Ventricular Assist Devices

Free Online Webinar organized by the EACTA Educational Committee in collaboration with the VAD Committee
Click here to see the recordings (content available for EACTAIC members)

Take home message

We designed this webinar to update perioperative challenges of cardiac mechanical circulatory support both in terms of the implantation period and when these patients present for noncardiac surgery. In addition, we wanted to bring an update on the development of resuscitation guidelines for these high-risk patients.

The amazing progress of this field was compared to natural landscapes. Changing lives of patients suffering from end stage heart failure with the prospect of certain death to nearly ninety percent one-year survival was compared to sunset and sunrise, to winter and spring. We marvelled on the technological achievements with devices able to pump nearly 100000 hours with only limited effects on blood elements. Like our natural inner longing for beautiful outdoors and natural landscapes seeking the “geography of hope” and fullness of life, patients needing LVAD insertion also long for quality of life. But this is only achieved around 80% with others suffering from adverse events and poor quality of life. In selected patients we have achieved the ultimate success of LVAD therapy leading to full recovery and living once again without LVAD and without heart failure. The perioperative period is high risk and despite major breakthroughs in surgical techniques and anaesthesia management, organ failure and multiple organ failure is prevalent and dramatically influence morbidity and survival.

One of the main issues relates to preservation of right ventricle function, which remains the Achilles heel of the entire process. The RV is prone to fail, affected by many interrelated and antiquate physiological and molecular events before during and after LVAD implantation. As the response of the RV to the LVAD flow is difficult to predict, emphasis must be on vigilant monitoring of every physiological parameters and dynamics of RV function and utilise fully our general measures, specific RV optimising pharmacology and RV mechanical support, a true precision medicine approach for clinical anaesthesia.

One crucial event is the perioperative development of vasoplegia. While basic mechanisms are unknown, it is likely party of an inflammatory response and changes in the body's endogenous mechanisms to maintain vascular tone. Most classical vasoplegia definitions cannot be applied to the LVAD operation but unifying definitions reveal one third of patients being affected. These have major impact on outcomes. Prediction is poor highlighting the importance of intraoperative events and our repertoire to effectively treat the condition remains limited.

With the increasing population of patient equipped with an LVAD, there is an increase of these patients needing non cardiac and sometimes emergency surgery. As a consequence, non-cardiac anaesthetists should be familiar with the devices and implications to physiology and clinical management. In the current era, continuous flow devices are the most common that impacts on clinical monitoring including blood pressure and saturation. Teams should have alternative means for monitoring and be prepared for rapid and severe haemodynamic changes during these surgeries. A multidisciplinary collaborative approach with ever presence of a VAD team ensures the best outcome for these patients.

The public and no specialist hospital staff should be prepared to encounter LVAD patients with device malfunction. There are multiple considerations especially publicly recognised vital signs such as detecting pulse or applying chest compressions could be difficult. New algorithms have been developed to cover most scenarios with clear instructions for rapid initial assessment in the prehospital emergency setting. The message is not to waste time for trying to assess pulse but to make all attempts to restart the LVAD. The priority is to sustain life and on balance, administration of CPR with chest compression is acceptable until further resuscitative manoeuvres become available. Training ambulance crews, ER personnel and hospital staff are underway.

In summary, we have visited many landscapes. We have achieved a lot, but we need to do more. We have reached the end of the pioneering period; we now need new breakthroughs towards excellence and to fulfil the landscape of hope. We need to learn more about our different approaches to perioperative management, come to consensus on best practices and promote these in the wider professional communities.

The EACTA Transplant and VAD Subcommittee has been a driving force in this direction and currently conducts the worldwide PURSUDE Survey and organising a consensus statement on anaesthesia and intensive care management of LVAD insertion. This should be a welcoming platform for all European perioperative teams to join and contribute actively. We also invite colleagues in other parts of the world and other associations to make closer links and collaborations with us.

The perioperative landscape of mechanical support remains inspiring and beautiful.

The faculty of the EACTA LVAD Webinar, November 9th, 2020.

What’s in it for me?

After this webinar, you will better understand:

  • The perioperative challenges for patients with mechanical circulatory support.
  • The perioperative care of patients with right ventricular failure.
  • The perioperative complications in patients who undergo VAD insertion.
  • The strategy for perioperative management of patients with VAD who undergo noncardiac surgery.
  • Resuscitation of patients with VAD.
Target Audience:

Cardiac and vascular surgeons, cardiovascular anaesthetists, perfusionists, intensivists, general anaesthetists, anaesthesia certified nurses, nurses, interns, and medical students

Head of the Scientific Committee:

Mohamed R. El Tahan
EACTA Education Chair

The Ventricular Assisst Devices, Rome (live streaming), Italy, 09/11/2020-09/11/2020 has been accredited by the European Accreditation Council for Continuing Medical Education (EACCME®) with2 European CME credits (ECMEC®s).



