Perioperative management of patients with a ventricular assist device undergoing non-cardiac surgery

Question 1

Ventricular Assist Device Components

Answer 1

Inflow cannula from the left ventricle -> Pump (Axial or Centrifugal) -> Outflow cannula to aorta
- A percutaneous lead connects a battery and system controller to the pump which exits the skin in the upper abdominal wall

Question 2

Indications for Ventricular Assist Device Insertion

Answer 2

• A bridge to cardiac transplantation
• Destination therapy if the patient becomes unsuitable for cardiac transplantation

Question 3

Common complications of ventricular assist devices

Answer 3

• GI bleeds
• Pump thrombosis
• CVA
• Arrhythmias
• Pump infection
• RV failure

Question 4

Pre-operative considerations for patients with ventricular assist devices

Answer 4

• Ideally managed at a specialist VAD centre
• MDT care including VAD specialist nurse
• VAD history and complications
• Up to date ECHO
• VAD interrogation
• If surgery involves upper abdomen or thorax a CT scan should be obtained to confirm the position of device and cannulae
• Management of anticoagulation- patients will be on warfarin and DAPT
• X-matched blood

Question 5

Intra-operative considerations for patients with ventricular assist devices

Answer 5

• VADS produce non-pulsatile flow therefore NIBP and SpO2 will not work
• Arterial lines need to be used
• Consider NIRS
• ECG leads should be placed as far away as possible from the device
• TOE probe- the best way of monitoring pre-load. Large LV = fluid overload. Large RV = Hypovolaemia
• Depth of anaesthesia monitoring as normal tachycardia and hypertensive response to pain will be blunted
• VADs are pre-load dependent and afterload sensitive. Aim MAP 60-80 throughout

Question 6

Perioperative emergencies specific to ventricular assist devices

Answer 6

• Suction events: inadequate preload to pump causing the LV to collapse occluding the inflow cannula. If occurs pump speed should be dropped in increments of 200rpm and IV fluid boluses given ideally using TOE to assess response
• Thrombus in the inflow cannula or pump: Restart or increase anti-coagulation and refer to VAD team
• Cardiac arrest: Can be difficult to diagnose. Defib is fine but chest compressions are relatively contraindicated unless sustained MAP <50 and EtCO2 <20mmHg