Case report
Experience in anaesthetic management of non-cardiac surgery in patients with ventricular assist devices
Experiencia en manejo anestésico para cirugía no cardiaca en pacientes con asistencias ventriculares
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Se observa la importancia de la correcta posición de las cánulas para garantizar un correcto funcionamiento, y la correcta posición del paciente para evitar complicaciones asociadas a la posición quirúrgica.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Albajar Bobes, M. Casado Salcedo, E. Rincón Gómez-Limón, J.M. Álvarez Avello, A.I. González Román, M. Vidal Fernández, A. Forteza Gil, M. Gómez-Bueno, J. Segovia Cubero, J. García Fernández" "autores" => array:10 [ 0 => array:2 [ "nombre" => "A. Albajar" "apellidos" => "Bobes" ] 1 => array:2 [ "nombre" => "M. Casado" "apellidos" => "Salcedo" ] 2 => array:2 [ "nombre" => "E. Rincón" "apellidos" => "Gómez-Limón" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Álvarez Avello" ] 4 => array:2 [ "nombre" => "A.I." "apellidos" => "González Román" ] 5 => array:2 [ "nombre" => "M. Vidal" "apellidos" => "Fernández" ] 6 => array:2 [ "nombre" => "A. Forteza" "apellidos" => "Gil" ] 7 => array:2 [ "nombre" => "M." 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Albajar Bobes, M. Casado Salcedo, E. Rincón Gómez-Limón, J.M. Álvarez Avello, A.I. González Román, M. Vidal Fernández, A. Forteza Gil, M. Gómez-Bueno, J. Segovia Cubero, J. García Fernández" "autores" => array:10 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Albajar Bobes" "email" => array:1 [ 0 => "andrea.albajar@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Casado Salcedo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Rincón Gómez-Limón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.M." "apellidos" => "Álvarez Avello" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "A.I." "apellidos" => "González Román" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Vidal Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "A." "apellidos" => "Forteza Gil" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "M." "apellidos" => "Gómez-Bueno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 8 => array:3 [ "nombre" => "J." "apellidos" => "Segovia Cubero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 9 => array:3 [ "nombre" => "J." "apellidos" => "García Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesia y Reanimación, Hospital Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Cardiaca, Hospital Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Experiencia en manejo anestésico para cirugía no cardiaca en pacientes con asistencias ventriculares" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1107 "Ancho" => 950 "Tamanyo" => 212026 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Levitronix biventricular VAD monitoring screen during hip prosthesis removal. In addition to adequate monitoring, the surgical team must have access to the VAD screens to check that they are functioning correctly and providing a steady flow. Changes observed on the screens could indicate possible complications, the most frequent being kinking of the cannulas or hypovolaemia.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure (HF) is a highly prevalent syndrome in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It affects 1%–2% of the total population, with a prevalence of 10%–20% in the over-75 population.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> It absorbs around 2% of overall health expenditure, and although survival has improved in recent decades, it still stands at only 50% five years after diagnosis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> All these factors have led to an increase in the number of heart disease patients scheduled for non-cardiac surgery. The anaesthetic management of this population is often highly challenging.</p><p id="par0010" class="elsevierStylePara elsevierViewall">When the symptoms of HF progress and become refractory to medical treatment, the best therapeutic option in suitable candidates is heart transplantation. Nevertheless, due to a shortage of donors and long waiting lists, many of these patients undergo implantation of a ventricular assist device (VAD).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The devices provide support to patients with advanced HF, and are used as a bridge to transplantation, as a bridge to recovery of cardiac function, or as a definitive treatment strategy in patients that are not candidates for transplantation.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">VADs can be classified according to their location (left, right or biventricular); according to their duration (temporary or definitive); according to the type of flow (continuous [centrifugal or axial] or pulsatile); according to the drive system (pneumatic, electric or electromagnetic); and according to whether they are placed outside the body (paracorporeal), or are implanted inside the body (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">First generation of VADs provided pulsatile flow. They are large, complex devices that are associated with many complications, including mechanical failure, infections and thromboembolic events. These problems led to the development of second-generation VADs, which provide continuous instead of pulsatile flow. These devices are placed in the left ventricle and drive blood to the aorta (left VAD), pulmonary artery (right VAD) or both (biventricular VAD) using either an axial or centrifugal flow pump. They are smaller and quieter, they can be implanted in the pericardial space, and require less anticoagulation.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite their advantages, they are more expensive than the earlier models, and although they are currently the most widely used, patients with first generation devices are still seen in clinical practice, so it is important to understand the mechanism of action of all available models, together with their potential complications.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients with VADs usually present associated comorbidities, such as kidney failure, ventricular arrhythmias, gastrointestinal bleeding, liver failure, and diabetes. Therefore, it is not uncommon for them to undergo non-cardiac surgery in the early years post-implantation.