Nichtkardiochirurgische operative Eingriffe bei Patienten nach Implantation eines „ventricular assist device“

Managementkonzepte in der Anästhesie
Übersichten

Zusammenfassung

Hintergrund

Im Vergleich zum Einsatz eines „ventricular assist device“ (VAD) als Überbrückung der Zeit bis zur Herztransplantation („bridge to transplantation“, BTT) wird die VAD-Implantation immer häufiger als finale Therapie der Herzinsuffizienz verwendet. Dies führt unabhängig von Eingriffen am Herzen zu einem Anstieg der Anzahl der operativen Eingriffe in dieser Patientengruppe.

Problemstellung

Durch den Anästhesisten sind verschiedene VAD-bezogene Komplikationen zu beachten, wie ein erhöhtes Blutungs- und Thromboserisiko, Hypotonie, Infektionen, physiologische Limitationen durch das VAD und Rechtsherzinsuffizienz. Die anästhesiologische Betreuung dieser Hochrisikopatienten stellt eine Herausforderung dar und hat signifikanten Einfluss auf das Outcome der Patienten nach nichtkardiochirurgischen operativen Eingriffen.

Lösungsansatz

Zusätzliche Forschung ist notwendig um Leitlinien zur Anästhesie von Patienten zu erstellen, denen ein VAD implantiert wurde und die sich einem nichtkardiochirurgischen operativen Eingriff unterziehen. ln dieser Arbeit werden verschiedene VAD-bezogene perioperative Komplikationen dargestellt und Konzepte des anästhesiologischen Managements evaluiert.

Schlüsselwörter

Herzchirurgie Thrombembolie Blutung Komplikationen Forschung 

Noncardiological surgical procedure for patients implanted with a ventricular assist device

Anesthesiological management concepts

Abstract

Background

The implantation of a ventricular assist device (VAD) is more frequently used as destination therapy of end-stage heart failure compared to the use of the device as bridge-to-transplantation, this results in an increasing number of noncardiac surgical procedures for patients implanted with a VAD.

Objective

For these procedures, the anesthesia provider faces various device-related complications, such as an increased risk for bleeding complications, thromboembolism, hypotension, infections, mechanical device limitations, and right heart failure. Anesthesia care is challenging in this high-risk patient population and has significant implications on patient outcome.

Conclusion

More research is needed to determine specific guidelines for the anesthesiological management of VAD patients undergoing noncardiac surgical procedures. In this manuscript, device-related perioperative complications and concepts of anesthesia care for noncardiac procedures in patients implanted with a VAD are briefly reviewed.

