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382 Mechanical Circulatory Support for
Advanced Heart Failure

Post-operative Management flows and loss of pulsatility). If needed, intravenous
inotropes could be used for an extended period of
The primary objective of early post-operativeman-
agement is to support organ recovery and to avoid time. All sustained atrial and ventricular arrhythmias
multi-system organ failure through optimization of should be treated with anti arrhythmic agents and
organ perfusion. Invasive monitoring of the patient synchronized cardioversion should be used in refrac-
for the first 48-72 hrs is used in order to ensure ad- tory cases.
equate optimization of hemodynamic support. Pump A comprehensive transthoracic echocardiogram
speed should be adjusted to maintain an output that should be obtained prior to discharge toevaluate
provides the patient with adequate cardiac output ventricular size and function, cannula position and
while avoiding left ventricular suction and septum flow, aortic valve opening,tricuspid valve regurgita-
deviation to the left. A low pump output should trig- tion and perform a ramp test to determine the best-
ger evaluationfor hypovolemia (e.g. bleeding), tam- pump speed that unloads the left ventricle without
ponade, right heart failure, and in rarecases, inflow inducing right ventriculardys function.
or outflow cannula obstruction. Surgical bleeding
that occurs despite correction of coagulopathies will Long-Term Management
require that the patient be returned promptly to the After implantation of the ventricular assist device
operating room to identify the source. Uncontrolled and discharge from the index hospitalization, the
bleeding should always be surgically evaluated.
clinician is faced with the challenge of caring for the
Intravenous heparin is started 24 hrsafter the surgi- patient in the outpatient setting. This phase of care
cal bleeding is controlled and the anticoagulation is may last years and the clinical concernsmay evolve
gradually increased (increasing partial thromboplas- (e.g. moving from rehabilitation in the early period to
tin time targets by 10-15 s every other day to a goal of preventing ortreating comorbid conditions over time).
55-65 s), and warfarin started when the chest tubes Patients can be followed at the implant center or in
have been removed. Aspirin 81 mg is started when coordination with the referring cardiologist (“shared
the platelet count has rebounded (usually 2-3 days care”). If a shared care approach is used, manage-
postoperatively). ment guidelines should be distributed to the referring
cardiologist to ensure a uniform approach and long-
The impact of the ventricular assist device on right
ventricular function can be both beneficial and det- term success.
rimental. The beneficial effects are realized through Patients can be seen in the outpatient clinic weekly
unloading the left ventricle and decreasing filling or biweekly for the first 30 days post discharge, then
pressures, thereby reducing right ventricular after- at 1 month and every 3 months afterwards. A panel
load. The potential detrimental effects include an in- of laboratory values (basic chemistry, complete blood
crease in rightventricular preload from the normalized count, lactate dehydrogenase, plasma free hemoglo-
cardiac support, and the septal shift observed with bin, international normalized ratio [INR],natriuretic
unloading the left ventricle. With lower left ventricu- peptide) can be obtained with every clinic visit and
lar filling pressures, the septum will tend to shift to monthly after the 1-month clinic visit.
the left and decrease the septal contribution toright All patients should be maintained on oral anticoagu-
ventricular output. Pump speed should be maintained lation with a combination of warfarin(target INR 2-2.5)
to achieve an optimal balance between an adequate and aspirin 81 mg daily. The INR target is lowered
cardiac output and avoidance of right ventricular dys- to 1.8-2.2 for patients with evidence of gastrointesti-
function.
nal bleeding or individuals older than age 70 years
Weaning of inotropic support should be initiated at high risk for bleeding. Blood pressure control is
once the patient is euvolemic and is clinically guid- key to preventing strokes in patients on ventricular
ed by the physical examination with close monitoring assist devices. In patients with pulsatile hemody-
of device parameters. As inotropes are weaned, the namics (pulse pressure more than 20 mmHg), one
clinician should evaluate for evidence of right ventric- should target a systolic blood pressure below 90-100
ular dysfunction including: increasing edema; eleva- mmHg while inpatients with non-pulsatile physiology
tion in jugular venous pressure above 12-15 mmHg; one should achieve mean arterial pressures of70-
low cardiac output (mean arterialpressure below 60 80 mmHg. Traditional neurohormonal antagonists
mmHg, poor urine output, decrease central venous (angiotensin convertingenzyme inhibitors, angioten-
saturation);end organ dysfunction (renal or liver fail- sin receptor blockers, mineralocorticoid receptoran-
ure); and change in pump parameters(decrease in tagonists, hydralazine) should be used as first line

GCDC 2017