The number of patients with LVADs is increasing mainly due to their success as a destination therapy in advanced heart failure. Therefore, these patients are increasingly encountered for noncardiac surgical procedures. Commonly encountered procedures include upper and lower GI procedures for bleeding due to arteriovenous malformation or larger and more extensive surgical procedures.

Preoperative evaluation should include a standard evaluation assessing current state of health and changes in exercise tolerance to screen for symptoms of acute heart failure. A careful physical examination should be performed to determine fluid status, right heart function, and signs of worsening heart failure. Medications, recent cardiology notes, and laboratory results should be reviewed. The medication list should be examined for diuretics, inotropes, anticoagulants, and anti-arrhythmic therapies. Laboratory results should be reviewed for baseline renal function, coagulation panel (as all these patients should be on anticoagulation), and hepatic function (which can indicate worsening right heart function). Patients often have renal impairment, and renal precautions should be taken during surgery. Coagulation status should be carefully assessed. The risk of bleeding versus thrombosis should be assessed for each individual procedure to determine whether to stop or bridge anticoagulation perioperatively.

The most recent cardiology note should be reviewed for the type of VAD, indication for device placement, settings (including flow rate, device alarms, power elevations, and backup battery life), and any other device interrogations (ie, pacemakers and implantable cardioverter-defibrillators [ICDs]). Many of these patients have implanted defibrillators. Depending on the procedure, tachyarrhythmia therapies might need to be disabled, and the pacemaker function might need to be switched to asynchronous mode if electrocautery interference is anticipated.

The most recent echocardiogram should be reviewed for inflow cannula position, outflow graft patency, and importantly RV function and tricuspid regurgitation. The most common valvular pathologies present in patients with LVAD are aortic stenosis and insufficiency, as well as tricuspid insufficiency.

Patients with VADs should ideally be cared for at a facility that has a support team dedicated to caring for these patients perioperatively. Members of this team should include a cardiologist, a VAD coordinator, cardiac surgeons, cardiac anesthesiologists, and perfusionists. The team should be notified in advance, if possible, that the patient with a VAD will be presenting for a procedure.

Patients with LVAD require extensive support services, including coverage by a specialized nurse or physician assistant specifically assigned to the hospital VAD program. These specialists may accompany patients with VAD to the operating room in some circumstances and are knowledgeable in the intricacies of individual VADs. In addition, device manufacturers have 24-hour support services and are a source of useful clinical information. These preoperative considerations are summarized in Table 6.3.

References

• Dalia AA, Cronin B, Stone ME, et al. Anesthetic management of patients with continuous-flow left ventricular assist devices undergoing noncardiac surgery: an update for anesthesiologists. J Cardiothorac Vasc Anesth. 2018;32:1001-1012.
• Han JJ, Acker MA, Atluri P. Left ventricular assist devices. Circulation. 2018;138:2841-2851.
• Nicolosi AC, Pagel PS. Perioperative considerations in the patient with a left ventricular assist device. Anesthesiology. 2003;98:565-570.