Most Important topics on LVAD Implantation

The Fellowship Seminar, Episode 3, is organised by the EACTAIC Education Committee in Collaboration with the Heart and Diabetes Center NRW, University Hospital of Ruhr-University Bochum, Bad Oeynhausen, Germany
Heart and Diabetes Center NRW, University Hospital of Ruhr-University Bochum, Bad Oeynhausen, Germany sponsors this seminar episode .

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What’s in it for me?

After participating in this webinar, you will better understand:

– Acquire information on the history and updates on the practice of VAD implantation.

– Identify the risks and develop a management strategy for right-side heart failure after LVAD implantation.

– Understanding the coagulation management of patients with HIT who undergo VAD implantation.

– Recognise the incidence and management options for vasoplegia after LVD implantation.

Moderation:

Vera von Dossow
Germany
Mohamed R. El Tahan
EGY

Programme:
Time Topic Speaker
18.00–18.15 History of LVAD implantation and new Insights M. Morshuis (Germany)
18.15–18.30 Early Risk stratification and strategy for Right heart failure: The HDZ approach H. Starke (Germany)
18.30–18.45 Coagulation management in LVAD Patients with HITT A. Koster (Germany)
18.45–19.00 Vasoplegia: Still a problem? E. De Waal (The Netherlands)
19.00–19.30 Open Discussion —


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Event Details
10
Days
50
Hours
10
Min
00
Sec
Start Date
July 04, 2022 6:00 pm
End Date
July 04, 2022 7:30 pm
Status
Expired

meet the speakers:

V. von Dossow
Moderator

Prof. Dr. med, Berlin, Germany
Director of the institute of anesthesiology and pain therapy
Heart and Diabetescenter Bad Oeynhausen
Ruhr-University Bochum, Germany

Previous Appointments
Ludwig-Maximilian-University, University Hospital of Munich (Germany), Department of Anesthesiology (since 2009)
Section head for cardiothoracic anesthesia
Chair: Professor Bernhard Zwißler, MD

M. R. El Tahan
Moderator

Professor of Cardiothoracic Anaesthesia & Surgical Intensive Care, Mansoura University, Mansoura, Egypt
Associate Professor of Cardiothoracic Anaesthesia & Surgical Intensive Care, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

  • European Association of Cardio-Thoracic Anaesthesiology (EACTA) Education Chair and Director at the Board of Directors.
  • Egyptian Cardiothoracic Anaesthesia Society (ECTAS), Thoracic Committee member.
  • Association of Cardiothoracic Anaesthetists and Critical Care (ACTACC), UK, member.
  • Association of Anaesthetists (UK).
  • He has 50 publications in PubMed indexed impacted journals in addition to seven book chapters on thoracic anaesthesia and airway management.
  • He is specialised in cardiothoracic and vascular anaesthesia.
  • His research interests include thoracic anaesthesia, one lung ventilation, protective ventilation, airway management, perfusion and cardiopulmonary bypass, haemodynamic monitoring and control, inflammatory response, cardiovascular anaesthesia, obstetric anaesthesia.
  • He stands as a peer reviewer in 10 specialized impacted journals. He works as an Associate Editor in the BMC Anesthesiology and Plos One and an Editor in the Saudi Journal of Anaesthesia.
  • He has participated in organizing, instructing and talking in more than 76 national and international scientific events.

M. Morshuis
Speaker

Senior Consultant and leader of the LVAD/Transplant program, Heart and Diabetescenter Bad Oeynhausen Ruhr University Bochum.
His clinical and research interest are Heart insufficiency, short-term and long-term mechanical assist device, heart transplantation.

H. Starke
Speaker

Henning Starke started his training as an anesthesiologist in 2012. From 2011–2015 he worked at the University Hospital Leipzig and from 2015–2020 at the Hannover Medical School. In 2020, he joined the team of the HDZ NRW in Bad Oeynhausen.

His scientific interests include thoracic anaesthesia (especially non-intubated VATS) and risk-adjusted therapy strategies in the LVAD field.

A. Koster
Speaker

Andreas Koster began training as an anesthesiologist in 1990. From 1994–2009 he worked in the German Heart Institute, Berlin. In 2010, he joined the HDZ NRW in Bad Oeynhausen.

His scientific interests include anticoagulation strategies and coagulation management during cardiac surgery, with special focus on HIT patients.

E. de Waal
Speaker

Eric E.C. de Waal graduated as a medical doctor in 1988, specialised in anaesthesiology in 1993, and has extensive experience in cardiac anaesthesia, transplantation, ventricular assist devices, and management of severe postoperative complications.

