Anesthetic management for abdominal aortic surgery in a patient with a left ventricular assist device: a case report.

Koko Adachi,Masanori Yamauchi,Toshihiro Wagatsuma,Takuya Shiga,Hiroaki Toyama

doi:10.1186/s40981-015-0011-8

Koko Adachi, Masanori Yamauchi + Show 3 more

Open Access

https://doi.org/10.1186/s40981-015-0011-8

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Journal: JA clinical reports	Publication Date: Nov 30, 2015
Citations: 15	License type: cc-by

Affiliation: Tohoku University

Abstract

Left ventricular assist devices (LVAD) are a currently established destination and bridge therapy until cardiac transplantation; hence, this patient population continues to increase. Here, we present the first report of abdominal aortic cross-clamping (ACC) in a LVAD patient undergoing emergency aneurysm repair. Anticoagulation was continued pre-and intra-operatively to avoid pump thrombosis. The pumping function of the LVAD is highly dependent on both preload and afterload. In this case, abdominal ACC, which increases the afterload, did not significantly influence circulatory dynamics. However, when the abdominal ACC was released, mean atrial pressure (MAP) fell to 42 mmHg, because preload reduction due to massive bleeding (3532 g) secondary to anticoagulation and afterload reduction by abdominal ACC release combined to cause critical hypotension. Maintenance of MAP required rapid infusion and use of an alpha-adrenergic agent. Surgical and anesthesia times were 411 and 525 min, respectively. Total blood loss was 5389 g, respectively. The patient was discharged after 25 postoperative days with no major complications. ACC release, with its accompanying decrease in preload and afterload, and massive bleeding due to anticoagulation in these patients require careful management.

Highlights

The presence of implanted left ventricular assist devices (LVAD) presents a dilemma when managing other serious medical problems in this patient population [1, 2]
There are some reports of anesthetic management in patients with LVAD undergoing non-cardiac surgery [3,4,5,6,7,8], this is the first report of abdominal aortic crossclamping (ACC) performed in a patient with a LVAD, which is known to be sensitive to preload and afterload
The patient was monitored for ECG, pulse oximetry, arterial blood pressure, central venous pressure (CVP), transesophageal echocardiography (TEE), and bispectral index (BIS)

Summary

Introduction

The presence of implanted left ventricular assist devices (LVAD) presents a dilemma when managing other serious medical problems in this patient population [1, 2]. Background The presence of implanted left ventricular assist devices (LVAD) presents a dilemma when managing other serious medical problems in this patient population [1, 2]. There are some reports of anesthetic management in patients with LVAD undergoing non-cardiac surgery [3,4,5,6,7,8], this is the first report of abdominal aortic crossclamping (ACC) performed in a patient with a LVAD, which is known to be sensitive to preload and afterload. Case presentation Written informed consent was obtained from the patient for publication of this Case report. The hemodynamic management of LVAD patients during non-LVAD surgery is important because the pump function depends on both preload and afterload [9].

Results

Conclusion