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In this article, we present 4 clinical cases involving patients with VADs who required surgical intervention. Three of them had long-term VADs: 2 EXCOR (pulsatile, paracorporeal) and 1 HEARTWARE (non-pulsatile, implanted), and the fourth had a short-term device; CentriMag biventricular Levitronix.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case reports</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0040" class="elsevierStylePara elsevierViewall">A 42-year-old man with a Berlin Heart (EXCOR) left ventricular assist device type implanted in December 2009 due to dilated cardiomyopathy with a left ventricular ejection fraction (LVEF) of 30%, severe mitral and tricuspid regurgitation, and severe pulmonary hypertension.</p><p id="par0045" class="elsevierStylePara elsevierViewall">According to his clinical history, he had no known drug allergies or other diseases of interest. As is frequently the case in these patients, his usual medication included dual antiplatelet therapy with dipyridamole 100<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>h and acetylsalicylic acid (ASA) 300<span class="elsevierStyleHsp" style=""></span>mg daily; anticoagulation with enoxaparin 80<span class="elsevierStyleHsp" style=""></span>mg/day for difficult INR control (>2.5)with acenocoumarol, and other drugs for heart failure, including carvedilol, captopril, sildenafil and allopurinol.</p><p id="par0050" class="elsevierStylePara elsevierViewall">He was admitted from the emergency room with a diagnosis of acute appendicitis and transferred to the surgical suite for an open appendectomy and drainage of appendiceal abscess. Although laparoscopy is not contraindicated in these patients, it was ruled out in this case due to the presence of associated peritonitis and the need for midline laparotomy in order to clean the abdominal cavity.</p><p id="par0055" class="elsevierStylePara elsevierViewall">After admission, he was kept under observation for 24<span class="elsevierStyleHsp" style=""></span>h before surgery, with haemodynamic monitoring and symptom control, to ensure complete reversal of the anticoagulant effect of enoxaparin.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The preoperative workup showed normal kidney function and coagulation values within normal ranges. However, residual effects of dipyridamole and ASA were detected, so he was given a pool of platelets before the start of surgery.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient was transferred to the operating room, supervised at all times by a specialist cardiac team to avoid complications, and standard and invasive monitoring was started: 3-lead ECG, pulse oximetry, capnography, left radial artery (IBP) line, right internal jugular vein (PVC) line, BIS, hourly diuresis, oesophageal temperature, rapid fluid infusion device, and thermal blanket.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although no anaesthetic agents are contraindicated in these patients, induction was performed with high-dose fentanyl to reduce the sympathetic reaction to laryngoscopy and thus avoid increasing the afterload; etomidate and rocuronium were given to decrease the vasodilation associated with other agents that could reduce the device's filling volume.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">During surgery, 3<span class="elsevierStyleHsp" style=""></span>L of ascitic fluid and 1<span class="elsevierStyleHsp" style=""></span>L of pleural fluid were drained from the right hemithorax, with characteristic transudate. This improved venous return and with it the cardiac output provided by the device.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Mechanical ventilation was started to avoid reducing venous return and to ensure correct function of the right ventricle, with adequate FiO<span class="elsevierStyleInf">2</span> for correct oxygenation, optimal PEEP levels to avoid alveolar overdistension, and a tidal volume (Vt) of around 7<span class="elsevierStyleHsp" style=""></span>mL/kg.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,9</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The patient remained haemodynamically stable throughout the procedure, with no significant intraoperative bleeding. At times, a decrease in VAD pump flow (cardiac output) was observed. This was treated intraoperatively with 1000<span class="elsevierStyleHsp" style=""></span>mL of crystalloid solution to ensure correct filling of the device (preload).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">After surgery, the patient was transferred to the postanaesthesia care unit (PACU), sedated with low-dose propofol to prevent vasodilation, with remifentanil for analgesia. Once in the PACU, he was connected to mechanical ventilation.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Analytical tests at PACU admission showed: 1.1<span class="elsevierStyleHsp" style=""></span>mmol/L lactate; troponin <span class="elsevierStyleSmallCaps">i</span>: 0.13<span class="elsevierStyleHsp" style=""></span>ng/mL; GOT: 26<span class="elsevierStyleHsp" style=""></span>IU/L; GGT: 122<span class="elsevierStyleHsp" style=""></span>IU/L; platelets: 383,000/μL; INR: 2.34; aPTT: 47.7<span class="elsevierStyleHsp" style=""></span>s; Hb: 10.2<span class="elsevierStyleHsp" style=""></span>g/dL; Htc 32%; urea: 60<span class="elsevierStyleHsp" style=""></span>mg/dL; creatinine: 0.9<span class="elsevierStyleHsp" style=""></span>mg/dL; leukocytes: 24,920/μL.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The patient was extubated 4<span class="elsevierStyleHsp" style=""></span>h after arrival at the PACU, maintaining good oxygenation and gas exchange, and receiving 2<span class="elsevierStyleHsp" style=""></span>Lpm oxygen through a nasal cannula.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Due to the peritonitis diagnosed on his arrival at the emergency room, we decided to continue the antibiotic treatment started at admission with meropenem and vancomycin.</p><p id="par0105" class="elsevierStylePara elsevierViewall">At 24<span class="elsevierStyleHsp" style=""></span>h, the patient remained stable, and his usual medication was resumed, including dual antiplatelet therapy with dipyridamole and acetylsalicylic acid, and infusion of 1000<span class="elsevierStyleHsp" style=""></span>IU heparin sodium, with serial follow-up of aPTT values of 40–60<span class="elsevierStyleHsp" style=""></span>s. No active bleeding or anaemia was observed during the postoperative period, or any other important complication, so the patient was discharged from the unit 72<span class="elsevierStyleHsp" style=""></span>h after admission.