Thoracic transplantation
Anesthesia for Ventricular Assist Device Placement: Experience From a Single Center

https://doi.org/10.1016/j.transproceed.2013.02.091Get rights and content

Abstract

Background

Circulatory support with ventricular assist systems has become a treatment alternative for patients with end-stage heart failure owing to the donor shortage. In this report, we have presented our institution's clinical experience in the anesthetic management of ventricular assist device (VAD) implantation.

Methods

Between April 2007 and August 2012, VAD implantation was performed in 84 adult patients with end-stage heart failure. The group included 75 male and 9 female patients of overall mean age, 47.6 ± 13.4 years. Our retrospective review analyzed elements of perioperative anesthetic care, including preoperative characteristics, general anesthetic care, and blood product usage.

Results

The indications for VAD implantation were dilated (n = 59; 70%) or ischemic cardiomyopathy (n = 25; 30%). An intra-aortic balloon pump had been placed in 16 patients. We monitored invasive arterial and central venous pressures as well as intraoperative transesophageal echocardiography. Etomidate was used as the induction agent in 79 of 84 patients (average dose, 18.75 ± 1.40 mg). Intraoperative fentanyl dose was 939.69 ± 212.44 μg. Anesthesia was maintained with sevoflurane (n = 55) or desflurane (n = 29). Dopamine, dobutamine, epinephrine, norepinephrine, and levosimendan were used in 74, 79, 60, 14, and 32 patients, respectively. Inhaled nitric oxide was administered to 38 subjects (45%). The amounts of perioperative blood, fresh frozen plasma, and thrombocyte suspension transfusions were 3.96 ± 2.78, 1.91 ± 1.21, 1.80 ± 2.48 u, respectively. On average, patients were extubated 13 hours after arrival in the intensive care unit and discharged therefrom on day 8. Thirty-one patients were successfully bridged to heart transplantation. While 27 patients (32%) died during the follow-up period, 26 are still living on VAD support.

Conclusion

Among patients undergoing VAD implantation, the anesthesiologist should become familiar with the device and consider the severity of cardiac and other end-organ dysfunction.

Section snippets

Methods

Between April 2007 and August 2012, VAD implantation was performed in 84 patients with acute or chronic end-stage heart failure. The cohort included 75 male and 9 female subjects of mean overall age of 47.6 ± 13.4 years. Before VAD implantation, all patients were in refractory heart failure with evolving or full multisystem involvement despite medical therapy. An intra-aortic balloon pump had been placed in 16 patients. Assist device implantations were performed by the surgical team with the

Results

The indications for VAD implantation were either dilated (n = 59; 70%) or ischemic cardiomyopathy (n = 25; 30%). Twenty-nine patients (34%) were INTERMACS Grade 1; 25 (30%) INTERMACS Grade 2 and 30 (36%) INTERMACS grade 3 at the time of VAD implantation. Patient demographic features and preoperative data are summarized in Table 1.

Review of intraoperative anesthesia records showed the following practices as an institutional protocol for all patients: In the operating room, we inserted one 16

Discussion

As the number of patients with heart failure is increasing and the donor shortage is continuing, VAD applications have become an important treatment option for patients with end-stage heart failure.6, 7 The classifications of VAD are based on the characteristics of device location (extra-, intra-, or paracorporeal), type of blood flow (pulsatile or nonpulsatile/axial); driving power (pneumatic or electric); and required level of anticoagulation (low or full).4 In this series, 45 patients were

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