Ventricular Assist Device Insertion

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What the Anesthesiologist Should Know before the Operative Procedure

Mechanical support of circulation has evolved rapidly since the development of the first artificial heart. Especially in the last decade, the evidence of favorable outcomes in heart failure patients has grown. The impressive reduction in mortality in end stage heart failure has largely fueled the increase in the use of ventricular assist devices (VADs), despite their relatively high cost.

The improvement in survival has occurred in parallel with significant advances in VAD technology, leading to a widening spectrum of indications and a broader choice of available devices. While a majority of VADs are designed for supporting the left ventricle (LV), specific devices can also be used to temporarily support the failing right ventricle (RV). Knowledge of VADs, their indications, specifications, and physiology are essential for anesthesiologists, since patients not only present for VAD insertion, but patients with working VADs also present for non-cardiac surgery, which itself is a reflection of improved survival.

Patients with advanced heart failure symptoms (NYHA Class III or IV) may present in a variety of ways as candidates for mechanical support. The Interagency Registry of Mechanically Assisted Circulatory Support (INTERMACS), an NIH-sponsored registry, has developed patient profiles for those that present with heart failure resistant to optimal medical therapy. See Table I.

Table I.

INTERMACS patient profiles
Profile Description Timeframe for VAD
1. Critical cardiogenic shock Life-threatening hypotension on escalating inotropic support Immediate, within hours
2. Progressive decline on inotropes Worsening end-organ function or inotrope intolerant Intervention required within a few days
3. Stable, but inotrope dependent Stable organ function but show failure to wean from inotropes Elective intervention over weeks or few months
4. Resting symptoms at home on oral therapy Show congestion at rest with normalized volume status Elective intervention over weeks or few months
5. Exertion intolerant Stable at rest but with severely reduced capacity for activities of daily living (ADL) Variable. Depends on maintenance of organ function, nutrition and activity
6. Exertion limited Stable at rest and with ADL, but unable to engage in more meaningful activity Variable. Depends on maintenance of organ function, nutrition and activity
7. Advanced NYHA Class III symptoms Stable but show recurrent episodes of unstable fluid balance Intervention not currently indicated

Therefore, patients presenting for VAD insertion are likely to have advanced heart failure of various etiology. Other issues relate to management and etiology of heart failure.

These patients therefore need a comprehensive preoperative work-up, which may not always be feasible. "Redo" sternotomies must prompt the anesthesiologist to be prepared to transfuse blood and blood products. Rhythm devices may need their shock functions to be disabled, which means that knowledge of the device type is mandatory.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

VADs are generally inserted in advanced heart failure patients, which implies an elevated sense of urgency. Certain cases that fit the INTERMACS profile 1 are always emergent and need to be performed within a few hours as a 'rescue' procedure. Other profiles offer some lead time in preparation and preoperative optimization. The need for additional information should be balanced against the time it would take to obtain this information with respect to the patient's worsening condition. In more elective situations, it is important to optimize organ function and reduce any risks such as systemic infection and coagulopathy.

  1. Emergent- Emergent VAD insertions are usually reserved for INTERMACS profile 1 cases. These patients are gravely ill, on multiple pressors, and may have had recent cardiac surgery. They are also referred to as the 'crash and burn' cases. Issues relevant to these cases include: (a) coagulopathy from ongoing antiplatelet agents or heparin use or multiple transfusions; (b) ongoing inotrope use with multiple pressors; (c) rhythm instability with epicardial or transvenous pacing; and (d) pulmonary issues with ongoing ventilatory support.

  2. Urgent- Urgent cases will likely be the INTERMACS profiles 2 and 3 patients. These cases typically offer a little more time for preoperative preparation. They may be on preoperative inotropes such as milrinone, dopamine and dobutamine. Patients may also be receiving intra-aortic balloon counterpulsation therapy and have several concurrent comorbidities that will have to be considered. Anticoagulant therapy is another therapy these patients frequently receive that can adversely impact intraoperative and postoperative management. Ongoing end-organ malperfusion from low cardiac output is also important to consider, especially relating to renal function. Patients with elevated preoperative creatinine are at risk of postoperative acute kidney injury (AKI). However, the enhanced perfusion after VAD implantation can be beneficial in mitigating this risk.

  3. Elective- Elective cases offer the best options for preoperative preparation and effective risk reduction. These patients may even be at home or stable inpatients under optimal medical therapy that is insufficient for a long-term solution.