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0110" class="elsevierStylePara elsevierViewall">A 50-year-old man with a Berlin Heart (EXCOR) biventricular LVAD implanted in 2015 for dilated phase hypertrophic cardiomyopathy with an LVEF of 25%. In this case, the patient was in treatment with acenocoumarol for an INR of around 2.5, and antiplatelet therapy with clopidogrel 75<span class="elsevierStyleHsp" style=""></span>mg daily. He was also taking bisoprolol, furosemide and omeprazole.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The patient was admitted for scheduled cholecystectomy due to cholelithiasis and recurrent biliary colic (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Given the high risk of bleeding and the presence of abdominal cannulae from the VAD that could cause complications in open surgery, a laparoscopic approach was decided, keeping the pneumoperitoneum pressure to the minimum required to maintain venous return and good visualisation of the surgical field.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Being a scheduled procedure, we were able to suspend acenocoumarol 3 days before surgery, and replace clopidogrel with ASA 100<span class="elsevierStyleHsp" style=""></span>mg 5 days before surgery.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,9</span></a> Despite suspension of acenocumarol, analytical tests at admission showed an INR of 2, so 1200<span class="elsevierStyleHsp" style=""></span>IU of prothrombin complex was administered before the start of surgery.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The patient was taken to the operating room accompanied by experts in VAD management, and after placing a peripheral line, he was given antibiotic prophylaxis with 2<span class="elsevierStyleHsp" style=""></span>g cefazolin<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> and standard and invasive monitoring was started: 3-lead ECG, pulse oximetry, capnography, IBP (CVC), and TOF. A fluid warmer and thermal blanket were also used. As this was a pulsatile VAD, we were able to rely on the pulse oximeter and NIBP values without the need for more invasive methods or serial blood gas measurements; however, in the interest of safety, an arterial line was also inserted.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Regional anaesthesia was not administered because laparoscopy is associated with low levels of postoperative pain. Despite the patient's haemodynamic stability at admission, anaesthesia was induced with high-dose fentanyl, etomidate and rocuronium, and maintained with sevoflurane for a MAC of between 0.8 and 1. Fentanyl and rocuronium were administered on demand, the latter being reversed with suggamadex according to TOF values to permit early extubation in the operating room.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In this case, during the intervention, and particularly during pneumoperitoneum and placement in the antitrendelenburg position to facilitate the surgical approach, the patient showed a tendency towards hypotension and insufficient ventricular filling, accompanied by a decrease in cardiac output shown on both the monitoring devices and the VAD screen. A total of 2000<span class="elsevierStyleHsp" style=""></span>cc crystalloid solution was administered for volume replacement, and vasoactive support was started with norepinephrine 0.05<span class="elsevierStyleHsp" style=""></span>mcg/kg/min, which resolved the situation.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Mechanical ventilation was similar to the previous case, with high FiO<span class="elsevierStyleInf">2</span> to ensure correct oxygenation and avoid pulmonary vasoconstriction, weight-adjusted Vt (7<span class="elsevierStyleHsp" style=""></span>mL/kg) and optimal PEEP to avoid both alveolar overdistention, which reduces right ventricle preload, and alveolar collapse, which can aggravate pulmonary vasoconstriction.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Intraoperative bleeding was not significant and no blood transfusion was required.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The patient was transferred to the PACU haemodynamically stable, without the need for vasoactive support, and extubated.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Analytical tests and blood gases on arrival at the PACU were: lactate 0.7<span class="elsevierStyleHsp" style=""></span>mmol/L; pO<span class="elsevierStyleInf">2</span>: 100<span class="elsevierStyleHsp" style=""></span>mmHg; pCO<span class="elsevierStyleInf">2</span>: 34.1<span class="elsevierStyleHsp" style=""></span>mmHg; pH 7.4; HCO<span class="elsevierStyleInf">3</span>: 22<span class="elsevierStyleHsp" style=""></span>mEq/L; platelets 262,000/μL; INR 1.4; aPTT 48.6<span class="elsevierStyleHsp" style=""></span>s; Hb: 7.60<span class="elsevierStyleHsp" style=""></span>g/dL; Htc 23%; urea: 46<span class="elsevierStyleHsp" style=""></span>mg/dL; creatinine: 0.85<span class="elsevierStyleHsp" style=""></span>mg/dL; leukocytes: 12,000/μL.</p><p id="par0165" class="elsevierStylePara elsevierViewall">On the basis of the analytical tests, the patient was given packed red blood cells to keep Hb levels at around 10<span class="elsevierStyleHsp" style=""></span>g/dL, as recommended in our protocol, and to ensure proper tissue oxygenation.</p><p id="par0170" class="elsevierStylePara elsevierViewall">At 24<span class="elsevierStyleHsp" style=""></span>h, after checking for active bleeding and anaemia, continuous infusion with heparin sodium 400<span class="elsevierStyleHsp" style=""></span>IU/h and serial aPTT testing was started. Oral intake was started, and the patient resumed his usual medication.</p><p id="par0175" class="elsevierStylePara elsevierViewall">He was discharged 48<span class="elsevierStyleHsp" style=""></span>h after surgery, with no signs of infection or active bleeding.