Stroke and Left Ventricular Assist Device (LVAD)

Robert P. From, David Hasan, Michael T. Froehler, Jennifer L. Goerbig-Campbell

Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, Iowa City, USA.

DOI: 10.4236/ojanes.2013.31014                

Abstract

Treatment of ischemic stroke for a patient on left ventricular assist device (LVAD) by neurointerventional means is rare and many anesthesia providers are unfamiliar with both LVAD and neurointerventional protocols. Examples of this include: 1) filling for continuous-flow LVAD depend on preload and the flow is inversely related to afterload; as mean arterial pressure (MAP) increases above 80 to90 mmHg, flow decreases; 2) there may be no palpable pulse in patients with continuous flow LVADs; 3) pulse oximetry may not work when pump flow is high and native myocardial function is minimal; 4) increasing MAP above80 mmHg potentially will maintain ischemic brain tissue—the penumbra—until flow is restored. This latter example creates a paradoxical management goal: increasing the mean arterial pressure (MAP) above80 mmHg while maintaining ischemic brain tissue, may decrease flow to the LVAD. Finally, there is controversy regarding which type of anesthesia is most efficacious for neuro interventional procedures. We describe three patients on LVAD suffering ischemic stroke requiring anesthesia for embolectomy and angioplasty during neruointeventioal radiology procedures.

Keywords

Stroke; Heart Failure; Endovascular; Embolectomy; Neurointerventional; HeartMate II; LVAD