2. Preoperative evaluation

Preoperative evaluation should include the careful consideration of several major cardiovascular and pulmonary conditions, including ischemic heart disease, valvular heart disease, pulmonary hypertension, renal disease, and pulmonary disease.

Patients presenting for VAD insertion in any of the INTERMACS profiles frequently have severe ischemic heart disease that has significantly advanced to a stage where native cardiac function is inadequate to meet circulatory demands. Patients may have coexisting coronary artery disease (CAD) with ongoing ischemia, which represents the severest form of the disease, or they may have stable CAD with a history of percutaneous or surgical revascularization. Recent percutaneous interventions will usually involve some type of robust antiplatelet therapy. Surgical revascularization implies a previous sternotomy that predicts technical challenges for the surgical team.

VAD patients frequently have significant coexisting valve disease. The most common is mitral regurgitation (MR). This MR could be a result of coexisting ischemic heart disease or exist independently as part of a chronically diseased valve from a degenerative or rheumatic process. While functional MR may not present a problem for VAD insertion, any mitral stenosis that results from rheumatic heart disease is an extremely important hemodynamic lesion. Mitral stenosis, by definition, restricts inflow through the mitral valve into the LVAD and needs to be addressed surgically in order to allow adequate LVAD filling. Other lesions that may impact intraoperative management include aortic regurgitation (AR) and tricuspid regurgitation (TR). While significant AR may make forward VAD flow ineffective, significant TR affects the ability of the RV to effectively fill the LVAD. Similar to the implications for AR on LVADs, pulmonary valve regurgitation could adversely impact forward flow for LVADs.

Chronic elevation of pulmonary artery pressures can result from advanced heart failure. A preoperative cardiac catheterization will frequently reveal the status of the pulmonary vasculature. Adequate precautions will need to be taken in the operating room to ensure that the RV is protected and flows to the left heart are not compromised.

Patients with chronically or acutely reduced cardiac output will often have evidence of compromised renal function. This can be assessed by measuring the serum creatinine (SC) and blood urea nitrogen (BUN) levels (a BUN:SC ratio of greater than 20 suggests pre-renal azotemia). Other issues related to chronic kidney disease (CKD) or AKI include their systemic consequences such as infection, coagulopathy, and neuropathy.

Advanced heart failure patients frequently exhibit coexisting chronic obstructive pulmonary disease (COPD). This could have implications for perioperative ventilator management and right heart function.

Medically unstable conditions warranting further evaluation include neurological impairment and hepatic impairment. Any impairment in the ability to function independently should be carefully evaluated, even if the indication is emergent or urgent. Appropriate mentation is imperative for the patient to care for the VAD and its components. Awareness of its functioning and basic troubleshooting is key to survival.

Concurrent hepatic impairment may be concealed by ongoing cardiovascular compromise. However, significant hepatic failure may require reassessment of the likelihood of success of VAD therapy. Chronic hepatic congestion from RV failure can also contribute to hepatic compromise, while shock liver can result from acute decompensated heart failure.

Delaying surgery may be indicated if there is evidence of ongoing systemic infection that would result in graft infection. Positive blood cultures, ongoing fever, progressively increasing white cell count, and endocarditis will all have a negative impact on the decision to implant a VAD.

3. What are the implications of co-existing disease on perioperative care?

Coexisting diseases can have a profound impact on perioperative care. These principally relate to diseases that affect the cardiovascular system. However, comorbid conditions of the neurologic, pulmonary and renal systems are also important to consider.

b. Cardiovascular system

INTERMACS profile 1 patients exhibit unstable hemodynamics. These patients are usually on multiple inotropes. They may also have concurrent intra-aortic balloon pump (IABP) support, as well as mechanical ventilatory support. They may have had recent cardiac surgery and have ongoing coagulopathy, as well, that can impact perioperative management.

For patients with baseline CAD or cardiac dysfunction, the goals of management include the maintenance of adequate circulatory support and forward flow while awaiting the institution of cardiopulmonary bypass (CPB). Avoidance of tachycardia and hypotension with the judicious use of inotropes is indicated. Patients with rhythm management devices may require them to be interrogated by the electrophysiology team to ensure appropriate function perioperatively. Patients have usually been investigated and treated for CAD and found to be refractory to medical therapy.

c. Pulmonary

Pulmonary issues, such as COPD, can complicate management since they impact the goal of oxygen delivery to the tissues. Significant COPD may imply sophisticated ventilator management strategies to ensure adequate oxygen delivery.

