Non-cardiac surgery in patients on long-term left
ventricular assist device support
Jeffrey A. Morgan, MD,
a
Gaetano Paone, MD,
a
Hassan W. Nemeh, MD,
a
Scott E. Henry, MD,
a
Brent Gerlach, BA,
a
Celeste T. Williams, MD,
b
David E. Lanfear, MD,
b
Cristina Tita, MD,
b
and Robert J. Brewer, MD
a
From the
a
Divisions of Cardiothoracic Surgery and
b
Cardiovascular Medicine, Heart and Vascular Institute, Henry Ford Hospital,
Detroit, Michigan.
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 signif-
icantly 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.
J Heart Lung Transplant 2012;31:757– 63
© 2012 International Society for Heart and Lung Transplantation. All rights reserved.
KEYWORDS:
left ventricular assist
device;
continuous flow;
non-cardiac surgery;
anti-coagulation;
word
Left ventricular assist devices (LVADs) have become
an accepted therapeutic strategy for bridge to transplant
(BTT) and destination therapy (DT) in patients with
refractory end-stage heart failure.
1–3
Miller et al
1
dem-
onstrated 75% survival at 6 months of LVAD support
along with a significant improvement in New York Heart
Association functional class status in 133 BTT patients
awaiting heart transplantation.
1
In the HeartMate II (Tho-
ratec Corp, Pleasanton, CA) pivotal BTT trial, Pagani et
al
2
reported that 79% of 281 patients successfully met the
primary end point of receiving a transplant, explanted for
cardiac recovery, or on ongoing support at 18 months.
As duration of LVAD support has increased, more of
these patients require elective non-cardiac surgery
(NCS).
3–10
These patients present numerous challenges to
non-cardiac care-takers, including anesthesiologists and op-
erating room nurses, who are not familiar with the manage-
ment of patients who are receiving continuous flow (CF)
LVAD support.
11,12
Reprint requests: Jeffrey A. Morgan, MD, Henry Ford Hospital, 2799
W. Grand Blvd, K-14, Rm 1439, Detroit, MI 48202. Telephone: 313-916-
2695. Fax: 313-916-2687.
E-mail address: jmorgan2@hfhs.org
http://www.jhltonline.org
1053-2498/$ -see front matter © 2012 International Society for Heart and Lung Transplantation. All rights reserved.
doi:10.1016/j.healun.2012.02.023