CASE REPORT
Cataract surgery in patients with left ventricular assist device support Allen O. Eghrari, MD, Richard J. Rivers, MD, PhD, MBA, Majed Alkharashi, MB BS, Fatemeh Rajaii, MD, PhD, Daniel Nyhan, MB BCh, Shameema Sikder, MD
Left ventricular assist devices (LVADs) have been increasingly used for 20 years in terminally ill patients with advanced heart failure or awaiting cardiac transplantation. Despite improvement in morbidity and mortality from use of these devices, quality of life may be limited by cataract. Access to cataract surgery in this predominantly elderly population is essential but limited by unfamiliarity with these devices. We describe phacoemulsification and intraocular lens implantation in 2 patients with LVADs. The patients had extensive preoperative cardiology evaluations and were instructed to continue warfarin through the day of surgery. Monitored sedation was used with fentanyl and midazolam. Both patients experienced significant improvement in visual acuity and quality of life. Neither experienced intraoperative hemodynamic instability. Cataract surgery may be safely performed in patients with LVAD support when adequate monitoring resources are available. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:675–678 Q 2014 ASCRS and ESCRS
Since approval of the first generation of left ventricular assist devices (LVADs) in 1994 for left ventricular failure, these devices have offered patients with end-stage heart disease improvements in time-to-transplantation and quality of life. Subsequent generations of LVADs, now implanted in thousands of individuals, provide continuous flow of blood with minimal mechanical moving parts and portability, which allows mobility and improved quality of life. These advances have permitted the use of LVADs as destination therapy for patients with advanced heart failure. The increase in expected lifespan of LVADs has raised the need to address issues of chronic noncardiac disease in these patients.1 Our experience with
Submitted: November 10, 2013. Final revision submitted: December 14, 2013. Accepted: December 17, 2013. From the Department of Ophthalmology (Eghrari, Alkharashi, Rajaii, Sikder) and the Department of Anesthesia and Critical Care (Rivers, Nyhan), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Corresponding author: Shameema Sikder, MD, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 7315 Wisconsin Avenue, Suite 610 West Tower, Bethesda, Maryland 20814, USA. E-mail: [email protected]. Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
patients with LVADs and cataract reveals that many of these patients are unable to obtain cataract surgery because the implications for anesthesia and surgical approaches in this setting are unclear. We describe 2 cases of cataract surgery in patients with LVADs and review considerations for the cataract surgeon operating on a patient with an LVAD. CASE REPORTS Case 1 A 69-year-old man weighing 77.1 kg initially presented to an ophthalmologist for cataract evaluation 1 year after implantation of a Heartmate II LVAD (Novacor) for dilated cardiomyopathy and subsequent heart failure. The corrected distance visual acuity (CDVA) was 20/80 and counting fingers in the right right eye and left eye, respectively. Slitlamp examination was significant for nuclear sclerosis of both lenses, 3C in the right eye and 4C in the left eye. The patient took warfarin daily for an international normalized ratio (INR) goal of 2.0 to 2.5. Given the risks of surgery and the patient's ability to ambulate using vision from the right eye, surgery was deferred at the time. The patient presented again 3 years after implantation of the LVAD, referred by his cardiologist due to significant limitations to his quality of life. The patient remained on his couch unable to see his surroundings and asked to be placed on hospice care due to his limited vision. The visual acuity was 20/200 in the right eye and light perception in the left eye, with a corresponding increase in the severity of nuclear sclerosis since the previous examination. In the right eye, the 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.01.024
675
676
CASE REPORT: CATARACT SURGERY IN PATIENTS WITH LVADS