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 3</span><p id="par0180" class="elsevierStylePara elsevierViewall">A 66-year-old man with HEARTWARE LVAD implanted due to ischaemic cardiomyopathy secondary to anterolateral myocardial infarction, with severe left ventricular dysfunction, congestive heart failure refractory to medical treatment, and severe pulmonary hypertension. His history was also significant for amiodarone-induced hypothyroidism.</p><p id="par0185" class="elsevierStylePara elsevierViewall">At the time of admission, his normal treatment consisted of Adiro<span class="elsevierStyleSup">®</span> 100<span class="elsevierStyleHsp" style=""></span>mg daily, acenocoumarol due to an INR of more than 2.5; carvedilol, candesartan, Eutirox<span class="elsevierStyleSup">®</span>, digoxin and omeprazole.</p><p id="par0190" class="elsevierStylePara elsevierViewall">He was admitted in June 2017 for craniotomy due to subarachnoid haemorrhage, which was secondary to mycotic aneurysms due to subacute endocarditis associated with VAD infection.</p><p id="par0195" class="elsevierStylePara elsevierViewall">The antiplatelet and anticoagulant strategy consisted of replacing acenocoumarol with enoxaparin 40<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h 3 days before surgery, and suspending low molecular weight heparin 24<span class="elsevierStyleHsp" style=""></span>h before surgery. Pre-operative INR was 1.45.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The antibiotic strategy consisted of ceftriaxone and gentamicin, which had been indicated some days earlier after the diagnosis of endocarditis associated with his VAD. Upon arrival in the operating room, he was given the corresponding doses of these antibiotics, which were maintained in the postoperative period, as indicated in the endocarditis protocol.</p><p id="par0205" class="elsevierStylePara elsevierViewall">The patient was taken to the operating room, per protocol, accompanied by experts in VAD management to ensure that the device functioned correctly at all times, with a supply of additional batteries.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Standard and invasive monitoring was started: 5-lead ECG, pulse oximetry, capnography, IBP (CVC), BIS, INVOS, TOF, hourly urine output and oesophageal temperature. A thermal blanket was also used. This patient carried a HEARTWARE LVAD, which unlike the EXCOR is a second generation continuous flow device. Because of this, we were unable to rely on pulse oximeter and NIBP values, and serial intraoperative blood gas measurements were required to ensure adequate oxygenation, and cerebral perfusion was monitored.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,7</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Total intravenous anaesthesia was performed with propofol and remifentanil adjusted to BIS and haemodynamic parameters. Rocuronium was given for muscular relaxation, adjusted to TOF values, and was subsequently reversed with suggamadex.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Adequate haemodynamic stability was achieved during surgery, without the need for vasoactive support or transfusion of blood products.</p><p id="par0225" class="elsevierStylePara elsevierViewall">Fluid replacement consisted of 1500<span class="elsevierStyleHsp" style=""></span>mL of 0.9% saline solution, without the need for colloid boluses to maintain VAD blood flow. Mannitol was given to prevent oedema, closely monitoring urine output and cardiac output recorded by the VAD after surgery, and anticonvulsant prophylaxis with levetiracetam was administered.</p><p id="par0230" class="elsevierStylePara elsevierViewall">Mechanical ventilation followed the same parameters and considerations as in the previous patients, since this VAD also depends on preload for correct operation, despite continuous flow.</p><p id="par0235" class="elsevierStylePara elsevierViewall">The patient was extubated in the operating room without incident, and was transferred to the PACU with 4<span class="elsevierStyleHsp" style=""></span>Lpm oxygen through nasal prongs to maintain saturation levels above 96% at all times.</p><p id="par0240" class="elsevierStylePara elsevierViewall">Analytical tests at admission were: pH: 7.26; pCO<span class="elsevierStyleInf">2</span>: 39<span class="elsevierStyleHsp" style=""></span>mmHg; pO<span class="elsevierStyleInf">2</span>: 114<span class="elsevierStyleHsp" style=""></span>mmHg; HCO<span class="elsevierStyleInf">3</span>: 18<span class="elsevierStyleHsp" style=""></span>mEq/L; Lact: 0.7<span class="elsevierStyleHsp" style=""></span>mmol/L; Hb: 9.30<span class="elsevierStyleHsp" style=""></span>g/dL; Htc: 27.4%; platelets: 249,000/μl; INR 1.36; aPTT 41.3<span class="elsevierStyleHsp" style=""></span>s; urea: 24.00<span class="elsevierStyleHsp" style=""></span>mg/dL; creatinine: 0.91<span class="elsevierStyleHsp" style=""></span>mg/dL; ions within normal ranges.</p><p id="par0245" class="elsevierStylePara elsevierViewall">His usual medication was restarted the same day of the intervention and anticoagulant treatment with enoxaparin 40<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h was started a 24 postoperative hours. Three days later, this was replaced with acenocoumarol 2<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0250" class="elsevierStylePara elsevierViewall">The patient was discharged to the hospital ward 48<span class="elsevierStyleHsp" style=""></span>h after surgery, with no signs of infection, bleeding or neurological complications.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Case 4</span><p id="par0255" class="elsevierStylePara elsevierViewall">A 43-year-old man with a LEVITRONIX biventricular VAD implanted due to dilated cardiomyopathy (LVEF 10%, severely depressed RVEF) secondary to cobalt intoxication after implantation of a cobalt-chromium hip prosthesis due to Perthes disease in July 2016. His history was only significant for uncontrolled hypertension.</p><p id="par0260" class="elsevierStylePara elsevierViewall">He underwent surgery to remove the prosthesis causing the toxicity 2 days after placement of the VAD.</p><p id="par0265" class="elsevierStylePara elsevierViewall">At the time of surgery he was not on anticoagulant treatment due persistent bleeding and anaemia after placement of the VAD. His preoperative workup was significant for: INR 1.26; aPTT: 39.4<span class="elsevierStyleHsp" style=""></span>s; Hb 8.20<span class="elsevierStyleHsp" style=""></span>g/dL and platelets 145,000/μL.