Insertion of ventricular assist device

Insertion of ventricular assist device

Anesthesia type	GA
Airway	ETT
Lines and access	Large bore IV, central access, arterial line
Monitors	Standard ASA, arterial line monitor, CVP, PA catheter, TEE
Primary anesthetic considerations
Preoperative
Intraoperative	Typically critically low EF requiring titrated induction. LVAD may have RH failure requiring RV support
Postoperative
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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

System	Considerations
Airway
Neurologic
Cardiovascular	Critically low EF (15-20%) is not atypical. May also have underlying CAD, pulmonary HTN, and Grade 3 RHF
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Review cardiac studies including TTE, cardiac catheterization, etc.

Operating room setup

• 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

Regional and neuraxial techniques

N/A

Intraoperative management

Monitoring and 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

Pre-induction arterial line typically indicated. Very careful titrated induction due to critically low EF.

Positioning

Supine

Maintenance and surgical considerations

• 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

Postoperative management

Disposition

ICU, typically remain intubated

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications