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Cardio Diabetes Medicine 2017 381

been proposed,there are currently no validated risk therisk for right ventricular ischemia if the mean ar-
prediction models to identify patients athighest risk terial pressure is below 65-70 mmHg.
for perioperative complications for ventricular assist Poor nutritional state is associated with a high risk
device implant.All efforts should be made to ensure of post-operative complications,including infections,
that all patients go into surgery with optimalorgan poor healing, poor functional recovery and prolonged
functions, irrespective of its baseline state.
length of stay. Patients with cardiac cachexia should
receive intensive nutritional optimization with high
Pre-operative Optimization caloric oral supplements, enteral feedings orparen-
The use of inotropes, vasopressors and temporary- teral nutrition in order to boost nutritional status on
mechanical circulatory support devices can improve the short term (e.g. few dayspre-op) and achieve a
renal blood flow, while judicious decongestion with pre-operative albumin and pre-albuminvalues of
combination of intravenous diuretics, aquaretics or above 3 mg/dL and 15 mg/dL, respectively.
ultrafiltration will reduce the central and renal venous
pressures. All attempts should be made to improve Intra-operative Management
renal function to pre-operative creatinine and blood The intraoperative period is the most critical time oft-
urea nitrogen values of less than 2 mg/dL and 50 he implant and proper anesthetic techniques, hemo-
mg/dL, respectively. Hepatic dysfunction in heart dynamic management and surgical techniques are
failure is a result of circulatory shock from acute key to a successful outcome. The right ventricle is
decompensation and persistently high right atrial particularly vulnerable during the implant procedure.
pressures in the setting of venous congestion and Right coronary artery hypoperfusion from hypoten-
poor rightventricular function.Hepatic dysfunction sion or air emboli should be avoided. Vasopres-
can lead to coagulation abnormalities and increased sors (or vasodilators as needed)should be used to
risk ofbleeding in patients undergoing ventricular maintain a mean arterial pressure of 70-75 mmHg
assist device implantation. Those with acute heart during the implant procedure. Inotropes should be
failure decompensation and elevations of transam- used to maintain a good contractile function and
inases or bilirubin should receive aggressive therapy intravenous diuretics or ultrafiltration should be
with diuresis, inotropes, and temporary mechanical used to maintain euvolemia.Judicious blood prod-
circulatory support devices as necessary to improve uct and fluid management is key in order to prevent
hepatic function prior to implantation, to pre-opera- right ventricular volume overload and dysfunction.
tive transaminases and bilirubin values of lessthan During surgical implantation, the ventricular assist
100 IU/L and 2 mg/dL, respectively.
device inflow cannula should be placed parallel to
Right ventricular dysfunction is common in advanced the septum directed towards the mitral valve, away
heart failure patients andis consequence of pulmo- from the free wall. This should be verified by transe-
nary venous hypertension from chronically elevated sophageal echocardiography. Correct inflow cannula
leftventricular filling pressures, valvular pathology, or placement will minimize thechance of suction events.
a combination of these processes. All patients with For patients where lateral thoracotomy is used for
right ventricular dysfunction (more than mild) should implantation,sufficient surgical space should be
be admitted to the hospital prior the implant surgery available for a good visualization of the coring area
and are optimized by receiving inotropes (e.g. dobu- and inflow cannula implantation. The outflow graft
tamine or milrinone) and/or temporary mechanical should be positioned to the right of sternal midline
circulatory support devices in order to increase the and avoid compression of right ventricle. Minimizing
cardiac index above 2.2 L/min/m2. In addition,all total cardiopulmonary bypass time may reduce the
patients should receive intravenous diuretics or ul- unfavorable extracorporeal-induced trauma of blood
trafiltration in order to achieve a preoperative central elements and the chance of bleeding. At the sepa-
venous pressure <10 mmHg. Patients with pulmonary ration from cardiopulmonary bypass, pulmonary va-
vascularresistance above five Wood units and mod- sodilation therapy with inhaled nitric oxide shouldbe
erate to severe right ventricular dysfunction should initiated prior to separation from bypass in order to
receive sildenafil or inhaled nitric oxide in order to provide the most favorable conditions for the right
decreasethe pulmonary vascular resistance and en- heart. Inotropic therapy should be continued or initi-
hance the right ventricular function pre-operatively. ated and volume management should be maintained.
Finally, low dose vasopressors (e.g. vasopressin, nor- Sequential atrio-ventricular pacing can enhance right
epinephrine) can be used to increase the perfusion ventricular function and should be attempted if brad-
pressure to the right coronary artery and minimize yarrhythmias exist.

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