Anesthesia and Imaging for Advanced Circulatory Support

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Key points

  • Continuous-flow left ventricular assist devices (LVADs) are the most commonly implanted form of durable mechanical circulatory support (MCS), and their implantation for destination therapy is rapidly increasing.

  • Right-sided heart failure following LVAD implantation continues to be difficult to predict and leads to worse outcomes; earlier intervention with mechanical support for the right ventricle (RV) may be warranted.

  • The use of percutaneous circulatory support devices has become more prevalent

Background and goals of therapy

Before the development of effective immunosuppression, heart transplant did not enjoy its current recognition as the gold standard treatment of advanced heart failure. The difficulties in heart transplant spurred the National Heart, Lung, and Blood Institute in 1977 to encourage development of circulatory devices that could be implanted for 2 years or more. The first total artificial heart (TAH) intended for permanent support was implanted in 1984 by DeVries and colleagues [3]. Although the

Indications and device types

In adult patients undergoing cardiac surgery, the incidence of refractory postcardiotomy cardiogenic shock, or the inability to wean from cardiopulmonary bypass (CPB), is estimated to be 0.5% to 1.5% [37]. Intra-aortic balloon pumps (IABPs) are by far the most common type of MCS provided for this indication, and techniques on their placement have been well-described elsewhere [38]. Historically, however, prognosis for a postcardiotomy patient requiring high-dose pressor support in addition to

Extracorporeal membrane oxygenation as mechanical circulatory support

VA ECMO is a rescue intervention capable of providing both respiratory and hemodynamic support to critically ill patients, and its use in adults has grown 10-fold over the past 20 years [47]. This form of MCS is based on a modified adaptation of a conventional CPB circuit, consisting of a venous drainage cannula, external blood pump, oxygenator, heat exchanger, and an arterial return cannula (Fig. 12). Most commonly, VA ECMO is initiated to salvage patients with refractory cardiogenic shock in

Summary

Since the 1960s, when Kantrowitz and colleagues [58] first reported their use of the IABP in cardiogenic shock, there have been tremendous advances in the field of MCS. The continuous-flow LVAD has become the dominant mode of supporting patients with heart failure who are both eligible and ineligible for heart transplant. The number of options for temporary support for postcardiotomy shock has increased as well. Cardiac anesthesiologists will need to keep abreast of these new technologies as

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  • Cited by (0)

    Disclosures: E. Teo, M.M. Townsley, and C.B. Nyman—none; R.M. Sniecinski: Grifols, Shire Viropharma, Nonin—research support; Grifols—advisory board.

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