Opening, Vera von Dossow, Mohamed El Tahan, July 5, 2022
https://youtu.be/P84RTPqMJCg

History of LVAD implantation and new Insights, M. Morshuis, July 5, 2022
https://youtu.be/okNogpRQnL8

Early Risk stratification and strategy for Right heart failure: The HDZ approach, H. Starke, July 5, 2022
https://youtu.be/yQa1tsJAPHk

Coagulation management in LVAD Patients with HITT, A. Koster, July 5, 2022
https://youtu.be/7HExC22pYBw 

Vasoplegia: Still a problem? E. De Waal (the Netherlands), July 5, 2022
https://youtu.be/3VFdWh085Hs

QA, Take-Home Message, Vera von Dossow (Germany), Mohamed El Tahan (Egypt), and the faculty, July 5, 2022
https://youtu.be/2XGVqWXSKho

We use Ilorost 20µg an Milrinon 50µg/kg per inhalation 15 minutes before weaning if CPB. We repeat this dose every 20-30 minutes.

Thank you for this question. Indeed PAPI was shown as s an independent predictor of RVF and the need for RVAD support after LVAD implantation several years ago (kang G 2016). I think it is included in one risk score (Loforte A 2018). We will include this parameter in our risk stratification assessement.

We fully agree. Prediction of RV failure is not 100%. Of course reasons like dysplacement of inflow cannula, air embolism etc. are not predictable by existing scores. Nevertheless, risk stratification is a good opportunity to be aware of several problems in this high risk patient cohort.

As already discussed, there is of course a good indication for milrinone. The use of levosimendan has specific reasons in our centre.

Some small studies report a potentially benefit for levosimendan treatment in those patients (Theiss HD 2014, Kocabeyoglu SS 2019, Segev A 2022). However robust data are missing as well as für Milrinon or NO. Due to the common discontinuation of milrinon therapy in our ICU we prefered levosimendan for center specific reasons. First results from our quality management showed a reduced incedence of RVF compared to the last year. Of course this is not a prove for the effect of levosimendan alone, especially in a single center, non randomised evaluation.

Difficult question: Evaluating RV function during long torm ECMO therapy remains diffcult. Additionally severe end organ dysfunctions including neurologic disorders have to be ruled out before LVAD implantation.

Yes, in our opinion this is feasible, especially when RV failure leads to hypotension. In case of vasoplegia you have to weigh up potentially benefits of milrinon versus triggered hypotension.

In case of new onset RVF we try to find out if it is a problemlem due to pre- or afterload issues or low contractility. This is done by a combination of TTE/TEE and pulmonary artery catheter measurement. Once you have a diagnosis we apply a targed controled therapy. Epinephrin, Milrinon and NO are usually used for therapy. If CO remains to low we favor a temporary RVAD implantation.

no, only in case of HIT or protamine allergy. However, indication does not matter. Heparin is a GAG and bivalirudin a protein. So, no cross reactivity of antibodies

we use the RoTEM (ExTEM, FibTEM shortly before weaning from CPB to get a picture of the coagulazion status

we dont use it. Evidence for FXIII adminitrtaion is low

will reduce the likelyhood of HIT but Fonda or argatroban are better . DOAC will play an important role in the futgure

an calibtarted ecarin clotting time (see early studies) However, to the best of my knowledge the only commercially available devive has been ref moved from the market

personyly not. However, all case reports show ineffective anticoagulation and excessive bleeding. Morfeover, no standardized protocol as for bivalirudin and PK' sare also not improved as hlf-life is longer and depends on liver Fx

First of all, think about independent predictors of postoperative vasoplegia (preoperative cardiothoracic surgery, impaired renal and/or liver function). measurement of preop IL-6 may be an indicator for enhanced change to develop postoperative vasoplegia. If possible, optimize the reanla and liver function preoperatively, and perhaps postpone the LVAD implantation. In addition, preop and intraop optimizing intravascular fluid content (Hct, Albumin, total protein), is important. Furthermore, other causes of low bloodpressure should be excluded and all vasodilating agents, such as milrinone or nitroglycerine should be stopped.

We should be cautious to extrapolate the results of the IV vit C trial in septic patients to postcardiac surgery vasoplegia, as the underlying mechanisms may be different. Moreover the doses used in this IV vit C trial in septic patients is much higher (50 mg /kg/6 hours) (3 times higher) as advocated in the paper of Busse et al (Crit Care 2020; 24:36) (1.5 gr/6 hours). There are currently no RCT's described about the use of lower dosages of vit C in post cardiac surgery vasoplegia, and I would advicde to use lower dosages.

To The best of my knowledge there are no data investigating methylene Blue on PVR. From our experience methylene application is not associated with pulmonary hypertension, at least slight • Methylene blue dosing: 1.5-2 mg/kg , no additional increase with ultrafiltration. However, methylenblue is off-label use in cardiopulmonary bypass

We have no experience with impella and RV failure

We try to make the decision within a week of starting ECMO therapy. For this purpose, we visit the patient 1-2 times a day. The prerequisites for implantation are that the left ventricular pump function does not recover and that the left ventricle is well unloaded. Furthermore, there must be no infection, no neurological disorders and all secondary organ failures must be reversible.

Of course, previous surgery is a risk factor for morbidity. Particularly in the case of haemostasis, great care must be taken during LVAD implantation. However, the existing difficulties are manageable

For patients with positive blood cultures, we usually wait 7-10 days after starting antibiotic therapy in line with microbiologically resistance. For second part of the question see above (1st question).