Management of patients with a recently implanted left ventricular assist device (LVAD) necessitates a thorough understanding of the postimplant period and of common critical care issues that may arise from the operating room to critical care discharge, according to a contemporary practical guide published in the Canadian Journal of Cardiology.
The guide authors discussed their approach to provide comprehensive care to patients in the acute phase following LVAD implantation, in an effort to ensure optimal outcomes in this population that frequently presents with multiple comorbid conditions. A systematic transfer of information and care from the operating room (ie, cardiac anesthesiologist, surgeon, perfusionist) to the intensive care unit (ie, intensivist, nurses, and respiratory therapists) is critical. This transfer should occur during a period of stability.
Postoperative critical care assessment includes early awakening and extubation from mechanical ventilation within 6 to 8 hours of surgery, and ensuring a low mean airway pressure to minimize pulmonary vascular resistance. Standard indications for renal replacement should be used in the case of renal failure, which affects approximately a third of patients undergoing LVAD implantation. The use of prophylactic antimicrobial treatment varies across institutions. The routine use of dual antimicrobial or antifungal prophylaxis is not deemed necessary.
During the acute postimplant period, complications including coagulopathy, labile hemodynamics, and metabolic disturbances may occur. Perioperative hemostasis is often challenging and is achieved by meticulous surgical technique. In patients with minimal chest drainage 6 hours after surgery, it is common practice to initiate treatment with unfractionated or low-molecular-weight heparin (partial thromboplastin target time, 50-60 seconds).
End-organ perfusion should be achieved with low mean arterial pressure to permit hemostasis. Treatment with milrinone and inhaled nitric oxide, reducing volume overload, inducing tachycardia, restoring sinus rhythm, and optimizing ventilation and oxygenation are strategies that can be used to avoid right ventricular failure.
“The clinician caring for a patient post-LVAD implantation needs to be aware of basic troubleshooting,” noted the guide authors. “Although rare, the complete failure of the LVAD pump may be life threatening. If the cardiac output or blood pressure continues to be low, severely decreased, or absent, cardiopulmonary resuscitation (CPR) should be initiated. CPR in the patient with an LVAD is subject to debate as to its safety and efficacy, and we support early resternotomy for failed initial resuscitation attempts in the perioperative period. The presence of an LVAD is not a contraindication to defibrillation and CPR.”
Nepomuceno RG, Goldraich LA, De S, et al. Critical care management of the acute postimplant LVAD patient. Can J Cardiol. 2020;36(2):313-316.