Non-cardiac surgery in patients on long-term left ventricular assist device support

• Published in: The Journal of heart and lung transplantation Vol. 31; no. 7; pp. 757 - 763
• Main Authors: Morgan, Jeffrey A., MD, Paone, Gaetano, MD, Nemeh, Hassan W., MD, Henry, Scott E., MD, Gerlach, Brent, BA, Williams, Celeste T., MD, Lanfear, David E., MD, Tita, Cristina, MD, Brewer, Robert J., MD
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.07.2012; Elsevier
• Subjects: Adult; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; anti-coagulation; Anticoagulants - adverse effects; Biological and medical sciences; Cardiology. Vascular system; continuous flow; Dose-Response Relationship, Drug; Elective Surgical Procedures - adverse effects; Emergency and intensive cardiocirculatory care. Cardiogenic shock. Coronary intensive care; Emergency Medical Services; Female; Heart Failure - mortality; Heart Failure - therapy; Heart-Assist Devices; Hemorrhage - epidemiology; Hemorrhage - etiology; Humans; Incidence; Intensive care medicine; Kaplan-Meier Estimate; left ventricular assist device; Male; Medical sciences; Middle Aged; non-cardiac surgery; Patient Safety; Retrospective Studies; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Treatment Outcome; word; continuous flow; non-cardiac surgery; left ventricular assist device; anti-coagulation; word; Artificial heart; Intensive cardiocirculatory care; Support; Artificial ventricle; Cardiocirculatory support; Auxiliary ventricule; Cardiovascular disease; Circulatory system; Cardiac surgery; Cardiology; Long term; Phlebology
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2012.02.023

Background An increasing number of patients on left ventricular assist device (LVAD) support are requiring non-cardiac surgical (NCS) procedures. We reviewed our experience with the management of patients on continuous flow (CF) LVAD support undergoing NCS. Methods From March 2006 through March 2011, 86 patients with chronic heart failure underwent implantation of a HeartMate II (Thoratec Corp, Pleasanton, CA) LVAD. Clinical records of these patients were reviewed to identify patients who underwent NCS while on LVAD support, with a focus on peri-operative death, bleeding, thrombosis, and device malfunction, as well as management of pre-operative anti-coagulation. Results While on CF-LVAD support, 20 patients underwent 25 NCSs, comprising 13 major and 12 minor procedures. Operations were performed electively in 22 and as emergencies in 3. No peri-operative deaths, thromboembolic complications, or device malfunctions occurred. The incidence of bleeding requiring transfusion of packed red blood cells was 36.0%, including 25% of patients undergoing minor NCSs and 46.2% undergoing major NCSs ( p = 0.004). All bleeding complications occurred in patients on both warfarin and aspirin pre-operatively. The only significant differences between patients who did and did not require transfusion were pre-operative warfarin use and significantly higher pre-operative international normalized ratio in the transfused group (1.9 ± 0.4 vs 1.4 ± 0.3; p = 0.008). Conclusions Non-cardiac operations can be performed safely in patients with CF-LVADs. It may possible to reduce peri-operative bleeding by lowering pre-operative anti-coagulation goals, especially before major surgery. However, additional analysis is required to determine if this can be performed safely.