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Ventricular Assist Devices
The document outlines the peri-operative care approach for patients with ventricular assist devices (VADs), emphasizing the importance of hemodynamic optimization and meticulous management of right ventricular (RV) function. Key considerations include intraoperative assessments, the use of inotropes, and post-operative care strategies to avoid complications such as RV dysfunction and bleeding. It also highlights the need for comprehensive patient education and contact with VAD coordinators in case of emergencies.
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Ventricular Assist Devices
- 1. Ventricular Assist Devices Peri-operativeCare Approach to Emergencies Priya Nair Intensive Care Unit
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- 6. Haemodynamic optimisation • • • • Comprehensive assessmentof RV function Pulmonary artery catheter CVP<15 Lowering PVR to optimise right heart function, reduce RAP & hepatic congestion • Aggressively managing volume to minimise RV workload • Inotropes, vasodilators +/- IABP • V-A ECMO as bridge to decision
- 7. • • • • • • Renal Function Hepatic Function Nutrition Infection Coagulationstatus Neurologic, psychosocial & psychiatric Slaughter M et al, Clinical management of continuous flow LVADs in advanced heart failure. Journal of Heart & Lung Transplantation, Vol 29, No 4S, April 2010.
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- 9. TOE assessment • • • • • • PFO/septal abnormalities AorticIncompetence- may be under-estimated Mitral Stenosis LV Thrombus Ascending Aorta ?TV annuloplasty • Chumnanvej S et al, Echocardiography for VAD implantation Anesth Analg 2007;105(583-601) • Scalia GM et al, Clinical utility of echocardiography in the management of implantable ventricular assist devices. J Am Soc Echocardiogr 2000;13
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- 17. Chumnanvej S etal, Echocardiography for VAD implantation Anesth Analg 2007;105(583-601)
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- 21. Pump placement -post
- 22. Inflow & OutflowDoppler Chumnanvej S et al, Echocardiography for VAD implantation Anesth Analg 2007;105(583-601)
- 23. Chumnanvej S etal, Echocardiography for VAD implantation Anesth Analg 2007;105(583-601)
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- 25. Speed adjustment • • • • MAP>65 mmHg, Midline interventricular septum position Intermittent aortic valve opening No more than mild MR
- 27. Chumnanvej S etal, Echocardiography for VAD implantation Anesth Analg 2007;105:583-601
- 30. Right-sided circulation • • • • • High capacitance Low–pressure Short isovolumic contraction time Near-continuous systolic ejection period Less tolerant to afterload changes
- 31. Response to RV& LV to experimental changes in afterload MacNee et al, AJRCCM 1994
- 32. • Lower sarcomereCa++ concentrations with reduced maximal shortening • Less Ca++ sensitivity during inotropic stimulation • Compromises rapidly leading to hepatic dysfunction & coagulopathy • Increases peri-op mortality from 10-15% to 38-43%
- 33. • Peri-op- TX-A2,TNF-α, Interleukin & catechol release during CPB, blood products, inadequate cardioprotection, vasoconstrictors can trigger RVF • LVAD adds to this – shifts inter-ventricular septum to left, – distorts TV lead to TR – improved CO & sudden increase in venous return
- 34. Management of RVdysfunction • • • • • • • • Meticulous haemostasis/ avoid blood products Avoid excess RV preload, diuretics Decrease RV afterload- iNO, Iloprost Inotropes- Adrenaline, Milrinone, Dobutamine Vasoconstrictors- to maintain perfusion pressure Pacing Decrease pump speed Consider RCA bypass &/or TV annuloplasty • V-PA ECMO
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- 36. • • • • • Fluids/inotropes Suction events RV dysfunction Bleeding& anticoagulation Tamponade
- 37. Suction event Mauermann WJ et al. Anesth Analg 2008;107:791-792
- 38. Cyclical LVAD suction Speed(RPM) Flow (L/min) 6 5 4 3 Positive pressure ventilation 2 PEEP 18cmH2O 2800 2700 2600 75 85 Time (seconds) 95
- 39. Fischer L etal Management of pulmonary hypertension Anesth Analg 2003;96:1603–16 Day/Month/Year Footnote to go here Page 39
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- 46. Take home messages • • • • • • Pre-ophaemodynamic optimisation Meticulous care of the RV Avoid over-pumping Serial echocardiography is vital Cautious anticoagulation VADs are preload dependent & afterload sensitive • Mortality and persistent heart failure determined by inefficient unloading of left side and persistent RV dysfunction
- 47. At discharge • Comprehensiveeducation of patient & NOK • Easy contact with VAD coordinator & hospital team • Spare controller & battery packs • Strict BP control
- 48. Emergency Department presentations • EMSguide January 2012, Mechanical Circulatory Support Organisation • www.jems.com • emcrit.org/wee/left-ventricular-assist-devices-lvads • heartware.org • mylvad.com
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- 51. • Bleeding – Anticoagulation-related –Abnormal von Willebrand factor • Infection – Driveline – Pump pocket
- 52. VAD emergencies Patient inExtremis
- 53. 1) AUSCULTATE FORPUMP HUM
- 54. NO HUM • Checkcables and connections • Check batteries
- 55. 2) CHECK MAP,ASSESS PERFUSION
- 56. 3) JUDICIOUS FLUIDCHALLENGE • Check pump flows and response. <65mmHg- Adrenaline/Noradrenaline/Vasopressin >65mmHg- Dobutamine/Milrinone • Early arterial line with ultrasound guidance • Care with CVC if RVAD in place
- 57. 4)MONITOR +/- DEFIBRILLATE •Check electrolytes, correct potassium • Avoid chest compressions
- 58. 5) URGENT ECHO •RV small- hypovolaemia, bleeding, sepsis • RV bigger than LV, D-shaped septum, TR- RV dysfunction • Large LV (+MR)• High power- pump thrombosis (haemolysis, altered hum) • Low power- inflow or outflow obstruction • Ischaemic events • Aortic Incompetence
- 59. AT ALL TIMES,BE GENTLE WITH THE RV
- 60. Pump flows &MAP OKLikely neurologic event
- 61. In short… • • • • • • • Call VADcentre Check connections & cables Auscultate for pump hum/doppler pulse Check doppler BP, perfusion Judicious fluid challenge, inotropes/pressors Echo if possible Consider non-VAD causes for presentation
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