</p><p id="par0270" class="elsevierStylePara elsevierViewall">Due to the urgent need to remove the prosthesis to reduce blood cobalt levels, the patient was intubated at admission and until completion of surgery 48<span class="elsevierStyleHsp" style=""></span>h later.</p><p id="par0275" class="elsevierStylePara elsevierViewall">He was transferred to the operating room accompanied by VAD management specialists after verifying that the device functioned correctly and the battery was sufficiently charged. On arrival, the VAD was connected to main power in the operating room to ensure it remained operational throughout the procedure. Left ventricle output was 5<span class="elsevierStyleHsp" style=""></span>L/min, and right output was 4.5<span class="elsevierStyleHsp" style=""></span>L/min.</p><p id="par0280" class="elsevierStylePara elsevierViewall">The antibiotic prophylaxis started during VAD placement (ciprofloxacin and daptomycin) was continued during the procedure, together with piperacillin tazobactam, which had been started on the day of admission due to elevated parameters of infection and increased bronchial secretions.</p><p id="par0285" class="elsevierStylePara elsevierViewall">Standard and invasive monitoring was started: 5-lead ECG, pulse oximetry, capnography, IBP (left arterial line), CVC (left internal jugular vein), BIS, INVOS, hourly urine output, oesophageal temperature, rapid volume infusor, and thermal blanket. Serial blood gas measurements and cerebral perfusion were monitored due to the continuous flow design of the LEVITRONIX.</p><p id="par0290" class="elsevierStylePara elsevierViewall">The patient was then placed in the left lateral decubitus position, making sure the catheters were not at risk for kinking, and VAD flow was not affected<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0295" class="elsevierStylePara elsevierViewall">As the patient was already intubated, and the surgery was performed a few hours after VAD placement, there was no need for regional anaesthesia, and a single dose of midazolam, fentanyl and rocuronium was administered before transfer to the operating room. Anaesthesia was maintained with Sevorane<span class="elsevierStyleSup">®</span> 2% (for a MAC of 0.8), target-controlled infusion of remifentanil for haemodynamic stability, and boluses of rocuronium as needed.</p><p id="par0300" class="elsevierStylePara elsevierViewall">The same mechanical ventilation parameters described in the previous cases were used: Vt of 7<span class="elsevierStyleHsp" style=""></span>mL/kg, respiratory frequency adjusted for pCO<span class="elsevierStyleInf">2</span> and EtCO<span class="elsevierStyleInf">2</span> within normal values, avoiding hypercapnia; optimal PEEP after recruitment manoeuvres, ensuring a mean arterial pressure of over 80<span class="elsevierStyleHsp" style=""></span>mmHg to prevent decreased cardiac output due to decreased preload, and FiO<span class="elsevierStyleInf">2</span> to ensure adequate oxygenation.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">The patient remained haemodynamically stable throughout surgery, with no need to increase vasoactive support.</p><p id="par0310" class="elsevierStylePara elsevierViewall">Based on blood gas values, a total of 2000<span class="elsevierStyleHsp" style=""></span>mL crystalloids and 4 units of RBCs were administered, together with 3 units of plasma and 2<span class="elsevierStyleHsp" style=""></span>g of plasma fibrinogen based on thromboelastography values to ensure optimal performance of the Levitronix VAD.</p><p id="par0315" class="elsevierStylePara elsevierViewall">The patient was transferred to the PACU intubated and sedated with dexmedetomidine, propofol and remifentanil. Analytical values on arrival were pO<span class="elsevierStyleInf">2</span>: 158<span class="elsevierStyleHsp" style=""></span>mmHg; pCO<span class="elsevierStyleInf">2</span>: 41<span class="elsevierStyleHsp" style=""></span>mmHg; pH 7.38; HCO<span class="elsevierStyleInf">3</span>: 24.9<span class="elsevierStyleHsp" style=""></span>mEq/L; Hb: 8.7<span class="elsevierStyleHsp" style=""></span>g/dL; Htc: 24%; platelets: 122,000/μL; urea: 30<span class="elsevierStyleHsp" style=""></span>mg/dL; creatinine: 0.87<span class="elsevierStyleHsp" style=""></span>mg/dL; ions within normal ranges; aPTT: 35.8<span class="elsevierStyleHsp" style=""></span>s; INR: 1.31.</p><p id="par0320" class="elsevierStylePara elsevierViewall">One unit of RCBs was transfused, and anticoagulation therapy was started with perfusion of heparin sodium for an aPPT of 50–60<span class="elsevierStyleHsp" style=""></span>s. The antibiotic therapy was continued due to the absence of increased signs of infection.</p><p id="par0325" class="elsevierStylePara elsevierViewall">Three days later, the patient was added to the national transplant waiting list due to persistent biventricular dysfunction, and underwent successful transplant surgery within 3 weeks of VAD implantation.</p><p id="par0330" class="elsevierStylePara elsevierViewall">The patient was discharged from our unit 43 days after admission for VAD placement and 21 days after heart transplantation.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0335" class="elsevierStylePara elsevierViewall">Perioperative management of VADs in patients with advanced heart failure is an increasingly common requirement in modern practice due to the growing prevalence of these devices. Estimates suggest that 20% of patients with VADs will require non-cardiac surgery<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> at some time. The presence of the VAD in combination with the morbidity associated with the underlying disease increases the risk of intra- and postoperative complications.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,10</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">Although these interventions are normally performed in specialised centres by specialist surgeons, the incidence of complications does not increase when they are performed in non-specialised centres. Nevertheless, it is important for the surgical team to be fully conversant with the physiology of VADs, the mode of operation of each type of VAD on the market, and the differences between each model. Hospitals must also draw up protocols establishing the preoperative evaluation and intra- and postoperative management of these patients.