1. Ventricular Assist Devices Peri-operative Care Approach to Emergencies Priya Nair Intensive Care Unit

2. Immediate Pre-operative considerations 3. Haemodynamic optimisation Comprehensive assessment of RV function Pulmonary artery catheter CVP65 mm Hg, Midline interventricular septum position Intermittent aortic valve opening No more than mild MR 20. Chumnanvej S et al, Echocardiography for VAD implantation Anesth Analg 2007;105:583-601 21. Right-sided circulation High capacitance Low pressure Short isovolumic contraction time Near-continuous systolic ejection period Less tolerant to afterload changes 22. Response to RV & LV to experimental changes in afterload MacNee et al, AJRCCM 1994 23. Lower sarcomere Ca++ concentrations with reduced maximal shortening Less Ca++ sensitivity during inotropic stimulation Compromises rapidly leading to hepatic dysfunction & coagulopathy Increases peri-op mortality from 10-15% to 38-43% 24. Peri-op- TX-A2, TNF-, Interleukin & catechol release during CPB, blood products, inadequate cardioprotection, vasoconstrictors can trigger RVF LVAD adds to this shifts inter-ventricular septum to left, distorts TV lead to TR improved CO & sudden increase in venous return 25. Management of RV dysfunction Meticulous haemostasis/ avoid blood products Avoid excess RV preload, diuretics Decrease RV afterload- iNO, Iloprost Inotropes- Adrenaline, Milrinone, Dobutamine Vasoconstrictors- to maintain perfusion pressure Pacing Decrease pump speed Consider RCA bypass &/or TV annuloplasty V-PA ECMO 26. Immediate post-op ICU care 27. Fluids/inotropes Suction events RV dysfunction Bleeding & anticoagulation Tamponade 28. Suction eventMauermann W J et al. Anesth Analg 2008;107:791-792 29. Cyclical LVAD suctionSpeed (RPM)Flow (L/min)6 5 4 3Positive pressure ventilation2PEEP 18cmH2O2800 2700 2600 7585Time (seconds)95 30. Fischer L et al Management of pulmonary hypertension Anesth Analg 2003;96:160316Day/Month/YearFootnote to go herePage 39 31. Pericardial collection 32. V-PA ECMO 33. Weaning from V-PA ECMO 34. Take home messages Pre-op haemodynamic optimisation Meticulous care of the RV Avoid over-pumping Serial echocardiography is vital Cautious anticoagulation VADs are preload dependent & afterload sensitive Mortality and persistent heart failure determined by inefficient unloading of left side and persistent RV dysfunction 35. At discharge Comprehensive education of patient & NOK Easy contact with VAD coordinator & hospital team Spare controller & battery packs Strict BP control 36. Emergency Department presentations EMS guide January 2012, Mechanical Circulatory Support Organisation www.jems.com emcrit.org/wee/left-ventricular-assist-devices-lvads heartware.org mylvad.com 37. Call VAD centre 38. Check with NOK 39. Bleeding Anticoagulation-related Abnormal von Willebrand factor Infection Driveline Pump pocket 40. VAD emergencies Patient in Extremis 41. 1) AUSCULTATE FOR PUMP HUM 42. NO HUM Check cables and connections Check batteries 43. 2) CHECK MAP, ASSESS PERFUSION 44. 3) JUDICIOUS FLUID CHALLENGE Check pump flows and response. 65mmHg- Dobutamine/Milrinone Early arterial line with ultrasound guidance Care with CVC if RVAD in place 45. 4)MONITOR +/- DEFIBRILLATE Check electrolytes, correct potassium Avoid chest compressions 46. 5) URGENT ECHO RV small- hypovolaemia, bleeding, sepsis RV bigger than LV, D-shaped septum, TR- RV dysfunction Large LV (+MR) High power- pump thrombosis (haemolysis, altered hum) Low power- inflow or outflow obstruction Ischaemic events Aortic Incompetence 47. AT ALL TIMES, BE GENTLE WITH THE RV 48. Pump flows & MAP OKLikely neurologic event 49. In short Call VAD centre Check connections & cables Auscultate for pump hum/doppler pulse Check doppler BP, perfusion Judicious fluid challenge, inotropes/pressors Echo if possible Consider non-VAD causes for presentation 50. Questions?