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Event Details
10
Days
50
Hours
10
Min
00
Sec
Start Date
November 09, 2020 5:00 pm
End Date
November 09, 2020 7:30 pm
Status
Expired
Scientific Moderators:

Eric de Waal
The Netherlands
Nandor Marczin
UK

Programme:
Time Topic Speaker
17:00–17:22 Perioperative landscape of cardiac mechanical circulatory support Nandor Marczin, UK
17:22–17:44 Physiology of RV function and RV failure during LVAD implantation Steffen Rex, Belgium
17:44–18:06 Vasoplegia after continuous flow-LVAD implantation Eric de Waal, The Netherlands
18:06–18:28 Non-cardiac surgery in LVAD patients Michele Mondino, Italy
18:28–18:50 Resuscitation guidelines of a patient with LVAD Chris Bowles, UK
18:50–19:00 Perioperative lessons of LVAD implantation — summary Eric de Waal, The Netherlands
Nandor Marczin, UK
19:00–19:30 Q&A from the audience -

A more than moderate TR should be fixed, in particular when caused by structural problems of the TV.
Speakers: Steffen Rex

Most LVAD patients suffer from venous pulmonary hypertension, i.e. as a consequence of LV failure. In these patients, pulmonary vasodilators are either uneffective or even dangerous. The best treatment is to treat LV failure, hence LVAD implantation! The only indication for pulmonary vasodilators is a situation in which the patient suffers additionally from another cause of pulmonary hypertension.
Speakers: Steffen Rex

I am very restrictive concerning the use of milrinone as I am afraid of systemic vasodilation which can precipitate RV failure.
Speakers: Steffen Rex

Only few data available on this. Some centers sucessfully use levosimendan in these patients. However, also levosimendan (comparable to milrinone) can cause severe systemic vasodilation which may jeopardize RV function. Sometimes, a trial with iNO is beneficial.
Speakers: Steffen Rex

Gut feeling: norepinephrine 0.2-0.3 µg/kg/mun, epinephrine 0.1-0.2 µg/kg/min
Speakers: Steffen Rex

All iuotropes have side effcets! In LVAD patients, I still prefer inopressors over inodilators.
Speakers: Steffen Rex

Yes, sometimes, for preoperative optimization.
Speakers: Steffen Rex

Inhaled nitric oxide or inhaled prostacyclins are of equal efficiency.
Speakers: Steffen Rex

Yes, OLV is possible in Lvad patients. One have to be carful of the increased afterlaod due to possibe hypoxemia. Invasive arterial pressure monitoring is recommended
Speakers: Michele Mondino

The Lvad is preload dependent. Potitioning that my reduce venous retourn can lead to instability and should be perfiremd carfully. Volume adjustemnet may be needed. Peritoneal insufflation sgould be made in steps. Spacial attention needs to be given to the drive line during positioning.
Speakers: Michele Mondino

Many thanks for this interesting question. Cerebral oxygenation depends on cerebral oxygenation: flow and MAP. Therefore a pronounced decrease in MAP during cardiac vasoplegia syndrome, might cause a decrease on cerebral oxygenation.
Speakers: Eric de Waal

The reported higher incidence of vasoplegia after pulsatile left ventricular assist device placement comes from and old publication from 1997. At that time, there were no continuous flow LVADs on the market, and thus included external or internal pulsatile LVADs. The definition of vasoplegia has an impact on the incidence. Argenziano et al used a MAP < 70 mm Hg despite Norepinpehrine administration > 8 µg/min and a CI > 2.5 l/min/m2 in the first 5 min after weaniong from cardiopulmonary bypass. It is obvious that this incidence seems quite high as a MAP of 70 mm Hg is a high cutt-off value, and the first 5 min after weaning from cardiopulmonary bypass is a quite unstable hemodynamic period due to adjusting preload, giving coagulation factors, such as protamine and blood products, and manipulation of the heart. Thus a high reported incidence on not really realistic grounds.
Speakers: Eric de Waal

Thyroid disease is an independent risk factor of vasoplegia with an Odds Ratio of 2.7 (95%CI 1.0-7.0, p = 0.04). Hypothyreoidie means high TSH levels with low T4 and free T4. It was reported that hypothyreoidie is related to endothelial dysfunction (Taddei, J Clin Endocrinol Metab 2003; 88: 3731-7) with a decrease in NO release, with a decrease in cGMP and decrease in myosin dephosphorylation, and thus more netto vasoconstriction. On the other hand, higher thyroxine levels are associated with a decreased SVR (Klein et al, Thyroid hormone and the cardiovascular system, N Engl J Med 2001; 344: 501-509). Thus hypothyreoidie finally vasoconstriction, hyperthyreoidie finally vasodilation. In the publication of Patarroyo in JHLT reporting vasoplegia in HTx patients, thyroid disease (in this publication hypothyroidism) is an independent risk factor of vasoplegia. However, as the impact seems to have a less vasodilating effect, it seems controversial. Preoperative hypothyroidisms seems to have an impact on cardiac output and tissue oxygen delivery (decreased) and probably an increase in preoperative pro-and antiinflammatory biomarkers with subsequent impact on postoperative vasoplegia. So yet not clearly to be explained.
Speakers: Eric de Waal

