dang NC, Topkara VK, Mercando M, Kay J, Kruger KH, Aboodi MS, et al. Right heart failure after left ventricular assist device implantation in patients with chronic congestive heart failure. J Heart Lung Transplant 2006;25:1-6.  Back to cited text no. 9
[PUBMED]    

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Correspondence Address:
Sandeep Chauhan
Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi
India
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