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7–10</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">The cardiac output provided by second and third generation VADs (cases 3 and 4) is directly proportional to pump speed, and inversely proportional to the pressure gradient across the pump, which will be greater the lower the preload and the greater the afterload of the left ventricle in the case of LVADs, or of both, in the case of biventricular VADs. For this reason, intravascular volume and right ventricle function have a significant impact on flow, and thus, on cardiac output. Conversely, the greater the afterload, the lower the flow and the lower the cardiac output, which means that an increase in systemic vascular resistance will adversely affect the performance of the VAD.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> In short, the goal is to maintain flow by ensuring adequate right ventricular preload (ample inflow and no kinks in the cannula) and function (inotropic support, avoid VCH, pulmonary vasodilators) and treat any increase or decrease in systemic vascular resistance (vasoconstrictors or vasodilators, as appropriate, and prevent kinking of outflow cannulas).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall">In order to assess cardiac function and act on the intraoperative changes observed, it is of vital importance that the surgical team be fully trained in the performance and interpretation of transoesophageal ultrasound; this should be the primary intraoperative diagnostic and follow-up technique.</p><p id="par0355" class="elsevierStylePara elsevierViewall">Another important consideration is the increased risk of bleeding in these patients, brought on by the need to administer anticoagulants to prevent the thromboembolic complications associated with these devices. VADs have also been associated with acquired von Willebrand syndrome, continuous flow mode-induced arteriovenous malformations, loss of capillary pressure, and platelet dysfunction.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> These factors, added to the need for anticoagulants and antiaggregants, make these patients more susceptible to spontaneous or intraoperative bleeding.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0360" class="elsevierStylePara elsevierViewall">Although there is no evidence of a higher incidence of infections in VAD patients undergoing non-cardiac surgery, the onset of infection can be fatal, so antibiotic prophylaxis should be administered according to the protocol in place in each centre.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Most of our patients presented signs of infection on arrival in the operating room, since most required emergency surgery. For this reason, we chose to continue the existing antibiotic therapy or administer antibiotics specific to the type of infection.</p><p id="par0365" class="elsevierStylePara elsevierViewall">The following factors are important to remember in the perioperative management of these patients.</p><p id="par0370" class="elsevierStylePara elsevierViewall">The preoperative assessment should be performed by a multidisciplinary team of experts, including anaesthesiologists, cardiologists, cardiac surgeons and dedicated VAD personnel. It may also be necessary to contact the VAD manufacturer for advice in emergency situations.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,9</span></a></p><p id="par0375" class="elsevierStylePara elsevierViewall">The anaesthesiology and cardiology teams should suspend and optimise the patient's usual heart medication, as required.</p><p id="par0380" class="elsevierStylePara elsevierViewall">It is important to perform an in-depth study and analysis of the different organs that may be affected, mainly liver, kidney, lung and brain. The function of these organs should be optimised as far as possible before surgery, and blood parameters should also be optimised according to the hospital's patient blood management programme or by a haematologist.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0385" class="elsevierStylePara elsevierViewall">Although the risks of haemorrhage should be weighed against the risk of thromboembolic events in these patients, suspending anticoagulants puts the patient at greater risk of bleeding; therefore, anticoagulants should be suspended between 3 and 5 days before surgery, and coagulation tests and a blood count must be performed before the intervention.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7–10</span></a></p><p id="par0390" class="elsevierStylePara elsevierViewall">Monitoring devices must be placed before anaesthesia induction. It is important to bear in mind that pulse oximetry and blood pressure readings may be spurious in these patients, because both are based on cardiac flow pulsatility. For this reason, all patients with second or third generation VADs (continuous flow) will require serial blood gas measurements and cerebral oxygenation monitoring (SctO<span class="elsevierStyleInf">2</span>). Furthermore, the intraoperative use of transoesophageal echocardiography to determine the preload and function of the right ventricle, together with EEG or BIS should be considered, since tachycardia and hypertension are not reliable measures of depth of anaesthesia in these patients.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0395" class="elsevierStylePara elsevierViewall">Although neuraxial anaesthesia is not contraindicated in these patients, most professionals prefer general anaesthesia for better control of the peripheral vasodilation and coagulation alterations typically observed in these patients.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0400" class="elsevierStylePara elsevierViewall">The first-choice strategy is general anaesthesia, which can be performed with any drug provided by the haemodynamic stability of the patient is guaranteed. High-dose fentanyl should be administered for induction to avoid the sympathetic reaction associated with laryngoscopy, which may have an adverse effect on the VAD by increasing vascular resistance, and a hypnotic that does not induce the opposite effect (decreased vascular tone) should be used.