Perioperative Management of Two Patients with Left Ventricular Assist Devices Presenting for Noncardiac Surgery in the Prone Position M. Megan Chacon, MD, Emily A. Hattrup, MD, and Sasha K. Shillcutt, MD, FASE Ventricular assist devices (VADs) provide mechanical circulatory support for patients with advanced heart failure. Patients with VADs are presenting for noncardiac surgery with increasing frequency. Understanding anesthetic management of patients with VADs is timely and necessary for perioperative physicians. We present 2 patients supported by left VADs who required intraoperative prone positioning, and how transesophageal echocardiography and VAD variables can be used to guide management. (A&A Case Reports. 2014;2:70–3.)
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entricular assist devices (VADs) are being used with greater frequency as mechanical circulatory support for patients with advanced heart failure. Patients may survive for years because the devices act as a bridge to transplantation or as long-term permananent support. As a result, patients with VADs are presenting for noncardiac surgery with increasing frequency. Understanding anesthetic management of patients with VADs is necessary for perioperative physicians. We present 2 patients, both with VADs, who required prone intraoperative positioning. Transesophageal echocardiography (TEE) was used to guide management during 1 case. For publication of this report, verbal consent was obtained from patient 1 and written consent was obtained from patient 2.
CASE DESCRIPTION Case 1
A 57-year-old man was found to have vertebral body collapse of C5 through C7 vertebrae secondary to infection. He had a HeartMate II Left Ventricular Assist Device (Thoratec Corporation, Pleasanton, CA) for the treatment of acute ischemic cardiomyopathy as a bridge to transplantation for the previous 8 months. The patient was placed in a cervical collar and admitted before proposed anterior cervical corpectomy of levels C5 through C7 with posterior fusion of levels C4 through T1. The patient was brought to the operating room, and a left radial arterial catheter was inserted. General anesthesia was induced with IV etomidate (10 mg), fentanyl (150 mcg), and succinylcholine (100 mg). Manual neck stabilization was applied during tracheal intubation using video From the Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska. Accepted for publication September 24, 2013 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.anesthesia-analgesia.org).
laryngoscopy, and central venous access was obtained under ultrasound guidance. TEE was used to monitor right ventricular function, monitor pulmonary pressures, and guide right and left ventricular filling. During the anterior corpectomy and while the patient was supine, interrogation of the left VAD revealed a fixed speed of 9400 rotations per minute, flow ranging from 5.5 to 5.7 L/min, and pulsatility index (PI) ranging from 3.3 to 4.4. His mean arterial blood pressure (MAP) ranged from 65 to 80 mm·Hg. Baseline TEE examination revealed severe left ventricular global hypokinesis, ejection fraction
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entricular assist devices (VADs) are being used with greater frequency as mechanical circulatory support for patients with advanced heart failure. Patients may survive for years because the devices act as a bridge to transplantation or as long-term permananent support. As a result, patients with VADs are presenting for noncardiac surgery with increasing frequency. Understanding anesthetic management of patients with VADs is necessary for perioperative physicians. We present 2 patients, both with VADs, who required prone intraoperative positioning. Transesophageal echocardiography (TEE) was used to guide management during 1 case. For publication of this report, verbal consent was obtained from patient 1 and written consent was obtained from patient 2.
CASE DESCRIPTION Case 1
A 57-year-old man was found to have vertebral body collapse of C5 through C7 vertebrae secondary to infection. He had a HeartMate II Left Ventricular Assist Device (Thoratec Corporation, Pleasanton, CA) for the treatment of acute ischemic cardiomyopathy as a bridge to transplantation for the previous 8 months. The patient was placed in a cervical collar and admitted before proposed anterior cervical corpectomy of levels C5 through C7 with posterior fusion of levels C4 through T1. The patient was brought to the operating room, and a left radial arterial catheter was inserted. General anesthesia was induced with IV etomidate (10 mg), fentanyl (150 mcg), and succinylcholine (100 mg). Manual neck stabilization was applied during tracheal intubation using video From the Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska. Accepted for publication September 24, 2013 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.anesthesia-analgesia.org).
laryngoscopy, and central venous access was obtained under ultrasound guidance. TEE was used to monitor right ventricular function, monitor pulmonary pressures, and guide right and left ventricular filling. During the anterior corpectomy and while the patient was supine, interrogation of the left VAD revealed a fixed speed of 9400 rotations per minute, flow ranging from 5.5 to 5.7 L/min, and pulsatility index (PI) ranging from 3.3 to 4.4. His mean arterial blood pressure (MAP) ranged from 65 to 80 mm·Hg. Baseline TEE examination revealed severe left ventricular global hypokinesis, ejection fraction
