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Perioperative Considerations in the Patient with a Left Ventricular Assist Device Alfred C

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Perioperative Considerations in the Patient with a Left Ventricular Assist Device Alfred C Ⅵ CLINICAL CONCEPTS AND COMMENTARY Richard B. Weiskopf, M.D., Editor Anesthesiology 2003; 98:565–70 © 2003 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Perioperative Considerations in the Patient with a Left Ventricular Assist Device Alfred C. Nicolosi, M.D.,* Paul S. Pagel, M.D., Ph.D.† MECHANICAL support of the cardiovascular system is an Device Features Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/98/2/565/336750/0000542-200302000-00038.pdf by guest on 27 September 2021 important therapeutic modality for a growing number of patients with congestive heart failure. Certain patients The three devices2-5 currently approved by the US with refractory end-stage failure who will likely succumb Food and Drug Administration for use as a “bridge to to their disease before a potential heart transplant may transplant” are the HeartMate® LVAD (Thoratec Corpo- be effectively “bridged to transplant” by a left ventricular ration, Pleasanton, CA), the Novacor® LVAD (World assist device (LVAD). Three such devices are currently Heart Corporation, Ottawa, Canada), and the Thoratec® approved by the US Food and Drug Administration for assist device (Thoratec Corporation) (fig. 1). The thera- this indication. Several ongoing multicenter clinical trials peutic goal of all three devices is to assume the pump are also evaluating LVAD therapy as an alternative to function of the failing left ventricle. To accomplish this transplantation (“destination therapy”). Preliminary data objective, each device is designed to drain the left ven- from the Randomized Evaluation of Mechanical Assis- tricular blood volume into a mechanical pump, which tance for the Treatment of Congestive Heart Failure Trial ejects the blood into the circulation via a conduit that indicate that an implantable LVAD prolongs survival and connects to the aorta. The Thoratec® device is unique in enhances quality of life in patients with end-stage heart that it may also be used to support the right ventricle failure.1 The efficacy of destination therapy will un- (RV) with a second pump that is interposed between the doubtedly lead to an expansion in the number of LVAD- RV and pulmonary artery. supported patients in future years. Some of these pa- Each device maintains unidirectional flow using valves tients will require operations for noncardiac, non-LVAD in the inflow and outflow conduits that connect LV to problems. Anesthesiologists should therefore be familiar pump and pump to aorta, respectively. Both the Heart- with the unique considerations related to these patients Mate® and Novacor® devices use porcine valves. The and their devices. blood-contacting surfaces of the HeartMate® pump Accordingly, this review presents important features chamber and its conduits are textured to promote the of the commonly used devices, describes the effects of formation of a pseudointimal lining that markedly re- LVAD therapy on the pathophysiology of heart failure, duces the thrombogenicity of the device. As a result of and discusses the major perioperative considerations for this surface and the use of tissue valves, most Heart- patients who come to the operating room with an im- Mate® patients are treated with chronic aspirin therapy planted LVAD. The discussion focuses on the patient alone; the vast majority do not require chronic anticoag- with a chronically implanted device, not on the implan- ulation therapy unless another clinical indication exists. tation procedure itself, which involves a different set of The pump chambers of the Novacor® and Thoratec® physiologic challenges and anesthetic considerations. devices contain smooth blood sacs that do not form a pseudointima. In addition, the Thoratec® device uses mechanical valves to maintain unidirectional flow. As a *Associate Professor of Surgery (Division of Cardiothoracic Surgery). †Pro- ® ® fessor and Director of Cardiac Anesthesia. result, patients with either Novacor or Thoratec de- Received from the Departments of Surgery (Division of Cardiothoracic Sur- vices must be chronically anticoagulated with warfarin. gery) and Anesthesiology, the Medical College of Wisconsin and the Clement J. Both the HeartMate® and Novacor® pumps are fully Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin. Submitted for publication June 4, 2002. Accepted for publication September 11, 2002. Sup- implanted in the body. The pumps are placed in the left ported in part by grant No. GM-08377 from the United States Public Health upper quadrant of the abdomen using an intraperitoneal Service, National Institutes of Health, Bethesda, Maryland. or preperitoneal technique. With each of these devices, Address reprint requests to Dr. Nicolosi: Division of Cardiothoracic Surgery, Froedtert Hospital, East Clinics, 9200 West Wisconsin Avenue, Milwaukee, Wiscon- only the driveline, which connects the pump to the sin 53226. Address electronic mail to: [email protected]. control unit, traverses the skin. The