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0405" class="elsevierStylePara elsevierViewall">Correct right ventricle preload and function depends on avoiding volume overload and ensuring adequate right ventricular contractility and good pulmonary vasculature tone. Therefore, it is best to maintain spontaneous ventilation as far as possible, and if this is not feasible, to ensure the patient is well oxygenated in order to avoid hypoxic pulmonary vasoconstriction. In addition, high Vt and excessively high or low PEEP should be avoided to prevent alveolar overdistension collapse, respectively.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">An action algorithm should be drawn up to deal with changes in VAD flow: the initial suspicion should always be decreased preload, which should be treated by administering fluids; secondly, cannula position and patency must be checked and any kinks removed; if the situation persists, steps should be taken to optimise right ventricular function and to either increase or decrease the systemic vascular resistance, depending on the information provided by the monitoring devices.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> If the patient does not improve despite all measures, the presence of a thrombus in one of the cannulas or of a suction event should be suspected; both of which can be assessed with intraoperative TEE.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall">Any manoeuvres to reposition the VAD should be performed with the utmost care. Pneumoperitoneum should be induced gradually using the lowest possible pressure when laparoscopic surgery is performed.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,10</span></a></p><p id="par0420" class="elsevierStylePara elsevierViewall">Finally, the patient should be extubated when the corresponding criteria have been met, and anticoagulant therapy should be restarted as soon as possible, especially in patients with first-generation VADs, due to their greater risk of thromboembolic events. Restart of antiplatelet therapy can be delayed by up to 1 week.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusion and recommendations</span><p id="par0425" class="elsevierStylePara elsevierViewall">The number of patients with VADs is increasing steadily, and estimates suggest that 20% of these will require non-cardiac surgery at some time.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">Given the complexity of these patients, such interventions should be centralised and performed in specialised centres equipped with multidisciplinary teams,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> even though there is no evidence of poorer outcome when the surgery is performed in non-specialised hospitals.</p><p id="par0435" class="elsevierStylePara elsevierViewall">It is also advisable to create protocols and action algorithms to ensure proper management from the moment of admission until the discharge of the patient. These should include the recommendations given in this article in respect of perioperative optimisation, knowledge of the physiology of the different types of VAD and of the diagnosis and treatment of possible complications.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0440" class="elsevierStylePara elsevierViewall">None of the authors has any conflict of interest to report.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1135241" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1067340" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1135242" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1067341" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case reports" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Case 3" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Case 4" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusion and recommendations" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack386399" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-25" "fechaAceptado" => "2018-07-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1067340" "palabras" => array:3 [ 0 => "Ventricular assist device" 1 => "Heart transplant" 2 => "Anaesthesia in non-cardiac surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1067341" "palabras" => array:3 [ 0 => "Asistencia ventricular" 1 => "Trasplante cardiaco" 2 => "Anestesia en cirugía no cardiaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Heart failure (HF) is a syndromic condition with a high incidence in current medicine. When the symptoms of HF progress, and become refractory, cardiac transplant is the best therapeutic option. However, due to the shortage of donors and the long waiting lists, many of those patients are candidates for implantation of ventricular assist devices as a bridge to the cardiac transplant, or when this is not an option, as a definitive therapy. A series of four clinical cases of patients with ventricular assist devices that required surgical intervention, is presented. Three of them were assisted with long-term care: two EXCOR (pulsatile and para-corporeal) and one HEARTWARE (non-pulsatile and intra-corporeal), and the last one with short-term assistance; CentriMag biventricular Levitronix. There is no significant literature on the peri-operative implications of these patients when they undergo urgent or scheduled surgery. The experience in our centre leads us to raise the need to determine a series of aspects: operation of each device, emphasising the correct placement of the cannulas during the surgery; the proper management of any medication, emphasising the importance of anticoagulant and anti-platelet therapies; the Pathophysiological changes at cardiopulmonary level due to the implantation of these devices; and the importance of the administration of a correct antibiotic therapy. Given the complexity of these cases, the limited experience in this field, and the few cases that exist in these situations, it is recommended to create protocols to ensure their proper management.