Anesthetic management for abdominal aortic surgery in a patient with a left ventricular assist device: a case report

Abstract

Left ventricular assist devices (LVAD) are a currently established destination and bridge therapy until cardiac transplantation; hence, this patient population continues to increase. Here, we present the first report of abdominal aortic cross-clamping (ACC) in a LVAD patient undergoing emergency aneurysm repair. Anticoagulation was continued pre-and intra-operatively to avoid pump thrombosis. The pumping function of the LVAD is highly dependent on both preload and afterload. In this case, abdominal ACC, which increases the afterload, did not significantly influence circulatory dynamics. However, when the abdominal ACC was released, mean atrial pressure (MAP) fell to 42 mmHg, because preload reduction due to massive bleeding (3532 g) secondary to anticoagulation and afterload reduction by abdominal ACC release combined to cause critical hypotension. Maintenance of MAP required rapid infusion and use of an alpha-adrenergic agent. Surgical and anesthesia times were 411 and 525 min, respectively. Total blood loss was 5389 g, respectively. The patient was discharged after 25 postoperative days with no major complications. ACC release, with its accompanying decrease in preload and afterload, and massive bleeding due to anticoagulation in these patients require careful management.

Keywords: Afterload; Anticoagulation; Aortic cross-clamping; Left ventricular assist devices; Preload.

Fig. 1

Anesthetic record. Pheny phenylephrine, HR heart rate, ART (M) mean arterial pressure, CVP (M) central venous pressure, EtCO2 end-tidal carbon dioxide, ACT activated clotting time, RCC red cell concentrate, FFP fresh frozen plasma, ACC aortic cross-clamping, ☓ start and completion of anesthesia, T intubation, ◎ start and completion of surgery