Management of aortic valve insufficiency in patients supported by long-term continuous flow left ventricular assist devices.

Continuous flow (CF) left ventricular assist devices (LVADs) have yielded improved outcomes in patient survival and quality of life compared with first-generation pulsatile pumps; however, they have been associated with an increased incidence of postimplant aortic valve insufficiency (AI), which can have can have serious clinical consequences if not diagnosed and treated expeditiously. We reviewed our experience with AI after LVAD since the start of our CF LVAD program. From March 2006 through July 2011, 94 patients with chronic heart failure underwent implantation of a HeartMate II (HM II) LVAD. Severe AI developed in three patients after CF LVAD implantation. The clinical records of these patients were reviewed to analyze the presenting signs and symptoms of AI, identify the duration of LVAD support when the AI occurred, how the AI was treated, and the outcomes.

Gastrointestinal bleeding with the HeartMate II left ventricular assist device.

BACKGROUND: Continuous flow left ventricular assist devices (CF-LVADs) have yielded improved outcomes compared with pulsatile flow devices for patients on long-term support. However, significant rates of gastrointestinal bleeding (GIB) have been observed during CF-LVAD support. METHODS: From March 2006 through March 2011, 86 patients with chronic heart failure underwent implantation of a CF-LVAD (HeartMate II; Thoratec Corp., Pleasanton, CA). Records were reviewed to determine the prevalence of post-implant GIB, location of the bleeding site and associated morbidity and mortality. Uni- and multivariate analyses were conducted to identify independent predictors of GIB. RESULTS: GIB occurred in 19 patients (22.1%) with a duration of support that ranged from 5 to 456 days. Sources of GIB included small bowel and rectum in 6 patients each, large bowel in 2 patients and stomach in 1 patient. No definite source was identified in 4 patients. There were no deaths referable to GIB. Recurrent GIB occurred in 4 patients. History of a GIB prior to LVAD implant was the only variable significantly different between patients with and without post-implant GIB (21.1% vs 10.4%, p = 0.016), and was the only independent predictor of GIB (OR = 2.24, 95% CI 2.121 to 2.435, p = 0.004). CONCLUSIONS: Gastrointestinal bleeding is a frequent source of morbidity for patients on HeartMate II LVAD support but does not significantly impact survival. As implantation of CF-LVADs with non-pulsatile flow gains popularity for both bridge-to-transplant and destination therapy, a better understanding of the pathophysiology of GIB in these patients will be needed for minimizing this complication.

Non-cardiac surgery in patients on long-term left ventricular assist device support.

BACKGROUND: An increasing number of patients on left ventricular assist device (LVAD) support are requiring non-cardiac surgical (NCS) procedures. We reviewed our experience with the management of patients on continuous flow (CF) LVAD support undergoing NCS. METHODS: From March 2006 through March 2011, 86 patients with chronic heart failure underwent implantation of a HeartMate II (Thoratec Corp, Pleasanton, CA) LVAD. Clinical records of these patients were reviewed to identify patients who underwent NCS while on LVAD support, with a focus on peri-operative death, bleeding, thrombosis, and device malfunction, as well as management of pre-operative anti-coagulation. RESULTS: While on CF-LVAD support, 20 patients underwent 25 NCSs, comprising 13 major and 12 minor procedures. Operations were performed electively in 22 and as emergencies in 3. No peri-operative deaths, thromboembolic complications, or device malfunctions occurred. The incidence of bleeding requiring transfusion of packed red blood cells was 36.0%, including 25% of patients undergoing minor NCSs and 46.2% undergoing major NCSs (p = 0.004). All bleeding complications occurred in patients on both warfarin and aspirin pre-operatively. The only significant differences between patients who did and did not require transfusion were pre-operative warfarin use and significantly higher pre-operative international normalized ratio in the transfused group (1.9 ± 0.4 vs 1.4 ± 0.3; p = 0.008). CONCLUSIONS: Non-cardiac operations can be performed safely in patients with CF-LVADs. It may possible to reduce peri-operative bleeding by lowering pre-operative anti-coagulation goals, especially before major surgery. However, additional analysis is required to determine if this can be performed safely.

Prospective evaluation of anesthetic technique for anorectal surgery.

PURPOSE: Deep intravenous sedation plus local anesthesia for anorectal surgery in the prone position is used frequently at our institution, but is not widely accepted because of concerns regarding airway management. The purpose of this study was to prospectively evaluate the safety and efficacy of this anesthetic technique for anorectal surgery. METHODS: Data were collected prospectively on 413 consecutive patients (mean age, 47 years; mean weight, 80 kg) undergoing anorectal surgical procedures. RESULTS: Of the 389 patients who underwent anorectal procedures in the prone position, 260 (67 percent) received intravenous sedation plus local anesthesia, 125 (32 percent) received regional anesthesia (spinal or epidural), and 4 (1 percent) received general endotracheal anesthesia. Of the 24 patients who underwent anorectal procedures in the lithotomy position, 13 (54 percent) received intravenous sedation plus local anesthesia, 2 (8 percent) received regional anesthesia, 2 (8 percent) received general endotracheal anesthesia, and 7 (29 percent) received mask inhalational anesthesia. Forty-two adverse events attributable to the anesthetic occurred in 18 patients: nausea and vomiting (n = 17), transient hypotension, bradycardia, or arrhythmia (n = 8), transient hypoxia or hypoventilation (n = 7), urinary retention (n = 6), and severe patient discomfort (n = 2). These complications occurred in 4 percent (10/273) of patients receiving intravenous sedation plus local anesthesia and in 6 percent (8/127) of patients receiving regional anesthesia. Two of 260 patients (0.8 percent) receiving intravenous sedation plus local anesthesia in the prone position were rolled supine before completing the surgical procedure. Recovery time before discharge for patients treated on an ambulatory basis was significantly shorter for those patients undergoing intravenous sedation plus local anesthesia (79 +/- 34 minutes, n = 174) than for patients undergoing regional anesthesia (161 +/- 63 minutes, n = 45; P < 0.001, t-test). CONCLUSION: Intravenous sedation plus local anesthesia in the prone position is safe and effective for anorectal surgery and offers potential cost savings by decreasing recovery room time for outpatient procedures.

Advanced ultrasonic diagnosis of extremity trauma: the FASTER examination.

BACKGROUND: Ultrasound is of proven accuracy in abdominal and thoracic trauma and may be useful for diagnosing extremity injury in situations where radiography is not available such as military and space applications. We prospectively evaluated the utility of extremity ultrasound performed by trained, nonphysician personnel in patients with extremity trauma to simulate remote aerospace or military applications. METHODS: Patients with extremity trauma were identified by history, physical examination, and radiographic studies. Ultrasound examination was performed bilaterally by nonphysician personnel, blinded to radiographic results, with a portable ultrasound device using a 10- to 5-MHz linear probe. Images were videorecorded for later analysis against radiography by Fisher's exact test. RESULTS: There were 158 examinations performed in 95 patients. The average time of examination was 4 minutes. Ultrasound accurately diagnosed extremity injury in 94% of patients with no false-positive examinations; accuracy was greater in midshaft locations and least in the metacarpal/metatarsals. Soft tissue/tendon injury was readily visualized. CONCLUSION: Extremity ultrasound can be performed quickly and accurately by nonphysician personnel with excellent accuracy. Pulmonary ultrasound appears promising; blinded verification of the utility of ultrasound in patients with extremity injury should be performed to determine whether extremity and respiratory evaluation should be added to the FAST examination (the FASTER examination) and to verify the technique in remote locations such as military and aerospace applications.