Reactive airway disease, such as asthma, may not be a significant problem compared to other comorbidities. However, chronic reactive airway disease may have effects on right ventricular performance that can subsequently impair LVAD function.

d. Renal-GI:

Renal dysfunction is frequently encountered in patients awaiting a VAD implant. This is usually a result of chronic or acute renal hypoperfusion from low cardiac output. Other etiologies for renal dysfunction include athero-embolism and inflammation. Renal dysfunction can occur as CKD or AKI. While CKD may be a function of chronic heart failure, AKI can be precipitated by acute decompensated heart failure or acute exposure to nephrotoxins, such as antibiotics and contrast agents, in the vulnerable setting of low cardiac output.

Preoperative evaluation should include routine renal function tests such as serum creatinine and blood urea nitrogen. These can indicate progression of renal disease and help identify patients at risk of further deterioration. While cardiovascular management goals usually take precedence, the appropriate management of intravascular volume should also be considered in the context of optimizing renal function.

e. Neurologic:

Neurologic issues are important to consider. While preoperative stroke or cerebrovascular accident (CVA) does not automatically exclude VAD implantation, significant cognitive impairment and limitation of physical activity, such as hemiparesis or hemiplegia, can impair the ability to operate the VAD effectively. Any suspicion of neurologic impairment should be thoroughly investigated with neuroimaging to rule out contraindications to VAD insertion. History of CVA should alert the anesthesia team to the high risk of postoperative neurological injury.

Emergent VAD insertion candidates may have underlying neurologic issues that may not have been adequately investigated. Examples include the INTERMACS profile 1 type cases that may not have had their neurologic status adequately assessed prior to VAD insertion.

Chronic neurologic impairment presents challenges to VAD insertion. Appropriate investigation combined with a thorough assessment of functional status should be performed. A decision to implant a VAD in the setting of mild neurologic impairment should be considered after careful discussion with the patient's social support system.

f. Endocrine:

Endocrine issues that assume importance include diabetes and adrenal function. Diabetes mellitus frequently coexists in these patients and should be managed appropriately. The VAD procedure itself is a stress that will induce transient glucose intolerance. The chronic effects of diabetes, such as nephropathy and neuropathy, should also be considered.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Effective hemostasis is profoundly important for this procedure. However, a number of pre-existing comorbidities involve the administration of medications that can impair normal hemostasis. Examples include antiplatelet agents and heparin that are administered to treat ischemic heart disease or peripheral vascular disease.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

  1. Chronic drug therapy

    1. Angiotensin converting enzyme (ACE) inhibitors

    2. Angiotensin receptor blockers

    3. Beta blockers

    4. Antiplatelet agents

    5. Diuretics

    6. Inotropes such as milrinone

  2. Acute drug therapy

    1. Inotropes such as epinephrine, norepinephrine, dopamine

    2. Antiarrhythmics such as amiodarone

    3. Heparin

    4. Nitroglycerin

i. What should be recommended with regard to continuation of medications taken chronically?

In the setting of VAD insertion, the general recommendation is to continue all medications until the time of surgery. The nature of the surgery and its urgency may preclude discontinuation of antiplatelet agents. However, the risk of perioperative bleeding with continued administration must be counter-balanced with the risk of thrombosis with discontinuation of the drug. Long-term ACE inhibitors or drugs that interact with the renin-angiotensin system may result in intraoperative hypotension that is challenging to manage without potent vasopressors. Other drugs and inotropes are usually continued up to surgery.

j. How to modify care for patients with known allergies -

Patients with known allergies to antibiotics will require a change in antibiotic protocols. Those with a history of heparin induced thrombocytopenia (HIT) present a special challenge. These cases may have persistent antiplatelet antibodies for up to 6 months following the last heparin exposure. However, it may be prudent to administer a one-time dose of heparin if six months or more have passed since the last exposure. Alternately, other agents, such as bivalirudin, may be useful for anticoagulation for CPB. These agents, however, are hampered by a lack of a suitable reversal agent. Preoperative plasmapheresis is also an option to minimize antibody levels prior to heparin administration.

Patients with known sensitivity to protamine may also present a special challenge. These cases may require a test dose to confirm true sensitivity and premedication with antihistamines and steroids. Alternatives to protamine are rarely used.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Latex allergy is not uncommon in the perioperative setting. Most modern operating rooms are adequately equipped with nonlatex equipment to be used for the surgery.

l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]

Penicillin allergic patients require a change in antibiotic protocols. At our institution, we usually prefer a combination of vancomycin, ciprofloxacin, and fluconazole for prophylaxis.

m. Does the patient have a history of allergy to anesthesia?

