Benefits of ultra-fast-track anesthesia in left ventricular assist device implantation: a retrospective, propensity score matched cohort study of a four-year single center experience.
BACKGROUND
The use of left ventricular assist devices (LVADs) has gained significant importance for treatment of end-stage heart failure. Fast-track procedures are well established in cardiac surgery, whereas knowledge of their benefits after LVAD implantation is sparse. We hypothesized that ultra-fast-track anesthesia (UFTA) with in-theater extubation or at a maximum of 4 h. after surgery is feasible in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 3 and 4 patients and might prevent postoperative complications.


METHODS
From March, 2010 to March, 2012, 53 LVADs (50 Heart Mate II and 3 Heart Ware) were implanted in patients in our department. UFTA was successfully performed (LVADultra) in 13 patients. After propensity score matching, we compared the LVADultragroup with a matched group (LVADmatch) receiving conventional anesthesia management.


RESULTS
Patients in the LVADultragroup had significantly lower incidences of pneumonia (p = 0.031), delirium (p = 0.031) and right ventricular failure (RVF) (p = 0.031). They showed a significantly higher cardiac index in the first 12 h. (p = 0.017); a significantly lower central venous pressure during the first 24 h. postoperatively (p = 0.005) and a significantly shorter intensive care unit (ICU) stay (p = 0.016). Kaplan-Meier analysis after four years of follow-up showed no significant difference in survival.


CONCLUSIONS
In this pilot study, we demonstrated the feasibility of ultra-fast-track anesthesia in LVAD implantation in selected patients with INTERMACS level 3-4. Patients had a lower incidence of postoperative complications, better hemodynamic performance, shorter length of ICU stay and lower incidence of RVF after UFTA. Prospective randomized investigations should examine the preservation of right ventricular function in larger numbers and identify appropriate selection criteria.
Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany. rzayat@ukaachen.de.
Rashad
http://orcid.org/0000-0003-2243-8743
R
Zayat
Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
Ares K
AK
Menon
Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
Andreas
A
Goetzenich
Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
Gereon
G
Schaelte
Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
Ruediger
R
Autschbach
Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
Christian
C
Stoppe
Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
Tim-Philipp
TP
Simon
Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
Lachmandath
L
Tewarie
Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
Ajay
A
Moza
D000758:Anesthesia / Q000379:methods*; D006348:Cardiac Surgical Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000503:physiopathology / Q000601:surgery*; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D057216:Propensity Score; D011446:Prospective Studies; D012042:Registries; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D018497:Ventricular Dysfunction, Right / Q000503:physiopathology
Fast-track-anesthesia; Left ventricular assist device; Postoperative complication; Right ventricular failure