Ventricular assist devices and non-cardiac surgery

Abstract

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.

Hemostatic complications associated with ventricular assist devices

“…Surgical causes may need operative correction and management. However, bleeding unrelated to the operation remains common (eg, GI bleeding) and must be monitored postoperatively …”

Anaesthesia for children with left ventricular assist devices undergoing non-cardiac surgery

“…Positive inotropic drugs, pulmonary vasodilators, or both may be required to maintain good RV function. 6 Afterload also has a significant impact on LVAD function. Increases in systemic vascular resistance (SVR) directly impede forward flow, reducing peripheral perfusion and, because of increased stasis, may also increase the risk of device thrombus formation.…”

“…Increases in systemic vascular resistance (SVR) directly impede forward flow, reducing peripheral perfusion and, because of increased stasis, may also increase the risk of device thrombus formation. 6 Meticulous attention to this preload dependence and afterload sensitivity is key to managing haemodynamics in patients who have an LVAD.…”

“…4,5 Patients with a VAD may develop complex coagulopathies in the context of heart failure-induced liver dysfunction and associated shear stress from the device; an acquired form of von Willebrand syndrome may be associated with CF-VADs. 6 Mechanical haemolysis and platelet dysfunction may be present.…”

“…Transoesophageal echocardiography (TOE) may be selectively used in high-risk patients to provide critical information on volume status, RV function, and VAD function, and allow informed perioperative adjustments to VAD setting to be made if required. 6,11…”