Anesthetic management for abdominal aortic surgery in a patient with a left ventricular assist device: a case report
© The Author(s) 2015
Received: 13 May 2015
Accepted: 4 August 2015
Published: 30 November 2015
Left ventricular assist devices (LVAD) are a currently established destination and bridge therapy until cardiac transplantation; hence, this patient population continues to increase. Here, we present the first report of abdominal aortic cross-clamping (ACC) in a LVAD patient undergoing emergency aneurysm repair. Anticoagulation was continued pre-and intra-operatively to avoid pump thrombosis. The pumping function of the LVAD is highly dependent on both preload and afterload. In this case, abdominal ACC, which increases the afterload, did not significantly influence circulatory dynamics. However, when the abdominal ACC was released, mean atrial pressure (MAP) fell to 42 mmHg, because preload reduction due to massive bleeding (3532 g) secondary to anticoagulation and afterload reduction by abdominal ACC release combined to cause critical hypotension. Maintenance of MAP required rapid infusion and use of an alpha-adrenergic agent. Surgical and anesthesia times were 411 and 525 min, respectively. Total blood loss was 5389 g, respectively. The patient was discharged after 25 postoperative days with no major complications. ACC release, with its accompanying decrease in preload and afterload, and massive bleeding due to anticoagulation in these patients require careful management.
KeywordsAortic cross-clamping Left ventricular assist devices Afterload Preload Anticoagulation
The presence of implanted left ventricular assist devices (LVAD) presents a dilemma when managing other serious medical problems in this patient population [1, 2]. Although there are some reports of anesthetic management in patients with LVAD undergoing non-cardiac surgery [3–8], this is the first report of abdominal aortic cross-clamping (ACC) performed in a patient with a LVAD, which is known to be sensitive to preload and afterload.
Written informed consent was obtained from the patient for publication of this Case report. The patient was a 51-year-old male (height 171 cm, weight 60 kg). He had had cardiac resynchronization therapy with a defibrillator device implanted 2 years earlier, as well as a HeartMate II (Thoratec Co., Pleasanton, CA, USA.) implanted 6 months earlier for ischemic cardiomyopathy. Concurrent anticoagulation therapy included warfarin and aspirin. He was urgently admitted to the hospital on the day prior to surgery due to infected pseudoaneurysms of the bilateral common iliac arteries, which were deemed suitable for Y-shaped graft replacement. Preoperative transthoracic echocardiography displayed an ejection fraction of 5 %. As his PT-INR was 3.28, warfarin was discontinued and an infusion of heparin 2000 U/day was commenced 1 day before surgery.
The patient was transferred to the intensive care unit and extubated the next day. He was discharged 25 days later with no major complications.
The hemodynamic management of LVAD patients during non-LVAD surgery is important because the pump function depends on both preload and afterload . Continuous flow LVADs are up to three times more sensitive to a change in afterload compared with normal heart function . Therefore, in this case, we were anxious about the hemodynamics at the time of ACC application and release. However, application of the ACC did not result in a significant change in MAP. This was assumed to be due to the venodilatation and relative dehydration resulting from anesthesia induction. Another reason for this may have been the fact that HeartMate II is an axial pump, and axial pumps are less afterload sensitive than centrifugal pumps . On the other hand, when the ACC was released, MAP decreased precipitously. This could be because ACC release pathophysiologically decreased both afterload and venous return . It has been reported that HeartMate II, in particular, demonstrates increased preload sensitivity in the low-afterload region as compared to other LVADs . In this case, blood loss increased rapidly 30 min before ACC release, together with a fall in CVP. Ideally, we should have started adequate preloading and infusion of an alpha-adrenergic agent before ACC release. Moreover, a pulmonary artery catheter should have been used to monitor actual cardiac output, since the calculated flow shown on the system console may not always have a high degree of fidelity with the patient’s true cardiac output . It is possible to perform this surgery using cardiopulmonary bypass. The advantage of cardiopulmonary bypass is that to achieve stable circulatory dynamics, and the disadvantage is to increase operative stress.
LVAD patients chronically require anticoagulation to avoid pump thrombosis [3, 14]. In this case, because ACC required systemic heparinization, heparin was continued. Hemostasis, on the other hand, required discontinuation of heparin, administration of protamine, and FFP transfusion. A previous report suggests that the risk of bleeding due to impaired platelet aggregation in HeartMate II-treated patients may be significant . Hence, the anesthetic management of LVAD patients should include a plan against massive bleeding preoperatively using FFP and platelet concentrates, while balancing intra-operative bleeding with pump thrombosis. Anticoagulant management is likely to be even more challenging when these patients present for emergency surgery.
RV dysfunction is another potential cause of reduced LVAD output. Thus, maintaining RV function in LVAD patients undergoing surgical procedures is extremely important. This can be achieved pharmacologically by a combination of inotropes and RV afterload reducers. We achieved this by using dobutamine, and avoiding increases in pulmonary vascular resistance (e.g., due to hypoxemia, hypercarbia, and acidosis).
This is the first report of abdominal ACC performed in a LVAD patient sensitive to preload and afterload. Application of the ACC did not significantly affect circulatory dynamics, although its release caused a marked decrease in MAP. ACC release, with its accompanying decrease in preload and afterload, and massive bleeding due to anticoagulation in these patients require careful management.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We thank clinical engineers who provided information of LVAD.
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