key: cord-0826183-ci1ttnxu authors: Sikachi, Rutuja R; Anca, Diana title: Anesthetic considerations in a patient with LVAD and COVID-19 undergoing video-assisted thoracic surgery: A Case Report: LVAD and VATS in patients with COVID-19 date: 2020-12-17 journal: J Cardiothorac Vasc Anesth DOI: 10.1053/j.jvca.2020.12.019 sha: a9f82e3a048604422f0abcfe0d1fd0bb985a0a4e doc_id: 826183 cord_uid: ci1ttnxu Increased survival with Left Ventricular Assist Device (LVAD) has led to a large number of patients with LVADs presenting for non-cardiac surgeries (NCS). With studies showing that a trained non-cardiac anesthesiologist can safely manage these patients when they present for NCS, it is vital that all anesthesiologists understand the LVAD physiology and its implications in various surgeries. This is even more relevant during the current pandemic where these complex cardiopulmonary interactions may be even more challenging in patients with COVID-19. We describe a case of a patient with COVID-19 with an LVAD who needed thoracoscopic decortication for recurrent complex pleural effusion and briefly discuss unique challenges presented and their management. Increased survival with Left Ventricular Assist Device (LVAD) has led to a large number of patients with LVADs presenting for non-cardiac surgeries (NCS) 1, 2 . These NCS may be needed for managing complications arising from LVAD or otherwise. With studies showing that a trained non-cardiac anesthesiologist can safely manage these patients when they present for NCS, it is vital that all anesthesiologists understand the LVAD physiology and its implications in various surgeries [3] [4] [5] . This is even more relevant during the current pandemic where these complex cardiopulmonary interactions may be even more challenging in patients with COVID-19. Patients with LVAD may present for minor procedures such as endoscopies or major surgeries including general, vascular or thoracic surgeries 6 . They may undergo monitored anesthesia care or general anesthesia with various monitoring modalities ranging from non-invasive to invasive depending on the clinical situation and stability of the patient 7 . We describe a case of a patient with COVID-19 with an LVAD who needed thoracoscopic decortication for recurrent complex pleural effusion. We briefly discuss unique challenges presented and their management in this report. A 51-year-old with a HEARTMATE 3 and hemodialysis dependent female was hospitalized for a COVID-19 infection (Height: 158cm, Weight: 59KG, BMI: 23.6 kg/m 2 ). She was transitioned from ECMO to LVAD as destination therapy six-months prior for stage D congestive heart failure from lymphocytic myocarditis. During her previous yearlong hospital stay, she had undergone multiple procedures. This included an indwelling tracheostomy that was decannulated recently. During the stay her chronic left sided pleural effusion was found to be increased and loculated on CT scans, not amenable to drainage with simple indwelling pleural catheter. Hence, she was planned to undergo left sided video assisted thoracic surgery for decortication. (Figure 1 -CT image) During preoperative evaluation, LVAD was found to be adequately functional with speed of 5600 RPM, flow 3.5 L/min, power 4.1 Watts and Pulsatility index 1.9 with a mean arterial pressure of 90. Pre-operative oxygenation was stable on room air. Transthoracic echocardiogram showed severe global left and right ventricular systolic dysfunction but no pericardial effusion, septal defects or cardiac thrombi. From physical examination and previous anesthesia records, she was found to have limited mouth opening, Mallampati grade 3 airway. Mask ventilation was easily achieved but intubations were performed with video laryngoscope (Glidescope) with moderate difficulty in the past. The respiratory exam had decreased air entry on the left side with no wheezing or stridor. Her anticoagulation with warfarin was bridged with heparin infusion for the surgery and was stopped on the morning of the surgery. Pre-operative coagulation profile was found to be normal. A pre-operative fiberoptic evaluation was not performed due to absence of any radiologic signs of stenosis on the CT scan and based on our discussions with the thoracic surgery team. In the operating room, routine 5 lead ECG applied to the chest and a pulse oximeter and NIBP cuff were applied to right arm. Defibrillator was available on standby. A preinduction arterial line was inserted in the left brachial artery under ultrasound guidance. A peripherally inserted central venous catheter was already present and was used for intravenous medications. General anesthesia was induced after low flow preoxygenation with intravenous etomidate 16 mg, 50mcg of Fentanyl and Succinylcholine 100 mg. Airway was secured once patient became completely apneic with an 8.0 mm standard cuffed endotracheal tube under video laryngoscopy visualisation. Adequate PPE was used during the entire procedure. An endobronchial blocker (Uniblocker, Fuji, 9 Fr) was inserted and secured in the left main stem bronchus under fiberoptic bronchoscopic (FOB) guidance. Patient was positioned in the right lateral position to