If a patient has a documented case of malignant hyperthermia(MH), avoid all trigger agents, such as succinylcholine, and inhalational agents. The anesthetic plan should be reviewed by all involved personnel preoperatively. This includes input from all subspecialty areas such as nursing, perfusion, and pharmacy. Adequate preparations should be taken to ensure OR scavenging systems are working. No inhalational agents are to be present and the machines must be checked to ensure they are free of these agents. An important consideration that is often overlooked is the volatile agent included in the CPB circuit. The perfusion team must, therefore, be involved with these discussions preoperatively.

The pharmacy MH cart must be available during the case and the use of available agents must be reviewed by the anesthesia team before anesthesia is planned. Additionally, any handover of the case must include a discussion of the MH plan.

If an MH patient has been identified, usual protocols should be followed for identifying family members at risk.

Local anesthetics are not used liberally for VAD insertion. Muscle relaxants should include only MH trigger-free agents.

5. What laboratory tests should be obtained and has everything been reviewed?

Standard preoperative laboratory tests may not be feasible in emergent INTERMACS profile 1 cases. While these cases may have had adequate preoperative work-ups, the situation may have dramatically changed since they developed the cardiovascular instability that warranted the need for a VAD. The urgent or elective VAD procedures offer more time to obtain specific laboratory tests.

Tests should include a comprehensive metabolic profile, including renal and hepatic function panels, complete blood counts and a coagulation profile. Other tests should include a chest X-ray and an electrocardiogram. Other tests are indication-driven according to underlying comorbid conditions. These include cardiac catheterization in patients with known or suspected right heart dysfunction or valve disease, neuroimaging for known or suspected neurological dysfunction, transesophageal or transthoracic echocardiographic imaging for ruling out intracardiac masses or endocarditis, and pulmonary function tests in COPD patients.

Most laboratory tests will reflect underlying disease severity according to age and gender. Special attention should be paid to tests that indicate a rising white cell count (indicative of a possible infection), a low red cell count or hemoglobin level (indicative of ongoing bleeding or chronic anemia), a low platelet count (indicative of anticipated postoperative bleeding), rising serum creatinine levels (indicative of ongoing AKI or CKD), and elevated hepatic enzymes (indicative of ongoing hepatic insufficiency from chronic or acute congestion).

Abnormally low hemoglobin levels suggest ongoing bleeding. In emergent cases, this may indicate ongoing acute bleeding, while, in more elective VAD cases, this may reflect chronic heart failure. An important exclusion for VAD implantation is malignancy that limits survival.

Abnormal potassium levels may be frequently seen since these patients are usually on diuretics and/or potassium supplements. Rhythm disorders are also common, which makes close monitoring of electrolyte levels mandatory.

Abnormal coagulation tests are almost always included in these cases due to the administration of antiplatelet agents or systemic anticoagulants such as heparin for underlying coronary artery disease or the presence of prosthetic mechanical valves.

Neuroimaging tests may be indicated in patients with known or suspected neurologic disease that precludes VAD insertion. Other tests such as echocardiograms may be performed if endocarditis or an intracardiac mass is suspected.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Patients for VAD insertion will require general anesthesia with extensive monitoring. Regional or other forms of anesthesia are not indicated. Patients are usually positioned supine for VAD insertion. Preparation of the groins may be indicated for access to the central circulation to institute cardiopulmonary bypass, especially in "redo" sternotomies. Alternately, the groin area may be used for additional femoral arterial access and femoral venous access for rapid volume infusion. The arms are usually available for insertion of radial artery catheters. Previous attempts may have rendered these challenging, while patients with low cardiac output and sluggish circulation will also present technical challenges.

a. Regional anesthesia –Regional anesthesia is not indicated for this procedure.

b. General anesthesia

General anesthesia is the technique of choice in these cases.