Keywords

Cardiac surgery  Thromboembolism Bleeding Complications  Research 

Literatur

  1. 1.
    Wilson SR, Givertz MM, Stewart GC, Mudge GH Jr (2009) Ventricular assist devices the challenges of outpatient management. J Am Coll Cardiol 54(18):1647–1659CrossRefPubMedGoogle Scholar
  2. 2.
    Claus M, Beling M, Baumann G (2004) Chirurgische Therapiemöglichkeiten bei fortgeschrittener Herzinsuffizienz. Intensivmed Notfallmed 41(1):6–11CrossRefGoogle Scholar
  3. 3.
    Ahmed M, Le H, Aranda JM Jr, Klodell CT (2012) Elective noncardiac surgery in patients with left ventricular assist devices. J Card Surg 27(5):639–642CrossRefPubMedGoogle Scholar
  4. 4.
    Brown JB, Hallinan WM, Massey HT et al (2009) Does the need for noncardiac surgery during ventricular assist device therapy impact clinical outcome? Surgery 146(4):627–633 (discussion 633–634)CrossRefPubMedGoogle Scholar
  5. 5.
    Goldstein DJ, Mullis SL, Delphin ES et al (1995) Noncardiac surgery in long-term implantable left ventricular assist-device recipients. Ann Surg 222(2):203–207CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Morgan JA, Paone G, Nemeh HW et al (2012) Non-cardiac surgery in patients on long-term left ventricular assist device support. J Heart Lung Transplant 31(7):757–763CrossRefPubMedGoogle Scholar
  7. 7.
    Schmid C, Wilhelm M, Dietl KH et al (2001) Noncardiac surgery in patients with left ventricular assist devices. Surgery 129(4):440–444CrossRefPubMedGoogle Scholar
  8. 8.
    Stehlik J, Nelson DM, Kfoury AG et al (2009) Outcome of noncardiac surgery in patients with ventricular assist devices. Am J Cardiol 103(5):709–712CrossRefPubMedGoogle Scholar
  9. 9.
    Tuzun E, Roberts K, Cohn WE et al (2007) In vivo evaluation of the HeartWare centrifugal ventricular assist device. Tex Heart Inst J 34(4):406–411PubMedCentralPubMedGoogle Scholar
  10. 10.
    Potapov EV, Stepanenko A, Kaufmann F et al (2013) Thrombosis and cable damage in the HeartWare pump: clinical decisions and surgical technique. ASAIO J 59(1):37–40CrossRefPubMedGoogle Scholar
  11. 11.
    Frazier OH, Gemmato C, Myers TJ et al (2007) Initial clinical experience with the HeartMate II axial-flow left ventricular assist device. Tex Heart Inst J 34(3):275–281PubMedCentralPubMedGoogle Scholar
  12. 12.
    Thunberg CA, Gaitan BD, Arabia FA et al (2010) Ventricular assist devices today and tomorrow. J Cardiothorac Vasc Anesth 24(4):656–680CrossRefPubMedGoogle Scholar
  13. 13.
    Miller LW, Pagani FD, Russell SD et al (2007) Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 357(9):885–896CrossRefPubMedGoogle Scholar
  14. 14.
    Shuhaiber JH, Jenkins D, Berman M et al (2008) The papworth experience with the levitronix CentriMag ventricular assist device. J Heart Lung Transplant 27(2):158–164CrossRefPubMedGoogle Scholar
  15. 15.
    Khemees TA, Shabsigh A (2012) Feasibility of robotic-assisted laparoscopic nephroureterectomy in left ventricular assist device patient. Case Rep Urol 2012:282680. doi:10.1155/2012/282680 (Epub 2012 Oct 10)PubMedCentralPubMedGoogle Scholar
  16. 16.
    Manger JP, Kern JA, Krupski TL (2011) Partial nephrectomy in a patient with a left ventricular assist device. Case Rep Urol 2011:526903PubMedCentralPubMedGoogle Scholar
  17. 17.
    Kartha V, Gomez W, Wu B, Tremper K (2008) Laparoscopic cholecystectomy in a patient with an implantable left ventricular assist device. Br J Anaesth 100(5):652–655. doi:10:1093/bja/aen052 (Epub 2008 Mar 15)CrossRefPubMedGoogle Scholar
  18. 18.
    Waldenberger F, Kim YI, Laycock S et al (1996) Effects of failure of the right side of the heart and increased pulmonary resistance on mechanical circulatory support with use of the miniaturized HIA-VAD displacement pump system. J Thorac Cardiovasc Surg 112(2):484–493CrossRefPubMedGoogle Scholar
  19. 19.
    Murakawa T, Murayama T, Nakajima J, Ono M (2011) Lung lobectomy in a patient with an implantable left ventricular assist device. Interact Cardiovasc Thorac Surg 13(6):676–678CrossRefPubMedGoogle Scholar
  20. 20.
    Hessel EA II (2014) Management of patients with implanted ventricular assist devices for noncardiac surgery: a clinical review. Semin Cardiothorac Vasc Anesth 18(1):57–70CrossRefPubMedGoogle Scholar
  21. 21.
    Bhat G, Kumar S, Aggarwal A et al (2012) Experience with noncardiac surgery in destination therapy left ventricular assist devices patients. ASAIO J 58(4):396–401CrossRefPubMedGoogle Scholar
  22. 22.
    Garatti A, Bruschi G, Colombo T et al (2009) Noncardiac surgical procedures in patient supported with long-term implantable left ventricular assist device. Am J Surg 197(6):710–714CrossRefPubMedGoogle Scholar
  23. 23.
    Boyle AJ, Russell SD, Teuteberg JJ et al (2009) Low thromboembolism and pump thrombosis with the HeartMate II left ventricular assist device: Analysis of outpatient anti-coagulation. J Heart Lung Transplant 28(9):881–887CrossRefPubMedGoogle Scholar
  24. 24.
    Chumnanvej S, Wood MJ, MacGillivray TE, Melo MF (2007) Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg 105(3):583–601CrossRefPubMedGoogle Scholar
  25. 25.
    Nussmeier NA, Probert CB, Hirsch D et al (2003) Anesthetic management for implantation of the jarvik 2000 left ventricular assist system. Anesth Analg 97(4):964–971CrossRefPubMedGoogle Scholar
  26. 26.