optic disc appeared healthy with a cup-to-disc ratio of 0.25 and intact macula and periphery. The B-scan of the left eye was within normal limits. The patient chose to have phacoemulsification in the worse-seeing left eye and provided informed consent to proceed. A consultation from anesthesiology was obtained. It was decided that for maximum safety, surgery should be performed in the presence of a perfusionist. As routine for cataract surgery, the case was performed using monitored anesthesia care. The patient was supine, and monitors for oxygen saturation and expired CO2 were placed. Despite LVAD support, the patient had sufficient pulsatile waveform for the automatic noninvasive blood pressure (NIBP) monitor to collect values. The blood pressure was recorded as the mean pressure. The heart was paced at its normal setting of 78 bpm. Supplemental oxygen was administered by nasal cannula at 3 L/min to ensure blood oxygen saturation was maintained between 97% and 100% throughout. A total of 25 mg fentanyl and 1 mg of midazolam was administered for sedation at the beginning of the case. The LVAD values during the case were speed, 9200 rpm; flow, 4.8 L/min; pulsatility index, 4.3. The mean blood pressure ranged between 81 mm Hg and 95 mm Hg; 400 mL of saline were infused during the case. A timeout was held, consent reviewed, and operative eye confirmed. After lidocaine jelly was applied to the ocular surface, 2 cc of lidocaine 2% and bupivacaine (Marcaine) 0.75% were administered to the inferotemporal sub-Tenon space. A modified Van Lint block was applied temporal to the eyelids because of significant squeezing. Trypan blue was used to stain the anterior capsule, and the anterior chamber was filled with an ophthalmic viscosurgical device in a soft-shell technique. Liquefied cortical material was aspirated and a stop-and-chop approach used for nuclear disassembly. The lens demonstrated a significant leathery posterior plate but was extracted without complication. A single-piece intraocular lens (IOL) (Acrysof SA60AT, Alcon Laboratories, Inc.) was placed in the bag and acetylcholine chloride (Miochol) used to induce miosis. Surgical time was 127 minutes, room time was 151 minutes, and anesthesia time was 161 minutes. Postoperatively, moxifloxacin 0.5% (Vigamox) and prednisolone acetate 1.0% were administered 4 times daily and tapered over 1 month. Visual acuity improved from light perception to uncorrected 20/60 on the first postoperative day and 20/50 at 1 week. The patient, who lived out of state, did not return for his 1-month appointment. He and his family communicated that he had since taken a multistate road trip and engaged in boating and fishing, activities that he had been unable to perform before the surgery.
Case 2 A 60-year-old man presented with decreased vision secondary to cataract in his left eye. He visited his local ophthalmology service but was declined surgery because of the LVAD. The patient had ischemic cardiomyopathy with an ejection fraction of 10% to 15%; a HeartMate II LVAD had been implanted 5 years before presentation. The electrocardiogram (EKG) showed left bundle branch block. The medical history included hypertension, dyslipidemia, depression, bilateral knee replacements, sigmoid colon polyp, adenocarcinoma, and gout. The patient had been on warfarin for 5 years with a target INR of 2.0 to 2.5.
On examination, the CDVA was 20/30 and 20/50 in the right eye and left eye, respectively. The left eye demonstrated 2C nuclear sclerotic and anterior cortical cataract. After discussion of the risks and benefits of surgery, the patient elected to proceed. The surgery was performed in the presence of a perfusionist using monitored anesthesia care. The patient was supine and monitored for oxygen saturation, expired CO2. The blood pressure was measured using a manual cuff with Doppler assistance and was recorded as systolic pressure. A total of 25 mg of fentanyl and 1 mg midazolam were administered intravenously at the beginning of the case, the latter in two 0.5 mg doses 13 minutes apart. Supplemental oxygen was provided by nasal cannula at 4 L/min and blood oxygen saturation maintained between 98% and 100%. Systolic values remained above 100 mm Hg for the entire case. The surgical time was 30 minutes, room time was 77 minutes, and anesthesia time was 93 minutes. Intraoperatively, lidocaine jelly was applied to the ocular surface, and then preservative-free lidocaine and epinephrine (1:10 000) were infused into the anterior chamber through a side-port incision. The nucleus was removed using a pop-and-chop technique. A single-piece IOL (Acrysof SA60AT) was placed in the bag. The eye was dressed at the end of the case with topical betaxolol, prednisolone acetate 1.0%, moxifloxacin, and gentamicin and prednisolone acetate ointment (Pred-G). Postoperatively, the uncorrected distance visual acuity was 20/20 3 in the left eye at day 1 and remained at 20/20 at 4 months. The patient elected to defer surgery in the right eye.