Induction of general anesthesia may be the most challenging part of the case for the anesthesiologist. These patients have extremely poor cardiac function and are in decompensated heart failure (either chronic or acute). If they are currently on inotropic therapy, these should be continued during induction. A sluggish circulation will lead to a prolonged arm-brain circulation time, making it important to administer induction agents slowly. Two large bore intravenous lines and an arterial line are mandatory prior to induction of anesthesia. Some cases may require pre-induction insertion of a central venous line and pulmonary artery catheter for hemodynamic monitoring and access to the central circulation for inotrope administration. A judicious combination of opioids such as fentanyl, benzodiazepines such as midazolam, and volatile agents may be sufficient for induction in some cases with limited cardiac reserve. Either propofol or etomidate may be administered as an induction agent, as well. Care should be taken to ensure cardiovascular stability during this critical phase.

If rhythm management devices are disabled from administering therapy, external shock pads will need to be in place should the patient have a malignant dysrhythmia requiring electrical treatment.

VAD insertions require extensive hemodynamic monitoring, including arterial pressure, central venous and pulmonary artery pressures, tissue oxygenation monitors, including pulse oximetry. Neuromonitoring should include the bispectral index. Monitoring of cerebral oximetry is optional. Continuous monitoring of cardiac function with transesophageal echocardiography (TEE) is essential. Special care should be taken to rule out the presence of key lesions such as intra-cardiac shunts such as a patent foramen ovale, significant aortic regurgitation, and, less commonly, mitral stenosis. The presence of intracardiac masses such as left atrial or left ventricular thrombi should be communicated to the surgical team for prompt removal during the VAD insertion phase.

Maintenance of anesthesia is accomplished with a combination of opioids, volatile agents and long acting muscle relaxants, as in most general anesthetic procedures. Vasopressor agents or inotropes may need to be initiated for the maintenance of cardiovascular stability prior to initiation of CPB. It is important to ensure the availability of blood and blood products throughout the case. Prior to discontinuation of CPB, it is important to have a plan to manage any coagulopathy that may occur. Administration of antifibrinolytics such as aminocaproic acid is routine in VAD cases.

c. Monitored Anesthesia Care - Monitored anesthesia care is not indicated for this procedure.

6. What is the author's preferred method of anesthesia technique and why?

  • What prophylactic antibiotics should be administered? Per the SCIP recommendations, antibiotic prophylaxis should include a broad spectrum first or second generation cephalosporin. VAD cases usually require an additional agent such as vancomycin since the patients are frequently inpatients for longer than 24 hours prior to surgery. At our institution, cefuroxime (1.5 grams) and vancomycin (20 mg/kg) are administered within one hour prior to skin incision. An additional antifungal agent is preferred since these cases involve the insertion of a prosthetic device with an externalized drive line that carries a higher than normal risk of fungal contamination.

  • What do I need to know about the surgical technique to optimize my anesthetic care? Elective VAD insertions will often involve the insertion of an IABP prior to sternotomy. Alternately, the surgical team may elect to insert a femoral arterial line for ready access to the femoral artery for insertion of an IABP prior to discontinuation of CPB. Cases with prior sternotomy may require alternate approaches to the aorta. The axillary artery or femoral artery may be cannulated to initiate bypass prior to sternotomy. It is always prudent to discuss these approaches with the surgical team since approaches like axillary artery cannulation may affect blood pressure monitoring with a radial arterial line on the same side. Communication of key findings on TEE (see above) is essential prior to cannulation of the right atrium and aorta since they may affect the surgical plan. Any intracardiac shunt would need to be closed prior to VAD insertion. Aortic regurgitation is a serious lesion that may require surgical correction. Prior to initiation of VAD flows, the anesthesiologist may notice a significant quantity of air bubbles during the TEE exam. These should be conveyed to the surgical team for proper de-airing procedures. A reassessment of intracardiac shunts and aortic regurgitation should be undertaken after discontinuation of bypass.

  • What can I do intraoperatively to assist the surgeon and optimize patient care? Communication regarding TEE findings are essential for the surgical team to plan the VAD insertion. Status of rhythm management devices is also important. If the therapy functions of rhythm management devices have been disabled intraoperatively to avoid interaction with the electrical cautery, the device should be re-enabled, if indicated, after surgery. Any findings of decrease in cerebral oximetry or bispectral index should be communicated immediately as they may indicate a flow problem with the VAD.

