Use of Rapid Ventricular Pacing for Facilitating Left Ventricular Assist Device Implantation

Abstract

We read with great interest the article by Fassl and Augoustides1Fassl J. Augoustides J.G.T. Transcatheter aortic valve implantation-part 2: Anesthesia management.J Cardiothorac Vasc Anesth. 2010; 24: 691-699Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar regarding the use of rapid ventricular pacing (RVP) in transcatheter aortic valve implantation (AVI). Herein, we present the use of RVP for facilitating left ventricular assist device (LVAD) implantation as an extension of the technique from cardiology and cardiac surgical situations. A 65-year-old man with end-stage heart failure (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS] level 3) because of ischemic cardiomyopathy ineligible for heart transplantation was considered for destination therapy. A Jarvik 2000 LVAD was selected for mechanical circulatory support. The standard technique through median sternotomy was applied using a minimal extracorporeal circulation system for circulatory support.1Fassl J. Augoustides J.G.T. Transcatheter aortic valve implantation-part 2: Anesthesia management.J Cardiothorac Vasc Anesth. 2010; 24: 691-699Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Temporary epicardial pacing wires were placed into the right ventricle. During coring of the left ventricular apex and device insertion, RVP at a rate of 190 beats/min was used in order to minimize the heart movement and facilitate the surgical maneuvers. No changes in mean arterial pressure and cerebral oximetry monitoring with near-infrared spectroscopy were recorded (Fig 1). Moreover, there was minimal blood loss during the insertion because of the absence of contraction of the heart muscle. The standard surgical technique for the implantation of the Jarvik 2000 involves the use of cardiopulmonary bypass support and ventricular fibrillation during coring of the apical ventricular muscle and device insertion.2Siegenthaler M.P. Martin J. Frazier O.H. et al.Implantation of the permanent Jarvik-2000 left-ventricular-assist-device: Surgical technique.Eur J Cardiothorac Surg. 2002; 21: 546-548Crossref PubMed Scopus (19) Google Scholar Cardioversion is mandatory, followed by inotropic support in most instances. Off-pump implantation provides an attractive alternative technique.3Anyanwu A.C. Fischer G.W. Plotkina I. et al.Off-pump implant of the Jarvik 2000 ventricular assist device through median sternotomy.Ann Thorac Surg. 2007; 84: 1405-1407Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar The main drawback of this approach is hemodynamic instability caused during manipulation of the heart in critically ill patients and significant blood loss during the insertion of devices like the Jarvik 2000. RVP at a rate of 180 to 200 beats/min is used routinely in electrophysiology studies to evaluate and terminate ventricular tachyarrhythmias. The loss of atrioventricular synchrony and the reduction of ventricular filling time result in decreased left ventricular preload, stroke volume, and cardiac output. It also has been implemented during the deployment of aortic endografts by creating controlled hypotension.4Pornratanarangsi S. Webster M.W. Alison P. et al.Rapid ventricular pacing to lower blood pressure during endograft deployment in the thoracic aorta.Ann Thorac Surg. 2006; 81: e21-e23Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The same technique applies in transcatheter procedures such as AVI,1Fassl J. Augoustides J.G.T. Transcatheter aortic valve implantation-part 2: Anesthesia management.J Cardiothorac Vasc Anesth. 2010; 24: 691-699Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar the correction of congenital aortic stenosis, and aortic coarctation.5Mehta C. Desai T. Shebani S. et al.Rapid ventricular pacing for catheter interventions in congenital aortic stenosis and coarctation: Effectiveness, safety, and rate titration for optimal results.J Interv Cardiol. 2010; 23: 7-13Crossref PubMed Scopus (20) Google Scholar We previously have shown that this technique does not affect cerebral oxygenation because it is associated with a minimal decline in regional cerebral oxygen saturation.6Argiriadou H. Anastasiadis K. Karapanagiotidis G. et al.Subclinical decline in cerebral oxymetry saturation during rapid pacing in transfemoral aortic valve replacement.Ann Thorac Surg. 2010; 90: 1023Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Moreover, the heart recovers immediately after ceasing the RVP without the need for cardioversion or pharmaceutic assistance. Serious complications associated with temporary rapid cardiac pacing are rare.7Murphy J.J. Current practice: Complications of temporary transvenous cardiac pacing.Br Med J. 1996; 312: 1134Crossref PubMed Scopus (78) Google Scholar Even though there is always the risk of entraining a ventricular tachyarrhythmia, overdrive pacing or cardioversion may restore normal heart rate. In conclusion, temporary RVP is a safe, simple, and effective method that facilitates proper implantation of a left ventricular assist device. Transcatheter Aortic Valve Implantation—Part 2: Anesthesia ManagementJournal of Cardiothoracic and Vascular AnesthesiaVol. 24Issue 4PreviewTRANSCATHETER AORTIC VALVE implantation (TC-AVI) techniques are new therapeutic options to treat patients suffering from severe aortic valve stenosis.1 These techniques are likely to displace conventional aortic valve replacement even further in the future. The breakthrough development of these aortic valve prostheses was recently achieved and has fundamentally changed the approach to aortic valve replacement in the cardiac operative environment. These procedures require a team approach among the cardiac surgeon, the cardiologist, and the cardiac anesthesiologist. Full-Text PDF