LVAD Insertion (HeartMate 3)
Patient phenotype
End-stage HF, EF < 25%, refractory to medical therapy. Bridge to transplant or destination therapy. Often inotrope-dependent on arrival. Frequent comorbidities: renal dysfunction, pulmonary HTN, RV dysfunction.
Procedure
Median sternotomy, CPB. Apex of LV cored, inflow cannula sewn in. Outflow graft to ascending aorta. Driveline tunneled out abdominal wall. CPB weaned with LVAD support. 4-6 hours.
Anesthetic plan
Same as transplant: high-dose opioid + etomidate + cisatracurium. TEE mandatory (positioning, deairing, RV assessment). PA catheter standard. Continuous inotropic + RV protective support.
Setup
- ·A-line PRE-induction
- ·CVC + PA catheter
- ·TEE
- ·Cell saver
- ·Defib pads (TAVR position — left lateral, right anterior)
- ·Multiple inotrope/vasopressor infusions
- ·iNO available
- ·External controller + driveline ready
Biggest concerns by phase
Avoid hemodynamic collapse
Same as transplant: minimize cardiac depression. High-dose opioid + etomidate. Continue inotropes. A-line first.
RV failure post-LVAD initiation
LVAD unloading LV → RV preload increases (now must pump full output). Failing RV may decompensate. Strategy: minimize PVR, milrinone + epi, iNO. Some need RVAD acutely.
Deairing + LVAD speed ramping
TEE confirms LV deairing — air in LVAD = pump fail or stroke. Slow ramp from 4000 to 5500 RPM (HM3) with TEE monitoring septal position, mitral regurg, RV function.
Coagulopathy + bleeding
Long CPB + heparin + redo (often) = bleeding. TEG-guided. Cell saver. Resume anticoagulation carefully postop (LVAD requires lifelong AC).
Pulsatility + LVAD physiology in ICU
LVAD = continuous flow → may not have palpable pulse, NIBP unreliable. A-line for MAP. Educate ICU + family on LVAD vitals.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
60-yo M, ischemic cardiomyopathy, EF 15%, PA pressures 55/30, RV mod-severe dysfunction, on milrinone + dobutamine, scheduled for HeartMate 3 destination therapy. Walk through anesthesia plan.
What an examiner probes for
- ▹Recognizes RV dysfunction + post-LVAD RV failure risk
- ▹Plans induction to minimize hemodynamic insult
- ▹TEE, PA, A-line all pre-induction
- ▹Inotrope continuation + escalation strategy
- ▹iNO + milrinone for PVR
Sources
- Kaplan's Cardiac 7e
- INTERMACS LVAD Anesthesia Review
Anatomy reference
Sourced reference images. 4 matches for "heart cardiac ventricle pump".
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