Anesthetic management of a patient with left ventricular assist device undergoing robotic laparoscopic prostatectomy: a case report

Primary neuraxial anesthetic for elective total knee arthroplasty in patient with left ventricular assist device

BACKGROUND

There is a rising number of patients with left ventricular assist devices (LVADs) undergoing non-cardiac procedures, both emergent and elective. Historically, anesthetic options for these patients have been limited to general anesthesia. Limited data exists for the use of neuraxial anesthesia in patients with LVADs despite its common use in orthopedic procedures for non-LVAD patients. Given the benefits of neuraxial anesthesia and the rising population of LVAD patients undergoing elective procedures, a better understanding of LVAD patients' candidacy for neuraxial anesthesia needs further investigation.

CASE PRESENTATION

We report the case of a patient with an LVAD who successfully underwent a total knee arthroplasty with neuraxial anesthesia at a tertiary academic center. Preoperative transthoracic echo demonstrated stable cardiac function and an ejection fraction of 10-15% with a HeartMate 3 LVAD. The primary anesthetic was a lumbar epidural that was slowly titrated to a surgical anesthetic level and an adductor canal peripheral nerve catheter was placed preoperatively for postoperative analgesia. The patient remained hemodynamically stable throughout the case, with a perfusionist monitoring the LVAD's function intraoperatively, and tolerated the anesthetic well. His postoperative course was uneventful.

CONCLUSION

Patients with LVADs should be considered candidates for neuraxial anesthesia with appropriate preoperative planning and perioperative management.

Combined General and Regional Anesthesia for a Patient With Duchenne Muscle Dystrophy With an Implanted Left Ventricular Assisted Device Undergoing Orthopedic Surgery

Duchenne muscular dystrophy (DMD) is an X-linked inherited dystrophinopathy, with an incidence of 1 in 3,600 - 5,000 male live-born infants. The leading cause of death is often cardiomyopathy-related heart failure. Given the progressive nature of the disorder with involvement of skeletal muscle, respiratory and cardiac function, perioperative care remains challenging with an increased incidence of perioperative morbidity and mortality. Perioperative care can be challenging due to life-threatening perioperative adverse events related to associated end-organ effects, as well as sensitivity to various anesthetic agents, rhabdomyolysis, hyperkalemia, hyperthermia, and cardiac arrest. We present a 22-year-old DMD patient with left ventricular assisted device (LVAD), who presented for repair of both left distal femur and tibial diaphysis fractures. Anesthetic care included the unique combination of total intravenous anesthesia with dexmedetomidine and remimazolam combined with regional anesthesia including a supra-inguinal fascia iliaca block, saphenous nerve block, and popliteal nerve block. The basics of dystrophinopathies are presented, perioperative concerns discussed, and previous reports of the use of regional anesthesia as an adjunct to general anesthesia in adult and pediatric patients with DMD are reviewed.

Quality Improvement in Anesthetic Management of Patients with Left Ventricular Assist Device Support Presenting for Non-Cardiac Surgery: A Single Center Experience

With the growing number of left ventricular assist device (LVAD) recipients requiring non-cardiac surgery and the limited availability of cardiac anesthesiologists, our study reviewed non-cardiac surgeries in HeartMate III patients with LVAD at our institution. We focused on anesthesiologist roles, detailing patient characteristics, anesthetic management, and outcomes and identifying improvement opportunities in this specialized care setting. A retrospective chart review was conducted of all patients with LVAD who underwent non-cardiac surgery at our institution between 2017 and 2022. Patient demographics, surgical characteristics, anesthetic management, and 30-day mortality rates were also assessed. A total of 23 patients were identified, with 17 (73.9%) males and a median age of 61 [53.5, 67.5] years. Cardiac anesthesiologists were present in nine (39.1%) cases. Elective surgeries were more common (73.9%), with intermediate-risk surgeries accounting for 52.2% of all surgeries. General anesthesia was administered to 18 patients (78.3%), with a median duration of 40 [24, 63.5] min. A single patient required reoperation because of bleeding, and two patients (8.7%) experienced 30-day mortality. Despite guidelines lacking detail, involving non-cardiac anesthesiologists in certain cases is essential. Sharing our experience aims to enhance the evolving discourse on non-cardiac surgeries for patients with LVAD, improving their outcomes and safety.