Free Online Webinar organized by the EACTA Educational Committee in collaboration with the VAD Committee
Take home message
We designed this webinar to update perioperative challenges of cardiac mechanical circulatory support both in terms of the implantation period and when these patients present for noncardiac surgery. In addition, we wanted to bring an update on the development of resuscitation guidelines for these high-risk patients.
The amazing progress of this field was compared to natural landscapes. Changing lives of patients suffering from end stage heart failure with the prospect of certain death to nearly ninety percent one-year survival was compared to sunset and sunrise, to winter and spring. We marvelled on the technological achievements with devices able to pump nearly 100000 hours with only limited effects on blood elements. Like our natural inner longing for beautiful outdoors and natural landscapes seeking the “geography of hope” and fullness of life, patients needing LVAD insertion also long for quality of life. But this is only achieved around 80% with others suffering from adverse events and poor quality of life. In selected patients we have achieved the ultimate success of LVAD therapy leading to full recovery and living once again without LVAD and without heart failure. The perioperative period is high risk and despite major breakthroughs in surgical techniques and anaesthesia management, organ failure and multiple organ failure is prevalent and dramatically influence morbidity and survival.
One of the main issues relates to preservation of right ventricle function, which remains the Achilles heel of the entire process. The RV is prone to fail, affected by many interrelated and antiquate physiological and molecular events before during and after LVAD implantation. As the response of the RV to the LVAD flow is difficult to predict, emphasis must be on vigilant monitoring of every physiological parameters and dynamics of RV function and utilise fully our general measure, specific RV optimising pharmacology and RV mechanical support, a true precision medicine approach for clinical anaesthesia.
One crucial event is the perioperative development of vasoplegia. While basic mechanisms are unknown, it is likely party of an inflammatory response and changes in the body’s endogenous mechanisms to maintain vascular tone. Most classical vasoplegia definitions cannot be applied to the LVAD operation but unifying definitions reveal one third of patients being affected. These have major impact on outcomes. Prediction is poor highlighting the importance of intraoperative events and our repertoire to effective treat the condition remains limited.
With the increasing population of patient equipped with an LVAD, there is an increase of these patients needing non cardiac and sometimes emergency surgery. As a consequence, non-cardiac anaesthetists should be familiar with the devices and implications to physiology and clinical management. In the current era, continuous flow devices are the most common that impacts on clinical monitoring including blood pressure and saturation. Teams should have alternative means for monitoring and be prepared for rapid and severe haemodynamic changes during these surgeries. A multidisciplinary collaborative approach with ever presence of a VAD team ensures the best outcome for these patients.
The public and no specialist hospital staff should be prepared to encounter LVAD patients with device malfunction. There are multiple considerations especially publicly recognised vital signs such as detecting pulse or applying chest compressions could be difficult. New algorithms have been developed to cover most scenarios with clear instructions for rapid initial assessment in the prehospital emergency setting. The message is not to waste time for trying to assess pulse but to make all attempts to restart the LVAD. The priority is to sustain life and on balance, administration of CPR with chest compression is acceptable until further resuscitative manoeuvres become available. Training ambulance crews, ER personnel and hospital staff are underway.
In summary, we have visited many landscapes. We have achieved a lot, but we need to do more. We have reached the end of the pioneering period; we now need new breakthroughs towards excellence and to fulfil the landscape of hope.
We need to learn more about our different approaches to perioperative management, come to consensus on best practices and promote these in the wider professional communities.
The EACTA Transplant and VAD Subcommittee has been a driving force in this direction and currently conducts the worldwide PURSUDE Survey and organising a consensus statement on anaesthesia and intensive care management of LVAD insertion. This should be a welcoming platform for all European perioperative teams to join and contribute actively. We also invite colleagues in other parts of the world and other associations to make closer links and collaborations with us.
The perioperative landscape of mechanical support remains inspiring and beautiful.
The faculty of the EACTA LVAD Webinar, November 9th, 2020.
What’s in it for me?
After this webinar, you will better understand:
- The perioperative challenges for patients with mechanical circulatory support.
- The perioperative care of patients with right ventricular failure.
- The perioperative complications in patients who undergo VAD insertion.
- The strategy for perioperative management of patients with VAD who undergo noncardiac surgery.
- Resuscitation of patients with VAD.
Cardiac and vascular surgeons, cardiovascular anaesthetists, perfusionists, intensivists, general anaesthetists, anaesthesia certified nurses, nurses, interns, and medical students
Head of the Scientific Committee: Mohamed R. El Tahan, EACTA Education Chair
The Ventricular Assisst Devices, Rome (live streaming), Italy, 09/11/2020-09/11/2020 has been accredited by the European Accreditation Council for Continuing Medical Education (EACCME®) with2 European CME credits (ECMEC®s).