Yes, we gave did. To summarise, there are four areas of controversy around external compressions: a) safety, b) efficacy, c) timing and d) delivery. Resolution of these issues has been hampered by an absence of high-quality evidence and insufficient methodological detail to draw firm conclusions from published case reports. a) Safety This is the greatest concern because of the perceived risk of cannula dislodgement/anastomotic rupture and features in warnings issued by device manufacturers. It is probably reasonable to assume that this risk is greatest in the peri-operative period and there is limited evidence the risk reduces after healing from surgery. Our initiative was targeted at ambulance clinicians. LVAD recipients are generally discharged into the community around four weeks after surgery by which time one would expect wound healing to be well established. We concluded that risks of mechanical trauma to the LVAD/circulation interface as a result of chest compressions had probably been previously overestimated, particularly after the peri-operative period. b) Efficacy The most powerful resuscitative tool available is to restart an LVAD which a) was functioning well prior to stopping, b) has recently stopped. This is because the LVAD blood path is non-occlusive and there is retrograde blood flow from aorta to left ventricle during ventricular diastole if the LVAD has stopped which worsens the systemic perfusion already limited by the dysfunctional heart. It is reasonable to assume that chest compressions in a patient with an LVAD which has stopped would therefore be less effective than in a patient without an LVAD. c) Timing Sometimes chest compressions were administered prior to restarting the LVAD though it is unclear whether this conferred more benefit than attempting to restart the LVAD directly. As expected, short periods of chest compression were associated with better outcomes. d) Delivery The options are normal chest compressions (normal depth and frequency), light chest compressions or abdominal. As chest compressions in a patient with a dysfunctional LVAD are likely to be less effective (in terms of restoration of systemic perfusion) than in a patient without an LVAD, we concluded that “light” chest compressions should not be recommended in the community. However, in the peri-operative setting, the risk of cannula dislodgement/anastomotic trauma is likely to be higher. Abdominal chest compressions are unlikely to be particularly effective in patient with a dysfunctional LVAD for the reasons described in b). Moreover, there may be an elevated risk of right sided failure as a result of their implementation in an LVAD recipient. There is a report of a patient who received abdominal compressions peri-operatively during LVAD exchange for suspected pump thrombosis (Rottenberg et al. J Cardiothorac Surg 2011;6:91). Abdominal compressions were implemented due to intra-operative cardiac arrest and refractory hypotension (presumably due to partial/complete occlusion of the LVAD flow path with thrombus) prior to pump exchange and were chosen to allow ECMO to be commenced. Chest compressions were not selected because the surgeon did not want to compress the chest due to the perceived risk of cannula dislodgement/anastomotic rupture. It is unclear whether the LVAD was functioning at least partially during the episode. The patient expired post-operatively. We concluded that chest compressions should be implemented as “a last resort” if attempts to restart the LVAD have failed or as a temporising measure until definitive treatment can be implemented.
Speakers: Christopher Bowles

Thank you for this important question. Yes, I believe there is a role for an algorithm for anaesthetists based on those I presented. Whilst there are many generalisable principles which pertain to both the intra-/perioperative and the outpatient settings it is important to remember that for the anaesthetist there are important distinctions, such as the possibility of concomitant RVAD, patient under general anaesthetic, etc. Critical considerations intra-operatively are not only a robust understanding of MCS but clear demarcation of responsibilities and good communication between the team which also involves the VAD co-ordinator/nurse and perfusionist. A key focus in the period after the cession of cardiopulmonary bypass is the preservation of right ventricular function as detailed in Professor Rex's presentation. It is important for the anaesthetist to be able to differentiate between LVAD related and medical issues which can have counterintuitive effects, e.g. a medical problem such as hypovolaemia can cause an LVAD low flow alarm. Conversely, an LVAD related problem can manifest as a medical problem.
Speakers: Christopher Bowles

This is a very interesting question and certainly preparedness and aupport of high risk PCI has been recently included in algorhythms. I feel that the pendulum is shifting towards Impella use compared to ECMO.
Speakers: Nandor Marczin

The study of Muslem looked at >240 patients with predominantly Haertmate 2 and Heartware impantatyion and assessed AKI by the KDIGO criteria. AKI criteria were metin 70% of patients,of whom nearly 50 % were AKI Satge I, about 10% in Stage II and 15 % in Stage III. These had evere influence on outcomes.
Speakers: Nandor Marczin

I think there is much knowledge on thyroid disease and heart failure but less in relation to LVAD. A recent study from Chicago showed that 44% of patients scheduled for LVAd had abnormal thyroid function.Despite lack of guidelines in this area, most centres aim to achieve an euthyroid state before device therapy or transplantation.
Speakers: Nandor Marczin

I have sought some advise for this question from Dr Bowles. We know that these patients can sleep on their side so we also believe that a short term procedure in the lateral position is permissible but extreme care should be exercised for positioning the drive line and monitoring. I would probably use TEE to ensure chamber geometry is preserved and suction phenomena are prevented and continuous blood flow to the device is maintained. Monitoring flow and pulsatility is of essence. OLV must be careful to maintain PVR as hypoventilation or high PEEP, hypoxia and hypercarbia could all destabilize RV function.
Speakers: Nandor Marczin