Anesthesia for left ventricular assist device placement

THE FIRST successful use of a left ventricular assist device (LVAD) as a bridge to transplantation occurred in 1985. Today, there is little information describing the anesthetic management for LVAD placement. Patients presenting for this operation have long-standing cardiac failure and often have associated hepatic and renal impairment, which may significantly alter the pharmacokinetics of administered drugs and render patients coagulopathic. These critically ill patients may be treated with cardiac drugs (vasodilators and antiarrhythmics) that may have potentially significant interactions with the administration of anesthetics and the stress of surgery. The anesthesiologist should be prepared to manage cardiac decompensation and acute desaturation before institution of cardiopulmonary bypass (CPB) as well as right ventricular failure and severe coagulopathic bleeding after CPB. This article discusses the anesthetic management of these challenging patients in the light of the aforementioned concerns and describes the utility of transesophageal echocardiography (TEE) in patient management.