    Riha H, Netuka I, Kotulak T et al (2010) Anesthesia management of a patient with a ventricular assist device for noncardiac surgery. Semin Cardiothorac Vasc Anesth 14(1):29–31CrossRefPubMedGoogle Scholar
  27. 27.
    Slininger KA, Haddadin AS, Mangi AA (2013) Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 27(4):752–759CrossRefPubMedGoogle Scholar
  28. 28.
    Nicolosi AC, Pagel PS (2003) Perioperative considerations in the patient with a left ventricular assist device. Anesthesiology 98(2):565–570CrossRefPubMedGoogle Scholar
  29. 29.
    Rich JD (2012) Right ventricular failure in patients with left ventricular assist devices. Cardiol Clin 30(2):291–302CrossRefPubMedGoogle Scholar
  30. 30.
    Lee MT, Klein TE (2013) Pharmacogenetics of warfarin: challenges and opportunities. J Hum Genet 58(6):334–338CrossRefPubMedGoogle Scholar
  31. 31.
    Uriel N, Pak SW, Jorde UP et al (2010) Acquired von willebrand syndrome after continuous-flow mechanical device support contributes to a high prevalence of bleeding during long-term support and at the time of transplantation. J Am Coll Cardiol 56(15):1207–1213CrossRefPubMedGoogle Scholar
  32. 32.
    Wilhelm MJ, Ruschitzka F, Falk V (2013) Destination therapy – time for a paradigm change in heart failure therapy. Swiss Med Wkly 143Google Scholar
  33. 33.
    Mahla E, Suarez TA, Bliden KP et al (2012) Platelet function measurement-based strategy to reduce bleeding and waiting time in clopidogrel-treated patients undergoing coronary artery bypass graft surgery: the timing based on platelet function strategy to reduce clopidogrel-associated bleeding related to CABG (TARGET-CABG) study. Circ Cardiovasc Interv 5(2):261–269CrossRefPubMedGoogle Scholar
  34. 34.
    Weitzel NS, Weitzel LB, Epperson LE et al (2012) Platelet mapping as part of modified thromboelastography (TEG®) in patients undergoing cardiac surgery and cardiopulmonary bypass. Anaesthesia 67(10):1158–1165CrossRefPubMedGoogle Scholar
  35. 35.
    Livingston ER, Fisher CA, Bibidakis EJ et al (1996) Increased activation of the coagulation and fibrinolytic systems leads to hemorrhagic complications during left ventricular assist implantation. Circulation 94(Suppl 9):II227–II234PubMedGoogle Scholar
  36. 36.
    Nicolosi AC, Pagel PS (2003) Perioperative considerations in the patient with a left ventricular assist device. Anesthesiology 98(2):565–570CrossRefPubMedGoogle Scholar
  37. 37.
    Stone ME, Soong W, Krol M, Reich DL (2002) The anesthetic considerations in patients with ventricular assist devices presenting for noncardiac surgery: A review of eight cases. Anesth Analg 95(1):42–49 (CrossRefPubMedGoogle Scholar
  38. 38.
    Singh S, Kuschner WG, Lighthall G (2011) Perioperative intravascular fluid assessment and monitoring: a narrative review of established and emerging techniques. Anesthesiol Res Pract 2011:231493PubMedCentralPubMedGoogle Scholar
  39. 39.
    Webb ST, Patil V, Vuylsteke A (2007) Anaesthesia for non-cardiac surgery in patient with becker’s muscular dystrophy supported with a left ventricular assist device. Eur J Anaesthesiol 24(7):640–642CrossRefPubMedGoogle Scholar
  40. 40.
    Madigan JD, Choudhri AF, Chen J et al (1999) Surgical management of the patient with an implanted cardiac device: Implications of electromagnetic interference. Ann Surg 230(5):639–647CrossRefPubMedCentralPubMedGoogle Scholar
  41. 41.
    O’Shea G, Teuteberg JJ, Severyn DA (2013) Monitoring patients with continuous-flow ventricular assist devices outside of the intensive care unit: novel challenges to bedside nursing. Prog Transplant 23(1):39–46CrossRefGoogle Scholar
  42. 42.
    Horton SC, Khodaverdian R, Powers A et al (2004) Left ventricular assist device malfunction: A systematic approach to diagnosis. J Am Coll Cardiol 43(9):1574–1583CrossRefPubMedGoogle Scholar
  43. 43.
    Helman DN, Addonizio LJ, Morales DL et al (2000) Implantable left ventricular assist devices can successfully bridge adolescent patients to transplant. J Heart Lung Transplant 19(2):121–126CrossRefPubMedGoogle Scholar
  44. 44.
    Siegenthaler MP, Martin J, Pernice K et al (2003) The jarvik 2000 is associated with less infections than the HeartMate left ventricular assist device. Eur J Cardiothorac Surg 23(5):748–754CrossRefPubMedGoogle Scholar
  45. 45.
    Abicht T, Gordon R, Meehan K et al (2013) Complex HeartMate II infection treated with pump exchange to HeartWare HVAD. ASAIO J 59(2):188–192CrossRefPubMedGoogle Scholar
  46. 46.
    Klotz S, Vahlhaus C, Riehl C et al (2010) Pre-operative prediction of post-VAD implant mortality using easily accessible clinical parameters. J Heart Lung Transplant 29(1):45–52CrossRefPubMedGoogle Scholar
  47. 47.
    Rossi M, Serraino GF, Jiritano F, Renzulli A (2012) What is the optimal anticoagulation in patients with a left ventricular assist device? Interact Cardiovasc Thorac Surg 15(4):733–740 (Epub 2012 Jul 3)CrossRefPubMedCentralPubMedGoogle Scholar
  48. 48.
    HeartWare Inc. (2013) HeartWare® Ventricular Assist System. Instruction for use. (http://www.heartware.com/sites/default/files/uploads/resources/ifu00001_rev17_hvasinstructionsforuse_us.pdf. Zugegriffen: 26. Juni 2014)Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Department of Internal MedicineWeiss Memorial Hospital, affiliate of the University of IllinoisChicagoUSA

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