Effect of Anesthesia Induction on Cardiac Hemodynamics in Patients Undergoing Durable Left Ventricular Assist Device Implantation: The EACH-LVAD Study

Abstract

Right ventricular (RV) dysfunction is common after left ventricular assist device (LVAD) implantation leading to clinical right heart failure (RHF) associated with worsened survival and quality of life. It is likely that intraoperative events such as anesthesia induction play a role in the development or unmasking of RV dysfunction in addition to known effects from hemodynamic changes that occur after LVAD implantation. The EACH-LVAD Study is a prospective, single-center, single-arm, observational cohort study of adult patients with advanced heart failure undergoing durable LVAD implantation with standard anesthesia induction. Intraoperative RV hemodynamics via central venous pressure, mean pulmonary artery pressure, pulmonary artery pulsatility index, and vasoactive-inotropic score (a simple weighted summation of standardized drug doses) and echocardiographic parameters (RV fractional area change, RV area in diastole, RV basal diameter, septum position, RV function, tricuspid regurgitation) were measured and compared at prespecified timepoints, including postinduction. Postoperative clinical RHF was determined based on published definitions. Forty-two patients receiving a first-time LVAD were included between September 2017 and March 2019. Propofol-based induction was used in 31 patients and etomidate-based induction in eight patients. A significant increase in central venous pressure (CVP; p < 0.001), mean pulmonary artery pressure (mPAP; p < 0.001), and vasoactive inotropic score (VIS; p < 0.001) with associated decrease in pulmonary artery pulsatility index (PAPi; p < 0.001) was observed. Right ventricular function worsened throughout. Right heart failure occurred in 70% of patients. Propofol-based induction was not associated with a higher risk of RHF (relative risk [RR], 1.01 [95% confidence interval {CI}, 0.64–1.61]). The EACH-LVAD study demonstrates an effect of anesthesia induction on worsened RV hemodynamics and echocardiographic changes which may have an effect on the development of RHF.

Right Ventricular Dysfunction During Left Ventricular Assist Device Implantation: Roles of Anesthesiologists

“…2 Higher RV FAC at chest closure was associated with lower chance of RV failure. 2 Based on TEE assessment of the interventricular septal shifting and severity of TR, the authors concluded that RV function worsened and TR improved from the baseline during the postanesthesia induction period through LVAD implantation and chest closure. 2 In terms of acute (postinduction), early postimplantation, and late RV failure, a higher CVP and lower pulmonary artery pulsatility index at 30 minutes and 60 minutes postinduction were associated with less RV failure.…”

“…1 The pathogenesis and timing of RV decline in patients undergoing LVAD implantation remain incompletely understood. 2 Although patient comorbidities, perioperative hemodynamic instability, and structural/functional cardiac changes after cardiopulmonary bypass (CPB) and LVAD implantation have been suggested as contributors to RV dysfunction after LVAD, there are specific intraoperative events before CPB and LVAD insertion that may adversely affect RV systolic and diastolic functions. Schurr et al 2 attempted to address this complex issue with a prospective, single-center, single-arm, observational cohort study of adult patients with advanced heart failure undergoing durable LVAD implantation with standard anesthesia induction at the University of Pennsylvania.…”

“…This article specifically attempts to analyze the impact of anesthesia induction on RV dysfunction/failure before LVAD implantation. 2 Anesthesia induction for a patient with a severely dysfunctional LV (those requiring an LVAD) could negatively impact RV systolic and diastolic functions in many ways. A period of preoxygenation for 3-5 minutes before anesthesia induction is critical due to biventricular dysfunctions and underlying respiratory diseases in this population.…”

“…2 In addition, RV fractional area change (FAC) and RV diastolic diameter decreased significantly postinduction and remained depressed until chest closure. 2 The mean RV/LV ratio increased through the operation but stabilized by chest closure on intraoperative transesophageal echocardiography (TEE). 2 Higher RV FAC at chest closure was associated with lower chance of RV failure.…”

“…2 The mean RV/LV ratio increased through the operation but stabilized by chest closure on intraoperative transesophageal echocardiography (TEE). 2 Higher RV FAC at chest closure was associated with lower chance of RV failure. 2 Based on TEE assessment of the interventricular septal shifting and severity of TR, the authors concluded that RV function worsened and TR improved from the baseline during the postanesthesia induction period through LVAD implantation and chest closure.…”