The patient with an LVAD
Stem
A 66-year-old man, 92 kg, with a continuous-flow centrifugal LVAD placed two years ago as destination therapy for ischemic cardiomyopathy, presents for elective laparoscopic sigmoid colectomy for cancer. He has an ICD, takes warfarin (INR 2.4) and aspirin, and is NYHA class II. Automated cuff readings fail; a Doppler pressure in clinic was 84 mmHg. The last echo showed mild right ventricular dysfunction and a midline septum.
Question
What is your perioperative plan for this patient?
Ideal answer
HeadlineI keep the pump filled and the right ventricle working, because his output depends on preload, afterload and RV function.1 I plan it with his VAD team.
- Baseline pump parameters; warfarin and aspirin stopped five days ahead, with an intravenous heparin bridge for this elective case,1 because the pump clots without anticoagulation.
- ICD tachy therapies off with external pads on, reactivated afterward.1
- Arterial line before induction, MAP 70 to 90 mmHg, because cuffs often fail with little pulsatility: ultrasound-guided if needed, plus cerebral oximetry and serial gases, as pulse oximetry can drop out.1
- Slow induction, fluid running, vasopressor ready, because vasodilation empties the left ventricle; no hypoxia, hypercarbia or high PEEP, to protect the right ventricle.1
- Low insufflation pressure and gradual positioning, since pneumoperitoneum cuts preload.1
Watch for: Pump flow, power and pulsatility index with the VAD coordinator in the room; TEE available.
Breaking down the answer
- The pump is preload dependent and afterload sensitive — a continuous-flow pump runs at fixed speed, so flow falls when filling drops or afterload rises.1 High MAP also favors thrombosis, so the target has a ceiling as well as a floor.2
- Doppler reads in about 94% — versus roughly half with automated cuffs, but an arterial line is the standard for major surgery.1,3 Planning the line before induction is the judgment the examiner looks for.
- The RV is the weak link — hypoxia and hypercarbia raise PVR, and one-lung ventilation and high PEEP add to RV afterload.1 Changes if: known RV dysfunction, which makes inhaled pulmonary vasodilators and an inotrope part of the backup plan.
- Read the pump numbers as a pattern — flow is calculated from power and speed; rising power suggests pump thrombosis, and a falling pulsatility index means less native filling.3,2 Speed changes belong to the VAD team.2
- INR 2.0–3.0 is planned around, not reversed by reflex — elective cases get bridging; urgent cases get plasma and platelets only as needed.1 Heparin restarts 24 to 48 hours after surgery until the INR is back in range.1
- Electrocautery and the device — cautery does not affect the LVAD, but it can trigger inappropriate ICD shocks.2
Follow-up question
Twenty minutes after insufflation in steep Trendelenburg, his MAP drops to 56 mmHg, the pump shows low flow with a low pulsatility index and a suction alarm, and he develops runs of ventricular tachycardia. What is happening and what do you do?
Follow-up answer
HeadlineA suction event: the empty left ventricle has pulled the septum onto the inflow cannula, dropping flow and triggering ventricular ectopy.1
I tell the surgeon to desufflate and level the table, and call the VAD coordinator. A fluid bolus and a vasopressor restore MAP, and I check TEE: a small, collapsed left ventricle with the septum bowed leftward confirms underfilling, while a dilated, failing right ventricle points me to inhaled nitric oxide, an inotrope, and correcting acidosis and hypercarbia.1 Sustained VT with hypotension gets cardioversion. If he arrests, I confirm with the ECG and an end-tidal CO2 below 20 mmHg and resuscitate per standard protocols.1 Once stable, we resume at lower pressure.
Pitfalls that cost points
- Changing pump speed yourself instead of involving the VAD team.
- Reversing anticoagulation for an elective case instead of bridging.
Rapid-fire
Q: What MAP do you target? A: 70 to 90 mmHg; below 70 is hypotension and above 90 favors thrombosis and reduces pump flow.1,2
Q: What does a rise in pump power suggest? A: Increased resistance in the pump, classically thrombus.3
Q: When do you restart heparin after surgery? A: 24 to 48 hours after the procedure, until the INR is therapeutic.1
Q: Do you perform chest compressions? A: Yes when he is truly arrested; the ESC paper says to resuscitate as for other patients, though device guidance varies and compressions can damage the outflow graft.1,3
Q: How do you monitor oxygenation if the pulse oximeter fails? A: Arterial blood gases and cerebral oximetry.1
Numbers to know
| Item | Value |
|---|---|
| MAP target | 70–90 mmHg1 |
| INR target | 2.0–3.01 |
| Stop warfarin and aspirin | 5 days before elective major surgery, heparin bridge;1 aspirin often continued for minor procedures4 |
| Restart heparin | 24–48 h after surgery1 |
| Doppler BP success | About 94% vs about 50% for automated cuffs1 |
| End-tidal CO2 in arrest | Below 20 mmHg1 |
Links
- Heart failure and reduced ejection fraction, Pacemakers and ICDs in the operating room, laparoscopy, Vasopressors and inotropes: choosing and titrating, Pulmonary hypertension and right ventricular failure, ACLS adapted to the operating room
- HFA of the ESC position paper on LVAD-supported patients, Part 3 (2021)
- AHA scientific statement on resuscitation in patients with mechanical circulatory support (2017)
Sources
- 1.HFA of the ESC position paper on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider Part 3: at the hospital and discharge · Heart Failure Association of the ESC (ESC Heart Failure), 2021 · pmc.ncbi.nlm.nih.gov
- 2.Anesthetic Approach for Non-Cardiac Procedures in Patients with a Left Ventricular Assist Device · Journal of Clinical Medicine (Comino-Trinidad et al.), 2024 · pmc.ncbi.nlm.nih.govSingle-center retrospective series of 22 procedures.
- 3.LVADs and Non-cardiac Surgery: What to Do When They Come to Your OR · IARS (The Daily Dose), 2018 · iars.org
- 4.Updates to perioperative and anesthetic management of the left ventricular assist device patient presenting for noncardiac surgery · Current Opinion in Anaesthesiology (Burcar, Korenke, Ebadi-Tehrani, Mathis, Toton), 2026 · europepmc.orgWarfarin held with IV heparin bridge below INR 2.0; aspirin typically continued for minor procedures; for major bleeding or high-risk procedures tailored with the device and surgical teams.
Facts on this page were checked against these sources on Oct 16, 2026. Guidelines change; confirm doses against current institutional protocols.