Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2012
Review Comparative StudyPulsatile vs. continuous flow in ventricular assist device therapy.
A left ventricular assist device (LVAD) is an important treatment option for a patient with end-stage heart failure. Both continuous and non-pulsatile devices are available, each with different effects on a patient's physiology. ⋯ Both devices increase survival beyond medical management. Continuous-flow devices are smaller and are associated with less overall morbidity than pulsatile devices.
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Best Pract Res Clin Anaesthesiol · Jun 2012
ReviewAnaesthesia for patients undergoing ventricular assist-device implantation.
In the last 10 years, implantation of ventricular-assist devices has become an interesting option as either bridge-to-transplantation or destination procedure for patients with end-stage congestive heart failure. In the future, the number of ventricular assist device implantations is expected to increase furthermore. In general, this patient cohort is associated with significant co-morbidities, for example, pulmonary hypertension, peripheral vascular disease and renal insufficiency. ⋯ Even minor changes in their haemodynamics and physiological parameters can cause significant morbidity and mortality. Experience in haemodynamic monitoring including echocardiography and pharmacological management (use of inotropes, phosphodiesterase inhibitors and vasopressors) is a requirement. Particularly, the diagnosis and therapy of right-sided heart failure after implantation of left-ventricular assist devices should be addressed.
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Best Pract Res Clin Anaesthesiol · Jun 2012
ReviewCoagulation management in patients undergoing mechanical circulatory support.
The incidence of bleeding and thrombo-embolic complications in patients undergoing mechanical circulatory support therapy remains high and is associated with bad outcomes and increased costs. The need for anticoagulation and anti-platelet therapy varies widely between different pulsatile and non-pulsatile ventricular-assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) systems. Therefore, a unique anticoagulation protocol cannot be recommended. ⋯ Furthermore, coagulation management can be hampered in non-pulsatile VADs by acquired von Willebrand syndrome, and in general by acquired factor XIII deficiency as well as by heparin-induced thrombocytopenia. In addition, POC testing can be used in bleeding patients to guide calculated goal-directed therapy with allogeneic blood products, haemostatic drugs and coagulation factor concentrates to optimise the haemostasis and to minimise transfusion requirements, transfusion-associated adverse events and to avoid thrombo-embolic complications, as well. However, coagulation management in patients undergoing mechanical circulatory support therapy is somehow like navigating between Scylla and Charybdis, and development of protocols based on POC testing seems to be beneficial.
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Best Pract Res Clin Anaesthesiol · Jun 2012
ReviewRight ventricular failure after LVAD implantation: prevention and treatment.
Right ventricular failure (RVF) complicates 20-50% of left ventricular assist device (LVAD) implantation cases and contributes to increased postoperative morbidity and mortality. Normal LVAD function alters the highly compliant right ventricular (RV) physiology, which may unmask RVF. ⋯ Treatment of RVF relies on inotropic support, decreasing pulmonary vascular resistance and adjusting LVAD flows to minimise distortion of RV geometry. RVAD insertion is a last recourse when RVF is refractory to medical treatment.
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Best Pract Res Clin Anaesthesiol · Jun 2012
ReviewMechanical circulatory support for cardiogenic shock.
Cardiogenic shock (CS) is a syndrome of progressive depression of myocardial function with systemic hypoperfusion. It occurs due to various aetiologies such as acute myocardial infarction, myocarditis, acute decompensated heart failure and postcardiotomy. Cardiogenic shock carries poor prognosis, and medical therapy alone is not effective. ⋯ Currently, there are several methods of mechanical circulatory support. These include extracorporeal life support, paracorporeal or extracorporeal ventricular-assist devices, percutaneous ventricular assist devices, intra-aortic balloon counterpulsation and total artificial heart. In this review, we discuss the role of each of these circulatory support devices in the management of acute cardiac failure.