Left Ventricular Assist Device #LVAD

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Ventricular assist device
Image via Wikipedia

The other day, I had the opportunity to participate in a LVAD case. In simple terms, this LVAD device is placed into patients whose heart needs extra assistance pumping blood to the body. Typically, these patients have or are failing medical therapy and are either on the heart transplant list waiting for a heart or are permanently placed on an LVAD.

A patient emergently came to the OR for an LVAD as he had several episodes of VTach overnight. His heart function was pretty minimal (EF10%, global hypokinesis with akinesis along the apex, LV dilatation, severe MR, PASP 40s-50s). Additionally, he was on an Intra-aortic Balloon Pump (IABP) to help assist his failing heart. He also had a femoral pulmonary catheter. We wheeled him from the ICU to the OR. He was on phenylephrine, dobutamine, and milrinone. The next challenge was transferring him from the ICU bed to the OR bed without disconnects (IABP, IV, etc) or sending him into VT. The lines were meticulously detangled while maintaining current cardiac infusions. Anesthetic induction would have to be cautious. Luckily, he had been NPO from the prior evening. I worked in a little bit of midazolam through his femoral venous line (while observing the femoral IABP a-line). Then gave some lidocaine and etomidate. He seemed to still be doing ok, worked in a bit of fentanyl and was able to mask him well. Upon good mask ventilation, I administered rocuronium and secured the airway with an 8.0ETT. Next organizational thought: where to go for additional venous access? He had a Left chest AICD, a Right IJ hemodialysis catheter. Therefore, I opted for a L IJ 9Fr introducer and we could float a PA cath after the case (we could use the femoral PA cath during the case). He received vancomycin and cefuroxime for antibiotic prophylaxis. The next challenge would be sternotomy as he had a previous 4 vessel CABG several years prior. Prior to skin incision, I worked in more fentanyl. After a careful sternotomy, dissection ensued. The heart and vessel grafts were pretty socked in. The surgeon was able to continue and prepare the heart and LVAD components. Aminocaproid acid was given. We went on cardiopulmonary bypass (CPB). We maintained the patient on milrinone, dobutamine, vasopressin, and nitric oxide (yes, breathing smaller tidal volumes on CPB). Additionally, we gave several packed cells on CPB and started DDAVP infusion. The real test would be coming off CPB…and catching up to all the bleeding. Initially, separating from CPB was a bit cautious. The patient needed more volume to prevent the LV from being sucked down with the LVAD. The perfusionist was able to give the patient back volume since the cannulas were still in. The oozing was still going. We continued to hang blood product (PRBC, FFP, platelets). We gave the protamine, the aortic cannula was removed. However, at times, we were still behind in volume. The surgeon cut one of the venous cannulas and hooked up the aortic cannula into the “venous” cannula to give volume back to the patient. Finally, after multiple periods of packing and waiting…the surgeons were able to cose the chest. We went through 15U PRBC, 15U FFP, 12U plt, 2 rounds of DDAVP infusion, 30g Amicar + amicar infusion, 7g calcium, some bumetanide, magnesium,etc. We took the patient to the SICU after the case. He was stable, maintaining his BP and Hct. It was a great case in transfusion therapy, cardiac physiology (pre-LVAD and post-LVAD), and OR teamwork. I can’t emphasize the OR teamwork enough: there was such great communication in the OR (nurses, scrub, anesthesia tech, surgeons, perfusionist, and anesthesiologists). This is the type of practice one dreams of… where camaraderie and work go hand-in-hand. So glad I found it!

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