Standard American Society of Anesthesiologists monitoring is used at a minimum. Due to the continuous flow of newer VADs, noninvasive blood pressure cuffs and pulse oximeters may not function reliably in all patients. Nevertheless, mean arterial blood pressure should be monitored with noninvasive or direct measurements, and oxygenation determined by arterial blood gas measurement or continuously by cerebral oxygenation monitors. When arterial line placement is necessary, an ultrasound can help locate the vessel, as the systemic pulse is weak or nonpalpable. Monitoring central venous pressure or placement of a PAC must be individualized based on anticipated fluid shifts and risk of the procedure as well as underlying RV function. In patients with impaired RV function or for procedures involving large fluid shifts, intraoperative TEE is recommended.

No consensus guidelines currently exist to recommend whether these patients should be cared for by a cardiac or general anesthesiologist in the setting of noncardiac surgery. It is generally agreed that the anesthesiologist should be familiar with LVAD settings and specific alarms. Increasingly, these patients are cared for safely by general anesthesiologists, especially patients who are stable on their LVADs, do not require pharmacologic support, and are scheduled for noncardiac surgery where significant hemodynamic changes are not expected. Patients with LVADs on medical therapy for heart failure, have major co-morbidities, and are scheduled for high-risk surgery with likely hemodynamic instability should be cared for by a cardiac anesthesiologist.

Invasive arterial blood pressure monitoring is recommended for major surgery, given its accuracy, reliability, and ability to obtain arterial blood gases. Mean arterial pressure (MAP) should generally be kept at less than 85 mm Hg, given concerns for reduced LVAD flow, pump stasis, and risk of stroke at higher MAPs.

In the event of cardiac arrest, standard advanced cardiac life support (ACLS) should be employed including chest compressions; this policy has changed in recent years because previously chest compressions were thought to be contraindicated due to fear of disrupting or dislodging the VAD cannulas. The priority of resuscitation should be to troubleshoot the malfunctioning LVAD.

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.
• Peberdy MA, Gluck JA, Ornato JP, et al. Cardiopulmonary resuscitation in adults and children with mechanical circulatory support: a scientific statement from the American Heart Association. Circulation. 2017;135:e1115-e1134.