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	A. C. Nicolosi and P. S. Pagel, “Perioperative Considerations in the Patient with a Left Ventricular Assist Device,” Anesthesiology, Vol. 98, No. 2, 2003, pp. 565-570. doi:10.1097/00000542-200302000-00038
[2]	M. Oleyar, M. Stone and S. M. Neustein, “Perioperative Management of a Patient with a Nonpulsatile Left Ventricular-Assist Device Presenting for Noncardiac Surgery,” Journal of Cardiothoracic and Vascular Anesthesia, Vol. 24, No. 5, 2010, pp. 820-823. doi:10.1053/j.jvca.2009.06.004
[3]	A. L. Hoefnagel, R. Pasternak, A. E. Curle and M. P. Eaton, “Laparoscopic Gastric Bypass in a Patient with an Implanted Left Ventricular Assist Device,” Journal of Cardiothoracic and Vascular Anesthesia, Vol. 26, No. 5, 2012, pp. 880-882. doi:10.1053/j.jvca.2011.02.012
[4]	V. Kartha, W. Gomez, B. Wu and K. Tremper, “Laparoscopic Cholecystectomy in a Patient with an Implantable Left Ventricular Assist Device,” British Journal of Anaesthesiology, Vol. 100, No. 5, 2008, pp. 652-655. doi:10.1093/bja/aen052
[5]	M. E. Stone, W. Soong, M. Krol and D. L. Reich, “The Anesthetic Considerations in Patients with Ventricular Assist Devices presenting for Noncardiac Surgery: A Review of Eight Cases,” Anesthesia & Analgesia, Vol. 95, No. 1, 2002, pp. 42-49. doi:10.1097/00000539-200207000-00007
[6]	G. Samoukovic, M. Vassiliou, N. Giannetti, S. Al-Sabah, V. Lash and R. Cecere, “Laparoscopic Splenectomy in a Patient with a Heartmate? II Left Ventricular Assist Device,” Journal of Laparoendoscopic & Advanced Surgical Techniques, Part A, Vol. 21, No. 6, 2011, pp. 535-538. doi:10.1089/lap.2011.0169
[7]	R. John, F. Kamdar, P. Eckman, et al., “Lessons Learned from Experience with over 100 Consecutive HeartMate II Left Ventricular Assist Devices,” The Annals of Thoracic Surgery, Vol. 92, No. 5, 2011, pp. 1593-1599. doi:10.1016/j.athoracsur.2011.06.081
[8]	R. Krishnamani, D. DeNofrio and M. A. Konstam, “Emerging Ventricular Assist Devices for Long-Term Cardiac Support,” Nature Reviews Cardiology, Vol. 7, No. 2, 2010, pp. 71-76. doi:10.1038/nrcardio.2009.222
[9]	M. C. Deng, L. B. Edwards, M. I. Hertz, et al., “Mechanical Circulatory Support Device Database of the International Society for Heart and Lung Transplantation: Third Annual Report—2005,” The Journal of Heart and Lung Transplantation: The Official Publication of the International Society for Heart Transplantation, Vol. 24, No. 9, 2005, pp. 1182-1187.
[10]	K. B. Shah, D. G. Tang, R. H. Cooke, et al., “Implantable Mechanical Circulatory Support: Demystifying Patients with Ventricular Assist Devices and Artificial Hearts,” Clinical Cardiology, Vol. 34, No. 3, 2011, pp. 147-152. doi:10.1002/clc.20825
[11]	O. H. Frazier, T. J. Myers, S. Westaby and I. D. Gregoric, “Clinical Experience with an Implantable, Intracardiac, Continuous Flow Circulatory Support Device: Physiologic Implications and their Relationship to Patient Selection,” The Annals of Thoracic Surgery, Vol. 77, No. 1, 2004, pp. 133-142. doi:10.1016/S0003-4975(03)01321-3
[12]	T. J. Myers, M. Bolmers, I. D. Gregoric, B. Kar and O. H. Frazier, “Assessment of Arterial Blood Pressure during Support with an Axial Flow Left Ventricular Assist Device,” The Journal of Heart and Lung Transplantation: the Official Publication of the International Society for Heart Transplantation, Vol. 28, No. 5, 2009, pp. 423 427.
[13]	C. A. Thunberg, B. D. Gaitan, F. A. Arabia, D. J. Cole and A. M. Grigore, “Ventricular Assist Devices Today and Tomorrow,” Journal Cardiothoracic and Vascular Anesthesia, Vol. 24, No. 4, 2010, pp. 656-680. doi:10.1053/j.jvca.2009.11.011
[14]	M. J. Schneck, J. Biller and C. M. Loftus, “Interventions for Acute Ischemic Stroke,” In: C. M. Loftus, Ed., Neurosurgical Emergencies, 2nd Edition, Thieme Medical Publishers, Inc., New York, 2008, pp. 102-114.
[15]	G. C. Fonarow, E. E. Smith, J. L. Saver, et al., “Improving Door-to-Needle Times in Acute Ischemic Stroke: The Design and Rationale for the American Heart Association/American Stroke Association's Target: Stroke Initiative,” Stroke, Vol. 42, No. 10, 2011, pp. 2983-2989. doi:10.1161/STROKEAHA.111.621342