facilitate surgery and the position of endobronchial blocker was confirmed with FOB once again. Patient was ventilated only after confirming 'closed system' throughout these maneuvers given the positive COVID-19 status. Anesthesia was maintained with intravenous fentanyl, sevoflurane/oxygen and cisatracurium. The LVAD parameters did not change after initiating one-lung ventilation. The arterial blood gas analysis once onelung ventilation was established demonstrated a pH of 7.27 with pCO 2 of 55 and PO 2 of 339. Ventilation was adjusted to maintain normocarbia and was monitored throughout the procedure using ETCO2 and frequent ABGs. The pH and PCO 2 showed improvement once ventilation was adjusted and adequate oxygenation was maintained. MAP was maintained around 80-90 mm Hg throughout, close to patient's baseline with balanced anesthesia using sevoflurane, fentanyl and cisatracurium. Administration of a vasopressor was not necessary. A transesophageal echocardiogram was on standby in case further invasive monitoring was required during the procedure. All the involved personnel in the room wore appropriate PPE during the surgery. TEE cart was covered with a plastic cover. Only required personnel, instruments and medications were kept in the room with one circulating nurse right outside the room to help with additional supplies if required. At the end of the surgery, an intercostal block was performed with liposomal suspension of 1.3% Bupivacaine as post operative opioid PCA was rendered inappropriate for this patient. Bronchial blocker was removed and two-lung ventilation was established. Patient was extubated after reversal with neostigmine and glycopyrrolate and meeting all the extubation criteria. She was transferred to the ICU awake and alert with supplemental oxygen and was restarted on intravenous heparin infusion. The surgical pathology from the procedure demonstrated an acute fibrinous pleuritis that was managed with antibiotics. . Patients with LVAD often have reduced right ventricular function and it is thus imperative to avoid factors that worsen pulmonary vascular resistance during the anesthetic management. Anesthetic management of these patients becomes even more challenging during thoracoscopic procedures given the cross interactions between the LVAD physiology and one lung ventilation physiology. In addition, patients with COVID-19 often present with pulmonary findings that can affect the pulmonary vascular resistance secondary to hypoxemia and make the management of these patients even more challenging. Another additional anesthetic consideration in the management of such a patient with COVID-19 undergoing one lung ventilation is to avoid exposure of health care personnel given its potential as an aerosol generating procedure. In our patient, one-lung ventilation was achieved with bronchial blocker. The bronchial blocker can offer less hemodynamic disturbances as compared to a double lumen tube 8 . Known difficult airway, history of tracheal stoma or constriction, limited mouth opening are relative contraindications for use of double lumen tube and our patient had all of them 9,10 . The Uniblocker was selected based upon the ease of use and the preference of the attending anesthesiologist. Also, during the COVID-19 pandemic a survey conducted by European Association of Cardiothoracic Anesthesia showed that a bronchial blocker was the preferred technique for lung isolation in patients who were COVID-19 positive, were already intubated and had difficult airways 11 . It is also easy to maintain 'closed circuit' with bronchial blocker and can help minimize aerosolization and exposure of perioperative personnel to the virus 12 there were no hemodynamic disturbances noted in our patient and the use of vasopressor was not necessary. Postoperatively, these patients should be cared for in the ICU setting by personnel knowledgeable about LVADs. For pain management, regional and non-opioid analgesia techniques should be preferred as opioids can lead to hypoventilation causing hypoxia, hypercarbia, acidosis which have caused fatalities 15 . In addition, it is important to optimally manage the anticoagulation status during surgical interventions in patients with LVAD. While anticoagulation carries the risk of bleeding during the procedure, being off anticoagulation for prolonged periods can lead to pump thrombosis. A well-coordinated multi-disciplinary approach is essential to minimize the time off anticoagulation. For surgeries with high risk of bleeding, warfarin can be held and bridged with heparin infusion, which can be stopped on the morning of the planned procedure. After the procedure, warfarin may be resumed when the risk of bleeding is acceptable. The patient can be bridged with heparin while waiting for INR to reach target reach. 7, 16 . In our patient, the patient was bridged with heparin, which was stopped on the morning of the procedure, and restarted once the patient was stable postoperatively Thus in summary, we describe the challenges of dealing with patients with LVAD undergoing non-cardiac surgeries, especially during the COVID-19 pandemic. 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