Anesthetic management for withdrawal from a right ventricular assist device and Fontan procedure in a patient with an implantable left ventricular assist device for fulminant cardiomyopathy

BACKGROUND

We herein report the anesthetic management for extracardiac conduit-total cavopulmonary connection (EC-TCPC) for weaning from an extracorporeal right ventricular assist device (RVAD) in a patient with an implantable left ventricular assist device (LVAD) for fulminant cardiomyopathy.

CASE PRESENTATION

A 24-year-old man developed fulminant cardiomyopathy and was placed on a biventricular assist device (BiVAD) comprising an implantable LVAD and an extracorporeal RVAD. The Fontan procedure was performed to wean the patient from the RVAD and allow him to be discharged home. Atrial septal defect creation, right ventricular suture, and tricuspid valve closure were then simultaneously performed to ensure sufficient left ventricular preload to drive the LVAD. Furthermore, to keep the central venous pressure lower, the inflow cannula of the LVAD was oriented in the correct direction.

CONCLUSION

This is the first report of anesthetic management of the Fontan procedure in a patient with a BiVAD.

Relapsing low-flow alarms due to suboptimal alignment of the left ventricular assist device inflow cannula

OBJECTIVES

This retrospective study investigated the correlation between the angular position of the left ventricular assist device (LVAD) inflow cannula and relapsing low-flow alarms.

METHODS

Medical charts were reviewed of all patients with HeartMate 3 LVAD support for relapsing low-flow alarms. A standardized protocol was created to measure the angular position with a contrast-enhanced computed tomography scan. Statistics were done using a gamma frailty model with a constant rate function.

RESULTS

For this analysis, 48 LVAD-supported patients were included. The majority of the patients were male (79%) with a median age of 57 years and a median follow-up of 30 months (interquartile range: 19-41). Low-flow alarm(s) were experienced in 30 (63%) patients. Angulation towards the septal-lateral plane showed a significant increase in low-flow alarms over time with a constant rate function of 0.031 increase in low-flow alarms per month of follow-up per increasing degree of angulation (P = 0.048). When dividing this group using an optimal cut-off point, a significant increase in low-flow alarms was observed when the septal-lateral angulation was 28° or more (P = 0.001). Anterior-posterior and maximal inflow cannula angulation did not show a significant difference.

CONCLUSIONS

This study showed an increasing number of low-flow alarms when the degrees of LVAD inflow cannula expand towards the septal-lateral plane. This emphasizes the importance of the LVAD inflow cannula angular position to prevent relapsing low-flow alarms with the risk of diminished quality of life and morbidity.

A 3D printed exoskeleton facilitates HeartMate III inflow cannula position

The optimal placement of the inflow cannula is critical for adequate ventricular unloading and device function in left ventricular assist device implantation. The anatomy of the left ventricle varies widely between patients yielding unpredictable surgical results depending on cannula position. We therefore aimed at devising a novel approach for optimal placement of the cannula in the clinical setting using computer-aided three-dimensional (3D) reconstruction and 3D printed guiding exoskeleton. This novel cannula positioning technique provides a personalized left ventricular assist device implantation considering the anatomical aspects of the implantation before the surgery. Local Ethical Board number 202/2005.