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La insuficiencia cardiaca constituye un cuadro sindrómico de elevada incidencia en la medicina actual. Cuando los síntomas de la insuficiencia cardiaca progresan y se convierten en refractarios, la indicación de trasplante cardiaco es la mejor opción terapéutica. Sin embargo, debido a la escasez de donantes y a las largas listas de espera, muchos de estos pacientes necesitan la implantación de dispositivos de asistencia ventricular como puente a este trasplante, o en algunos casos, cuando el trasplante no es una opción, como terapia definitiva. En este artículo se presenta una serie de 4 casos clínicos en pacientes portadores de dispositivos de asistencia ventricular que precisaron intervención quirúrgica. Tres de ellos estaban asistidos con asistencias de larga duración: 2 EXCOR (pulsátiles y paracorpórea) y un HEARTWARE (no pulsátil e intracorpórea) y el último con una asistencia de corta duración; CentriMag Levitronix biventricular. No existe bibliografía significativa sobre las implicaciones perioperatorias de estos pacientes cuando son sometidos a cirugía urgente o programada. La experiencia en nuestro centro nos lleva a plantear la necesidad de conocer una serie de aspectos: funcionamiento de cada dispositivo, recalcando la correcta colocación de las cánulas durante la cirugía; el manejo apropiado de la medicación, recalcando la importancia de las terapias anticoagulantes y antiagregantes; los cambios fisiopatológicos a nivel cardiopulmonar debidos a la implantación de estos dispositivos; y la importancia de la administración de una correcta antibioterapia. Ante la complejidad que presentan estos casos, la escasa experiencia en este campo y los pocos casos que existen de estas situaciones se recomienda la creación de protocolos para garantizar un manejo correcto de estos.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Albajar Bobes A, Casado Salcedo M, Rincón Gómez-Limón E, Álvarez Avello JM, González Román AI, Vidal Fernández M, et al. Experiencia en manejo anestésico para cirugía no cardiaca en pacientes con asistencias ventriculares. Rev Esp Anestesiol Reanim. 2019;66:37–45.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 597 "Ancho" => 950 "Tamanyo" => 87774 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Image prior to the start of laparoscopic cholecystectomy in a patient with an EXCOR biventricular VAD (Berlin Heart). Note the typical paracorporeal placement of this VAD model.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 630 "Ancho" => 950 "Tamanyo" => 84213 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic cholecystectomy in a patient with EXCOR biventricular VAD (Berlin Heart). The image shows the importance of correctly placing the cannulae during the procedure to avoid kinking, which would reduce preload and compromise the VAD.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 660 "Ancho" => 950 "Tamanyo" => 134732 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Removal of hip prosthesis in a patient with double Levitronix. Observe the importance of correctly placing the cannulae to ensure the VAD functions correctly, and of correctly positioning the patient to prevent position-related complications.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1107 "Ancho" => 950 "Tamanyo" => 212026 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Levitronix biventricular VAD monitoring screen during hip prosthesis removal. In addition to adequate monitoring, the surgical team must have access to the VAD screens to check that they are functioning correctly and providing a steady flow. Changes observed on the screens could indicate possible complications, the most frequent being kinking of the cannulas or hypovolaemia.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Classification</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Device \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pulsatile \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Paracorporeal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1st generation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thoratec PVAD<br>EXCOR Berlin Heart<br>Abiomed<br>Medos \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Implanted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1st generation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HeartMate XVE<br>Novacor<br>CardioWest<br>AbioCor \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Non-pulsatile</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Axial</td><td class="td" title="table-entry " align="left" valign="top">2nd generation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HeartMate II<br>Jarvik 2000<br>INCOR Berlin Heart<br>Heart Assist 5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3rd generation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HeartWare<br>Dura Heart \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Centrifugal</td><td class="td" title="table-entry " align="left" valign="top">2nd generation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CentriMag Levitronix<br>Biomedicus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3rd generation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MagLev \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1936719.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Classification of ventricular assist devices.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Álvarez Escudero J, Calvo Vecino JM, Baluja A, Cabadas R, Cariñena A, García R, et al. 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Hessel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Sem Cardiothorac Vasc Anesth" "fecha" => "2013" "volumen" => "XX" "paginaInicial" => "1" "paginaFinal" => "14" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack386399" "titulo" => "Acknowledgements" "texto" => "<p id="par0445" class="elsevierStylePara elsevierViewall">Our most sincere thanks to the entire Anaesthesia and Critical Care Service of the Puerta de Hierro Hospital, and to each and every member of staff who give their best every day. Special thanks go to José Manuel Álvarez Avello, who devoted so much time to correcting and improving this manuscript, and to all the professionals we have had the good fortune to meet, for their suggestions and corrections. Thanks to Ana González for the initial idea for this article, for her great professionalism, but above all, for her positive attitude and drive. And last but not least, thanks to all the patients who, to their misfortune and our fortune, surround us every day; particularly those described in this manuscript, without whom none of this would have been possible.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006600000001/v1_201901100606/S2341192918301859/v1_201901100606/en/main.assets" "Apartado" => array:4 [ "identificador" => "65601" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006600000001/v1_201901100606/S2341192918301859/v1_201901100606/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918301859?idApp=UINPBA00004N" ]
