Elsevier

Cardiology Clinics

Volume 36, Issue 4, November 2018, Pages 495-506
Cardiology Clinics

Perioperative Management of the Right and Left Ventricles

https://doi.org/10.1016/j.ccl.2018.06.004Get rights and content

Section snippets

Key points

  • The greatest risk of death after left ventricular assist device is within the early postoperative period, with in-hospital deaths accounting for two-thirds of all deaths in the first year.

  • Preoperative strategies to reduce mortality emphasize medical and mechanical support of the left and right ventricles to improve volume status and organ perfusion; improving nutrition, hematologic abnormalities, and renal function; and reducing infection risks.

  • Intraoperative approaches highlight anesthesia

Optimization of the left ventricle

Previously reserved for short-term support of patients in cardiogenic shock, LVADs have improved sufficiently to allow for intermediate and long-term support in patients waiting for cardiac transplant or as destination therapy in the transplant ineligible. Yet, patients in progressive cardiogenic shock have worse survival (Fig. 2) and longer lengths of stay than “less sick” inotrope dependent patients.4, 7 Accordingly, the percentage of LVAD implants in stable, inotrope dependent patients

Optimization of the right ventricle

Most patients with advanced LV dysfunction have some degree of RV dysfunction and RV failure complicates up to 40% of LVAD implants.28, 29, 30 Acute RV failure after LVAD implant is defined by the INTERMACS as documented elevations of central venous pressure (CVP) and its manifestations, such as edema, ascites, or worsening hepatic or renal dysfunction (Table 2).31 There is also increasing recognition of chronic RV failure occurring weeks to months after LVAD implantation.32 RV failure after

Nutrition

Malnutrition can increase the risk of postoperative infection and delayed wound healing and has been associated with increased mortality after cardiac surgery.43 Specially, serum albumin less than 3.3 mg/dL is associated with a 6.6-fold increase in mortality after LVAD implantation, making it a considerable risk factor.5 Screening for malnutrition in patients prior to LVAD implantation should include at least measures of serum albumin and prealbumin.33 When a malnourished patient is identified,

Intraoperative optimization

There are many technical considerations during LVAD implantation that influence surgical and long-term outcomes. Key matters include anesthesia-related issues, management of concomitant valve disease, RV failure, and weaning from cardiopulmonary bypass.

Early postoperative optimization

The primary goals of early postoperative optimization are to augment RV function, support other end-organ recovery, and quickly identify potential complications. Most patients have at least 1 adverse event in the first 60 days after LVAD implant with the most common events being bleeding and infection.60 Several strategies can be used to minimize these risks.

Invasive arterial and pulmonary artery catheter monitoring should be maintained in the early postoperative period to allow for

Summary

LVADs provide substantial improvements in survival and quality of life in select advanced heart failure patients. With improved technology, patient selection, and management strategies, the rate of LVAD implantation continues to grow. LVAD support, however, remains associated with significant morbidity and mortality with the greatest risk of death occurring during the implant hospitalization. Numerous strategies are used throughout the perioperative period minimize this risk. Medical and

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    • Impact of thoracotomy approach on right ventricular failure and length of stay in left ventricular assist device implants: an intermacs registry analysis

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      RVF remains an all too common complication after LVAD placement.11 There have been numerous risk scores developed using clinical, echocardiographic, and hemodynamic factors to predict RVF.4 However, no single factor or score has been reliable for patient selection given the complicated interplay of patient characteristics and intraoperative factors that result in RVF.

    • Outcomes based on blood pressure in patients on continuous flow left ventricular assist device support: An Interagency Registry for Mechanically Assisted Circulatory Support analysis

      2020, Journal of Heart and Lung Transplantation
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      Although this analysis is not designed to elucidate cause and effect, it is likely that hypotension is a marker of coexisting illness on device support rather than a cause of RV failure or infection. Hypotheses for the correlation between hypotension and RV and renal failure can be devised based on prior clinical studies.7,8 Low pulsatility in the vasculature of CF-LVAD patients compounded by reduced systemic vascular resistance may lead to hypoperfusion in the renal vascular beds and worsening renal function.7

    • LVAD inpatient management

      2021, Case-Based Device Therapy for Heart Failure

    Disclosure Statement: Dr B.C. Lampert is a consultant for Abbott and has received travel grants from Abiomed and Medtronic.

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