[16]	K. R. Lees, E. Bluhmki, R. von Kummer, et al., “Time to Treatment with Intravenous Alteplase and Outcome in Stroke: An Updated Pooled Analysis of ECASS, ATLANTIS, NINDS, and EPITHET Trials,” Lancet, Vol. 375, No. 9727, 2010, pp. 1695-1703. doi:10.1016/S0140-6736(10)60491-6
[17]	K. Becker, “Endovascular Treatment of Acute Stroke,” Current Treatment Options in Neurology, Vol. 9, No. 6, 2007, pp. 463-469. doi:10.1007/s11940-007-0047-9
[18]	W. S. Smith, G. Sung, J. Saver, et al., “Mechanical Throm bectomy for Acute Ischemic Stroke: Final Results of the Multi MERCI Trial,” Stroke, Vol. 39, No. 4, 2008, pp. 1205-1212. doi:10.1161/STROKEAHA.107.497115
[19]	Investigators Penumbra Pivotal Stroke Trial, “The Penumbra Pivotal Stroke Trial: Safety and Effectiveness of a New Generation of Mechanical Devices for Clot Removal in Intracranial Large Vessel Occlusive Disease,” Stroke, Vol. 40, No. 8, 2009, pp. 2761-2768. doi:10.1161/STROKEAHA.108.544957
[20]	A. Furlan, R. Higashida, L. Wechsler, et al., “Intra-Arterial Prourokinase for Acute Ischemic Stroke. The PROACT II Study: A Randomized Controlled Trial. Prolyse in Acute Cerebral Thromboembolism,” JAMA: The Journal of the American Medical Association, Vol. 282, No. 21, 1999, pp. 2003-2011. doi:10.1001/jama.282.21.2003
[21]	E. I. Levy, A. H. Siddiqui, A. Crumlish, et al., “First Food and Drug Administration-Approved Prospective Trial of Primary Intracranial Stenting for Acute Stroke: SARIS (Stent-Assisted Recanalization in Acute Ischemic Stroke),” Stroke, Vol. 40, No. 11, 2009, pp. 3552-3556. doi:10.1161/STROKEAHA.109.561274
[22]	H. P. Adams Jr., G. del Zoppo, M. J. Alberts, et al., “Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups,” Circulation, Vol. 115, No. 20, 2007, pp. 478-534. doi:10.1161/CIRCULATIONAHA.107.181486
[23]	M. J. Davis, B. K. Menon, L. B. Baghirzada, et al., “Anesthetic Management and Outcome in Patients during Endovascular Therapy for Acute Stroke,” Anesthesiology, Vol. 116, No. 2, 2012, pp. 396-405. doi:10.1097/ALN.0b013e318242a5d2
[24]	C. Geeganage and P. M. Bath, “Interventions for Deliberately Altering Blood Pressure in Acute Stroke,” Cochrane Database of Systematic Reviews, Vol. 3, 2008, Article ID: CD000039.
[25]	A. Abou-Chebl, R. Lin, M. S. Hussain, et al., “Conscious Sedation versus General Anesthesia during Endovascular Therapy for Acute Anterior Circulation Stroke: Preliminary Results from a Retrospective, Multicenter Study,” Stroke, Vol. 41, No. 6, 2010, pp. 1175-1179. doi:10.1161/STROKEAHA.109.574129
[26]	R. Gupta, “Local Is Better than General Anesthesia during Endovascular Acute Stroke Interventions,” Stroke, Vol. 41, No. 11, 2010, pp. 2718-2719. doi:10.1161/STROKEAHA.110.596015
[27]	C. Nichols, J. Carrozzella, S. Yeatts, T. Tomsick, J. Bro derick and P. Khatri, “Is Periprocedural Sedation during Acute Stroke Therapy Associated with Poorer Functional Outcomes?” Journal of Neurointerventional Surgery, Vol. 2, No. 1, 2010, pp. 67-70. doi:10.1136/jnis.2009.001768
[28]	C. Brekenfeld, H. P. Mattle and G. Schroth, “General Is Better than Local Anesthesia during Endovascular Procedures,” Stroke, Vol. 41, No. 11, 2010, pp. 2716-2717. doi:10.1161/STROKEAHA.110.594622
[29]	L. B. Hemmer, C. Zeeni and D. K. Gupta, “Generalizations about General Anesthesia: The Unsubstantiated Condemnation of General Anesthesia for Patients Undergoing Intra-arterial Therapy for Anterior Circulation Stroke,” Stroke, Vol. 41, No. 10, 2010, p. e573. doi:10.1161/STROKEAHA.110.588806
[30]	C. A. Molina and M. H. Selim, “General or Local Anesthesia during Endovascular Procedures: Sailing Quiet in the Darkness or Fast under a Daylight Storm,” Stroke, Vol. 41, No. 11, 2010, pp. 2720-2721. doi:10.1161/STROKEAHA.110.595447
[31]	M. T. Froehler, J. T. Fifi, A. Majid, A. Bhatt, M. Ouyang and D. L. McDonagh, “Anesthesia for Endovascular Treatment of Acute Ischemic Stroke,” Neurology, Vol. 79, No. 13, 2012, pp. 167-173. doi:10.1212/WNL.0b013e31826959c2
[32]	GALA Trial Collaborative Group, S. C. Lewis, C. P. Warlow, et al., “General Anaesthesia versus Local Anaesthesia for Carotid Surgery,” Lancet, Vol. 372, No. 9656, 2008, pp. 2132-2142. doi:10.1016/S0140-6736(08)61699-2