View source for Insertion of ventricular assist device

{{Infobox surgical procedure
| anesthesia_type = GA
| airway = ETT
| lines_access = Large bore IV, central access, arterial line
| monitors = Standard ASA, arterial line monitor, CVP, PA catheter, TEE
| considerations_preoperative = 
| considerations_intraoperative = Typically critically low EF requiring titrated induction. LVAD may have RH failure requiring RV support
| considerations_postoperative = 
}}

A '''ventricular assist device (VAD)''' is a pump designed to assist the left or right ventricle in severe heart failure. These devices may help the left ventricle ('''LVAD'''), the right ventricle ('''RVAD'''), or bilateral ventricles ('''BiVAD'''). The device may be placed as a permanent solution or as a bridge to cardiac transplant.

== Overview ==

=== Indications ===
Severe heart failure

=== Surgical procedure ===

===== LVAD =====
Surgeons will perform sternotomy for exposure and either cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO). The device is placed at the apex of the left ventricle with an outflow graft anastomosed to the ascending aorta.

== Preoperative management ==

=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
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|Airway
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|Neurologic
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|Cardiovascular
|Critically low EF (15-20%) is not atypical. May also have underlying CAD, pulmonary HTN, and Grade 3 RHF
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|Pulmonary
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|Hematologic
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=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
Review cardiac studies including TTE, cardiac catheterization, etc.

=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===

* Infusions: norepinephrine and epinephrine
** Also can consider infusions for insulin, dexmedetomidine, ketamine, cefazolin, TXA, heparin
* Arterial line setup
* Central line setup w/ PA catheter
* TEE setup

=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
N/A

== Intraoperative management ==

=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

* Arterial line monitoring
* Central access
** large bore catheter (e.g. Cordis, MAC, etc)
** Infusion line (e.g. single lumen catheter)
** CVP monitoring
**PA catheter monitoring
* TEE

=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
Pre-induction arterial line typically indicated. Very careful titrated induction due to critically low EF.

=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
Supine

=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

* CPB often used (full heparinization), though cardioplegia can usually be avoided
* For LVAD, as RPMs are increased, right heart may struggle to keep up with increased cardiac output
** Consider hyperventilation, FiO2 100%, inhaled nitric oxide, milrinone, dobutamine for RV contractility augmentation
* Aortic root vent and Trendelenburg after VAD is inserted to avoid air embolism

=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

== Postoperative management ==

=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
ICU, typically remain intubated

=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

{| class="wikitable wikitable-horizontal-scroll"
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|EBL
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== References ==

[[Category:Surgical procedures]]