  • What are the most common intraoperative complications and how can they be avoided/treated? Prioritize complications by urgency. The most common intraoperative complications relate to the cardiovascular system. Patients will frequently display hypotension and low cardiac output prior to initiation of bypass. These should be anticipated and treated with inotropes and vasopressors, as appropriate. Dysrhythmias should be promptly treated, especially those requiring electrical conversion, since patients may have their rhythm management devices disabled. The other major intraoperative complication relates to bleeding. A combination of CPB and exposure of blood elements to the synthetic surface of the VAD chamber can result in a significant coagulopathy. Therefore, administration of an anti-fibrinolytic is routine and strict monitoring of the coagulation profile is essential. Thromboelastography is useful to tailor blood product administration according to the coagulation deficiency present. Similarly, platelet counts and fibrinogen levels sent before discontinuation of bypass help in decision making regarding blood product administration. Excessive bleeding requires the availability of a rapid infusion device.

Cardiac complications relate to hypotension and low cardiac output as detailed above. Right ventricular failure is a serious complication and can occur after VAD insertion from loss of ventricular interdependence or from a change in septal geometry from excessive VAD speeds in the left ventricle. Severe right ventricular dysfunction may require the insertion of a right-sided VAD as a short-term or long-term measure in combination with an LVAD.

Pulmonary complications relate principally to the pulmonary vasculature. High pulmonary artery pressures may require the administration of potent pulmonary vasodilators, such as nitric oxide, to protect the RV.

Neurologic complications may relate to thrombo-emboli from either intra-cardiac thrombi that existed prior to the VAD insertion, or from the development of new thrombi within the VAD chamber. This is a rare occurrence and is more typically seen when anticoagulation regimens are suboptimal in the postoperative period. Other neurologic sequelae include cognitive dysfunction from multiple emboli, low flow or hypoperfusion.

b. If the patient is intubated, are there any special criteria for extubation?

Patients are left intubated in the postoperative period until they are hemodynamically stable, with minimal bleeding and satisfactory blood gases. Patients may also have the sternum left open for secondary closure after 24 to 48 hours to allow for resolution of any coagulopathy and edema.

c. Postoperative management

  1. What analgesic modalities can I implement? Postoperative analgesic strategies are usually restricted to systemic opioid administration. Intermittent fentanyl, morphine, or hydromorphone are all suitable postoperative analgesics.

  2. What level bed acuity is appropriate? VAD cases will require intensive care unit admission for at least 24 to 48 hours in largely uncomplicated cases, and perhaps longer as complications are resolved.

  3. What are common postoperative complications, and ways to prevent and treat them? VAD cases are among the most complex cases to manage postoperatively. The most common complications relate to cardiovascular instability and right ventricular dysfunction. Inotropes may have to be continued to support the RV until there is return of reasonable function. Pulmonary vasodilators such as nitric oxide or ino-dilators such as milrinone are usually indicated to reduce right ventricular afterload. Inhaled prostacyclin is also a reasonable alternative to inhaled nitric oxide. Patients may also have persistent ventricular dysrhythmias. These may not cause an immediate reduction in cerebral blood flow since a VAD is able to maintain minimal cardiac output. However, the RV may suffer as a result of any dysrhythmias, thereby affecting flow to the VAD. Postoperative coagulopathy is common. Strict monitoring of the coagulation profile is mandatory, as is prompt treatment with an appropriate blood product. Caution should be exercised in patients who have had a VAD as a bridge to transplant. Unnecessary blood transfusion can sensitize a potential heart transplant candidate to major histocompatibility complex (MHC) antigens. These can lead to a high incidence of subsequent allograft rejection. Postoperative infection should be strictly avoided. The impact of systemic infection on a prosthetic device such as a VAD can be lethal.

What's the Evidence?

Slaughter, MS, Meyer, AL, Birks, EJ. "Destination therapy with left ventricular assist devices: Patient selection and outcomes". Curr Opin Cardiol. vol. 26. 2011. pp. 232-6.

Caccamo, M, Eckman, P, John, R. "Current state of ventricular assist devices". Curr Heart Fail Rep. vol. 8. 2011. pp. 91-8.

Boyle, AJ, Ascheim, DD, Russo, MJ, Kormos, RL, John, R, Naka, Y, Gelijns, AC, Hong, KN, Teuteberg, JJ. "Clinical outcomes for continuous-flow left ventricular assist device patients stratified by pre-operative intermacs classification". J Heart Lung Transplant. vol. 30. 2011. pp. 402-7.

Kirklin, JK, Naftel, DC, Stevenson, LW, Kormos, RL, Pagani, FD, Miller, MA, Ulisney, K, Young, JB. "Intermacs database for durable devices for circulatory support: First annual report". J Heart Lung Transplant. vol. 27. 2008. pp. 1065-72.

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