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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.

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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. Pleasanton, CA, USA) left ventricular assist device (LVAD), who underwent a successful major laparoscopic abdominal surgery. Key issues highlighted are the limitations of oxygen saturation (SpO2) monitoring, accuracy of blood pressure (BP) measurement, and the potential usefulness of intraoperative transesophageal echocardiography (TEE). The hemodynamic changes, impact on the LVAD function during laparoscopic surgery, and the multidisciplinary approach are addressed.

Isoflurane enhances myocardial functional recovery and improves energy levels after ischemia. We sought to determine whether isoflurane-induced cardioprotection is mediated by protein kinase C (PKC). The Langendorff model was used, and isolated perfused rat hearts were separated into untreated, isoflurane, chelerythrine (PKC inhibitor) plus isoflurane, and chelerythrine groups. All hearts were subjected to treatment before ischemia, followed by 30 min of ischemia and 60 min of reperfusion. We recorded hemodynamic variables, measured metabolites by high-performance liquid chromatography, and analyzed subcellular localization of PKC isoforms by Western blot analysis. Isoflurane significantly improved the recovery of left ventricular developed pressure, attenuated the depletion of myocardial adenosine triphosphate (ATP) and creatine phosphate at 15 min of ischemia, enhanced the recovery of myocardial ATP and creatine phosphate concentrations after ischemia, and was associated with the translocation of PKC-delta and -epsilon to the membrane. Chelerythrine suppressed the translocation of PKC-delta and -epsilon and blocked the improvement of cardiac function and ATP. We conclude that isoflurane delays the decrease in ATP during ischemia and improves the recovery of mechanical function and the energy state 60 min after ischemia. These effects of isoflurane are dependent on the activation of PKC.

Kawasaki disease, although common in children, may rarely affect the coronary arteries, leading to aneurysm formation and potential for coronary thrombus formation. Extremely rarely, coronary aneurysms from Kawasaki disease can thrombose, resulting in ischemic myocardium. We present a case of a 31-month-old patient requiring a left ventricular assist device after thrombosis of giant coronary aneurysms led to ischemic cardiomyopathy. At the termination of the surgical procedure, we encountered 2 periods of ventricular assist device dropout requiring intervention. With the increase in the number of pediatric patients with assist devices, we review the basic care for a patient requiring emergent surgery.

Kawasaki disease is an acquired vasculitis that can affect the coronary arteries placing the patient at risk for coronary artery thrombosis, myocardial ischemia and infarction. The risk of complications related to coronary artery involvement persists for years despite recovery from the acute illness phase. The risk of late coronary disease progression necessitates long term follow-up generally accomplished by non-invasive echocardiography in pediatric patients. We review the utility of echocardiography in patients with Kawasaki disease as it relates to initial management, risk stratification and follow-up of these children.

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