Thoratec®,onthe The illustration for this section is prepared by Dimitri Karetnikov, 7 Tennyson other hand, is a “paracorporeal” device, in that the in- Drive, Plainsboro, New Jersey, 08536. On November 6, 2002, the United States Food and Drug Administration flow and outflow conduits traverse the skin to connect approved the vented electric model of the HeartMate® LVAD (Thoratec Corpo- with the pump, which lies externally on the skin of the ration., Pleasanton, CA) for ‘destination therapy‘ in patients with end-stage heart failure who are not candidates for heart transplantation and who have a projected upper abdomen. Any product containing acetone (e.g., life expectancy of less than two years. tape remover or nail polish remover) must be strictly Anesthesiology, V 98, No 2, Feb 2003 565 566 A. C. NICOLOSI AND P. S. PAGEL Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/98/2/565/336750/0000542-200302000-00038.pdf by guest on 27 September 2021 Fig. 1. Effects of chronic circulatory support with a left ventricular assist device (LVAD) on the pathophysiology of end-stage heart failure. Chronic LVAD therapy leads to reversal of both myocardial and systemic changes that are associated with heart failure. avoided in patients with a Thoratec® LVAD because the within the pump chamber is automatically emptied into exposed polycarbonate housing may crack in the pres- the circulation each time the control unit senses that the ence of liquid or vapor acetone. chamber is nearly full. Total LVAD flow in this mode All three devices provide pulsatile flow. Intermittently, depends on the rate of the filling–emptying cycle, as- the blood chamber in the LVAD pump is rapidly com- suming that pump emptying is complete in each cycle. pressed, leading to ejection of a “stroke volume” that is The cycling time in this mode fluctuates with changes in determined both by the preejection chamber volume pulmonary venous return, which in turn is determined and the outflow resistance. The HeartMate® delivers a both by the patient’s intravascular volume state and the maximum stroke volume of 85 ml, the Novacor® delivers capabilities of the RV. When pumping in the “automatic” a maximum stroke volume of 70 ml, and the Thoratec® mode, both the HeartMate® and Novacor® devices are delivers a maximum stroke volume of 65 ml. The heart capable of generating flows in excess of 10 l/min., while continues to beat in its own rhythm. While the left the Thoratec® can generate flows of approximately ventricle may at times contract simultaneous with pump 7 l/min. Each pump may also be programmed to operate ejection, it generally remains volume unloaded through- in a fixed-rate mode, such that the filling–emptying cycle out the cardiac cycle and thus usually has negligible remains constant. Depending on the set rate, flow in this contribution to aortic flow in the absence of LVAD mode may be limited by underfilling of the pump in each problems. The RV continues to function as the pump for cycle. In either pumping mode, automatic or fixed-rate, the pulmonary circulation, except in cases where the RV LVAD pumping is not synchronized with the rhythm of is supported by a second Thoratec® pump. the heart. All three pumps normally function in a “fill-to-empty” With all three devices, the pump is connected to a (or “automatic”) mode, in which the blood volume control unit by a driveline. The Novacor® control unit is Anesthesiology, V 98, No 2, Feb 2003 THE LVAD PATIENT 567 Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/98/2/565/336750/0000542-200302000-00038.pdf by guest on 27 September 2021 Fig. 2. Important features of the Heartmate®, Novacor®, and Thoratec® left ventricular assist devices. The anesthesiologist must consider the potential impact of these features when caring for a patient with one of these devices in place for the treatment of end-stage heart failure. portable and may be worn on a belt or vest. The pump normal values, and it improves function of other organ is powered by rechargeable, wearable batteries. The systems, particularly the liver and kidneys.2,3 Relief from Thoratec® controller–driver is portable, although not LV pressure–volume overload also leads to reversal of wearable. The pump is powered pneumatically; blood is many of the structural and functional abnormalities of ejected when the blood sac inside the rigid pump hous- the failing heart itself. Left ventricular dilatation in par- ing is compressed by pressurized air supplied by the ticular is reduced (“reverse remodeling”),6,7 and the im- ® driver. The HeartMate is available in two models, one provement in LV geometry is associated with both in- powered pneumatically (IP model) and the other elec- creased chamber compliance6 and reduced myocardial trically (VE model). The IP model functions much the damage.7 ® same as the Thoratec , via a portable, although not Chronic hemodynamic unloading is associated with wearable controller–driver. The VE model pump is con- recovery of cellular function as well. Cardiomyocytes trolled by a wearable processor and is powered by re- obtained from heart failure patients who were treated chargeable batteries, similar to the Novacor®.
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