Complications, Risk Factors, and Staffing Patterns for Noncardiac Surgery in Patients with Left Ventricular Assist Devices

Abstract

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.

Pediatric ventricular assist devices: Bridge to a new era of perioperative care

“…The majority of pediatric procedures are for vascular access and nutritional support but also include abdominal explorations, neurosurgery, ENT procedures, imaging and cardiac catheterization studies. Publications have addressed single center perioperative management issues for children with Berlin Heart Excor devices undergoing non‐cardiac surgery but published clinical experience with CF devices and non‐cardiac procedures is limited to the adult population . Figures and provide some guidelines for troubleshooting both pulsatile and CF VADS during the perioperative period.…”

“…Therefore, this pump operates in a fixed pre‐load dependent mode and is very sensitive to decreases in preload and SVR during general anesthesia . In contrast, CF pumps are also pre‐load dependent but do not tolerate increases in SVR or hypertension . Pre‐induction administration of a fluid bolus (5‐10 mls/kg) while watching pump parameters such as VAD flow and PI/flow pulsatility (for CF devices) or chamber filling and emptying (Berlin Heart) may help mitigate the hypotension that is commonly reported with induction in these patients .…”

“…Alpha agonists such as phenylephrine or vasopressin should be available to treat vasodilation induced hypotension as well as inotropic medications. Up to 72% of LVAD adult patients with CF devices required some intra‐operative pharmacological cardiovascular support …”

“…Publications have addressed single center perioperative management issues for children with Berlin Heart Excor devices undergoing non-cardiac surgery 33,34 but published clinical experience with CF devices and non-cardiac procedures is limited to the adult population. 36…”

In Reply

“…1 In their responses, they highlight critical points regarding the management of patients with left ventricular assist devices (LVADs) presenting for non-cardiac surgery: these include (1) LVAD patients are at high risk for perioperative complications, (2) frequency of invasive arterial line monitoring continues to decrease, despite high rates of intraoperative monitoring gaps, (3) potential hemodynamic instability in the setting of inadequate blood pressure monitoring may lead to increased incidence of complications (including acute kidney injury), and as such (4) alternatives to automated non-invasive cuff measurements for blood pressure monitoring must be more aggressively pursued.…”