Insertion of percutaneous ventricular assist device

Insertion of percutaneous ventricular assist device

Anesthesia type	GA vs. Regional vs. Local
Airway
Lines and access	Large-bored PIV, arterial line
Monitors	Intraoperative transesophageal echocardiography (TEE) if GA
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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Percutaneous ventricular assist device (pVADs) are temporary mechanical circulatory support devices that provide acute hemodynamic support.

Types of pVAD

1. Impella Devices
   1. Left-sided
      1. Examples: Impella 2.5 (femoral), CP 5.0 (femoral), Impella 5.0 or 5.5 (axillary)
         1. Femoral access may be done under local anesthesia
         2. Axillary access often requires surgical cutdown and general anesthesia
      2. Catheter-based pumps inserted via femoral artery and pump blood from left ventricle into ascending aorta, providing up to 5 L/min of flow
   2. Right-sided
      1. Example: RP
      2. Catheter-based pumps inserted via femoral vein and pump blood from right atrium to the pulmonary artery
2. Tandem Heart
   1. Continuous-flow centrifugal pump system that pumps blood from left atrium via a transseptal puncture to femoral artery, providing up to 5 L/min of flow
   2. May include ProtekDuo cannula for right ventricular support

Indications

• Cardiogenic shock (SCAI C-D stages)
• ECMO patients with left ventricular distention (ECPELLA)
• High risk PCI

Contraindications

• Biventricular failure
• High bleeding risk (inability to tolerate systemic anticoagulation)
• Left ventricular thrombus
• Aortic valve disease (moderate-severe aortic regurgitation, aortic stenosis, mechanical AVR)
• Aortic dissection
• Tamponade
• Severe peripheral artery disease

Preoperative management

Patient evaluation

System	Considerations
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

• Pre-operative echocardiography to ensure no clots in left ventricle, adequate right ventricular function to receive post-pVAD insertion increased cardiac output
• Type and screen

Operating room setup

• Arterial line set up
• Intraoperative transesopheageal echocardiography
• Near-infrared spectroscopy system (NIRs)

Patient preparation and premedication

• Patients often have pacemakers or ICDs
  • May need to contact electrophysiology to disable tachyarrhythmia therapy and place defibrillator pads on patient prior to procedure
  • If pacer dependent, will need to be placed in DOO at set rate

Intraoperative management

Monitoring and access

• Large peripheral IVs
• Arterial line on opposite side as axillary artery that will be used for Impella insertion
• Pulmonary artery catheter
• Intraoperative transesophageal echocardiography

Positioning

Supine, arms out

Maintenance and surgical considerations

• Hemodynamic management
• Adequate anticoagulation
  • Heparin to achieve goal ACT of 250-300 seconds
• Intraoperative TEE to exclude contraindications (e.g. LV thrombus, aortic valve pathology) and guide device positioning

Postoperative management

Potential complications

• Limb ischemia
• Vascular injury
• Bleeding
• Hemolysis
• Acute kidney injury
• Thromboembolism, air embolism
• Cardiac perforation
• Valve injury
• Device malposition
• Cardiac tamponade

Procedure variants

	Impella 5.0, 5.5	Impella 2.5, CP
Unique considerations	Axillary access Often GA, but may be done under regional	Femoral access Often local or regional anesthesia
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

1. Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care: Endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention. J Am Coll Cardiol. 2015;65(19):e7-e26. doi:10.1016/j.jacc.2015.03.036
2. Bernhardt AM, Copeland H, Deswal A, et al. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003