P009: ANESTHETIC MANAGEMENT OF ROBOT-ASSISTED COLOSTOMY REVERSAL IN A PATIENT WITH A HEARTMATE 3 LVAD
Ryan Stalder, MD; Jessica Bonilla, DO; Onassis Naim Campos, MD
Memorial Healthcare System
Introduction: The HeartMate 3 left ventricular assist device (LVAD) is a surgically implanted, continuous-flow mechanical pump that supports the left ventricle in pumping blood to the systemic circulation in patients with advanced heart failure. The increased prevalence of LVADs, along with improved survival rates of these patients, has led to an increase in LVAD patients presenting for non-cardiac surgery. Robot-assisted techniques present a unique anesthetic challenge in preload-dependent patients due to pneumoperitoneum and Trendelenburg positioning. Here we describe the anesthetic management of robot-assisted colostomy reversal in a patient with a HeartMate 3 LVAD.
Case Description: A 56-year-old female with past medical history of heart failure with reduced ejection fraction (NYHA class III/D) status post HeartMate 3 LVAD implant, atrial tachycardia status post placement of an AICD, pulmonary hypertension, primary hypertension, type 2 diabetes mellitus, and transverse loop colostomy presented for elective robotic colostomy reversal. Preoperative planning included device interrogation by the LVAD coordinator (fixed pump speed 5300 RPM, pump flow 3.7 L/min, pulse index 6.5, pump power 4.0 watts), perioperative speed management strategy, and extensive discussion with the surgeon regarding insufflation and patient positioning. An arterial line was placed pre-induction. R2 defibrillator pads were placed on the patient and the AICD was set to asynchronous mode (DOO) per protocol. Following induction with etomidate and endotracheal intubation, a quad lumen central venous catheter and TEE probe were placed. Propofol was utilized for maintenance anesthesia. Pre-insufflation milrinone and epinephrine infusions were used for right ventricular support, while a vasopressin infusion was utilized to augment systemic vascular resistance while minimizing increases in pulmonary vascular resistance. TEE assessment of septal position and RV size guided titration of inotropes and fluid administration during periods of reduced preload. Two units of pRBC were transfused. After a successful colostomy reversal, the patient was extubated and admitted to cardiac IMCU. The patient’s posteroperative course was uneventful and she was discharged on POD3.
Discussion: A growing number of continuous-flow LVAD patients are presenting for noncardiac surgery. Patients with these continuous-flow devices exhibit preload dependence, afterload sensitivity, and decreased reliability of pulsatile vital signs. In this case the pulse oximetry waveform was inconsistent, requiring use of serial ABGs to assess oxygenation. This case also presented surgery-specific challenges, including pneumoperitoneum and Trendelenburg positioning. TEE proved particularly useful for real-time assessment of preload, afterload, RV function, and global biventricular interaction.
Perioperative management of specific HeartMate 3 parameters such as flow, PI, and speed require multidisciplinary planning with LVAD coordinators, heart failure specialists, and the surgery team. Together with careful, TEE-guided anesthetic management, our HeartMate 3 patient safely underwent minimally invasive, robot-assisted reversal of her colostomy.
