[Anesthesiology problems for implant and explant of left ventricular Novacor systems]. / Problematiche anestesiologiche per l'impianto e l'espianto di sistemi di assistenza ventricolare sinistra Novacor.

OBJECTIVES: To review experience with anaesthetic management in patients undergoing a left ventricular assist system (LVAS) Novacor implant as a bridge to cardiac transplantation. DESIGN: Retrospective clinical study. SETTING: Cardiothoracic operating room in a university hospital. PATIENTS: Nine, aged 37-62 years, suffering from 8 dilated and 1 postischemic cardiomyopathy at end stage heart failure. INTERVENTIONS OR METHODS: Under general anaesthesia and cardio-pulmonary bypass the LVAS pump is placed in the abdomen and connected to the left ventricle through an inflow cannula and to the aorta through an outflow cannula. The pump has an output of 5-7 l/min and works in synchronous counterpulsation with the left ventricle. RESULTS: The mean Novacor support has been 75.56 days (DS +/- 85.95). Five out of 9 patients have been transplanted, while 3 are still waiting at home. Pretransplant CI was on average 1.66 l/min/m2 (DS +/- 0.27) and REF 11.44% (DS +/- 5.29); after the Novacor implant CI was 3.44 (DS +/- 0.49) and REF 22.22% (DS +/- 4.49). CONCLUSIONS: A LVAS can bridge patients to heart transplantation while improving or preserving their health conditions. Some factors are to be taken into account for the anaesthesiological management of the implant/explant of a LVAS: the patients' poor clinical conditions; the knowledge of the components and functioning of the LVAS that conditions the choice of the anaesthesiological drugs and volemia; the unassisted right ventricle function that has to be pharmacologically supported; the bleeding problem because of the adherences during the explant surgery.

Management of anesthesia during dynamic cardiomyoplasty.

STUDY OBJECTIVE: To review experience with anesthetic management in ten patients undergoing dynamic cardiomyoplasty (CMPL), a new surgical technique that serves as an alternative to heart transplantation. DESIGN: Retrospective clinical study. SETTING: Cardiothoracic operating room at a university hospital. PATIENTS: Ten male functional New York Heart Association (NYHA) class III and IV patients, aged 39 to 60 years, awaiting heart transplantation, 7 of whom were diagnosed with dilated cardiomyopathy, 3 with postischemic cardiomyopathy. INTERVENTIONS: Under general anesthesia, the latissimus dorsi muscle was harvested and rotated into the chest through a window in the second rib. The muscle was then wrapped around the heart. Starting from the second postoperative week, the latissimus dorsi was stimulated to provide assistance to a failing heart. MEASUREMENTS AND MAIN RESULTS: The mean left ventricular ejection fraction (LVEF) of the 10 patients was 24.89% +/- 9.17% (range 10% to 37%). No intraoperative death occurred. Two patients died of multiple organ failure and an apparent arrhythmia on the 15th and 25th postoperative days, respectively. The rest of the patients regained good working capacity postoperatively, as evidenced by improvement in NYHA grade. Nevertheless, the LVEF improved in only one patient. No significant differences were evident between preoperative and postoperative blood values, hemodynamic data, or spirometry. CONCLUSIONS: Dynamic CMPL is a considerable challenge for the anesthesiologist because these patients have poor cardiac reserve preoperatively and do not benefit from the procedure in the first two postoperative weeks. To date, CMPL seems to be an important alternative to heart transplantation because experience has shown an improvement in the quality of life with low intraoperative and postoperative complications.