DISCUSSION In this case series, 2 patients with cataracts of varying density had cataract extraction and IOL implantation with significant improvement in visual acuity and function. This is important to allow patients with LVADs to maximize their functional potential. As studies suggest, many of these patients live a relatively sedentary lifestyle.2 The goal of cataract surgery in patients with LVADs is to improve daily activity. A study of self-concept in patients after LVAD implantation found a common perception of “feeling alive” and a desire to integrate into mainstream society.3 The patient in Case 1 gained the ability to walk independently and travel away from home. In both cases, only 1 eye was operated on, as this provided the patient with the desired functional improvement and balanced the benefits with the surgical risk. Although surgical risks from anesthesia may cause individuals to wait until cataracts have significantly advanced before having cataract extraction, our evaluation of case time and risk for complications between cases leads us to recommend operating while the lens is of moderate density. Our cases were performed in the presence of a perfusionist, and the possible need for vitreoretinal surgery must be taken into account as complications can arise with a denser lens. Such risk must take into account that cataract surgery is elective;
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
CASE REPORT: CATARACT SURGERY IN PATIENTS WITH LVADS
as such, it has rarely been performed in this cohort. Studies of surgery among cohorts of LVAD patients reveal low but steadily increasing rates of noncardiac surgery at all time periods, including 8 of 28 patients from 1990 to 1994,4 14 of 71 patients from 1993 to 1999,5 11 of 77 patients from 1988 to 2007,6 and 20 of 86 patients from 2006 to 2011.7 Most of these cases were abdominal cases and not elective; none were ophthalmic. Additionally, in a recent 10-year study of elective noncardiac surgery in patients with LVADs, no ophthalmic procedures were conducted among 6 of 141 consecutive patients who had LVAD implantation and subsequently had elective surgery.8 To date, only 1 case of cataract surgery in a patient with LVAD support is known, presented as part of a series of noncardiac cases.A To reduce the number of surgeries for the patient, simultaneous binocular surgery can be considered under special circumstances. A patient who is able to tolerate surgery with little to no sedation or with mild cataract in the second eye would clearly benefit from sequential surgery. We believe most patients would fall into this category. However, in a patient with bilateral dense cataracts and unfavorable expectations for cardiovascular outcomes, simultaneous binocular surgery can be performed if the patient clearly understands the risks. In this scenario, waiting to perform cataract surgery in the second eye will likely increase surgical complexity in the future due to lens density and the immediate benefit of some stereopsis to aid mobility and minimize fall risk is worthwhile. Overall, cataract surgery provides minimal hemodynamic instability in the setting of an LVAD, but close monitoring is essential. We recommend that patients be maintained on anticoagulation throughout the surgery. Patients are generally supine, which is preferred due to the effect of position on venous return.9 Ensuring proper nothing-by-mouth status is essential as long-term LVADs with peritoneal-placed pumps may take up intraabdominal volume and precautions should be taken against pulmonary aspiration.10 Blood pressure was measured with cuff and Doppler scan in 1 of our cases; in the other case, pulsations were adequate for the NIBP monitor. An arterial catheter could be placed if desired, but no clear indication existed during these 2 cases. Notably, the monitored pulse rate will reflect LVAD ejection and may not necessarily be the same as the EKG.10 Intraoperatively, our first case was safely conducted with sub-Tenon block comprising lidocaine and bupivacaine and our second case was performed with topical and intracameral anesthesia. Preoperatively, the surgeon must evaluate the patient's ability to tolerate the procedure under sedation and consider
677
the possible need to convert to general anesthesia. Use of electrocautery must be judicious, and bipolar tips are preferred; whereas external devices such as the Abiomed and Thoratec are isolated and Novacor devices are well-shielded, the Heartmate is not wellshielded and may be reset to a fixed-rate mode by the electrocautery.10 Betaxolol was used at the completion of the first case due to its selectivity among betaadrenergic receptors and was well-tolerated. In the first case, the lengthened surgical time reflected several factors particular to operating on a patient with LVAD support. First, given the extreme density of the lens and the patient's hemodynamic state, utmost care was taken to avoid complications and the necessity of a second surgery. We would recommend operating earlier in the course of the disease to limit case time and risk for complications. Second, we experienced malfunction of the phacoemulsification unit, requiring real-time troubleshooting in a room designed for cardiac procedures. In anticipation of such a scenario, we used a superior approach and were prepared to convert to a smallincision extracapsular cataract surgery if necessary, thereby allowing us to rely on minimal equipment. Although this malfunction was resolved in our case, we recommend that surgeons be prepared with an alternate approach should they encounter difficulties with equipment. Prior to surgery, we used standard preoperative screening protocols for cataract evaluation. Visual potential should be assessed by the potential acuity meter or similar device to ascertain potential benefit from surgery. Although vision loss from previous intraoperative ischemia or decreased perfusion should be considered in patients who have had LVAD implantation, vascular studies suggest that cerebral blood flow autoregulation is preserved during and after LVAD insertion.11 Ischemic optic neuropathy should remain, however, on the differential if vision loss does not appear to be directly attributable to the cataract. Given the promise of improvement in daily function afforded by an LVAD for patients in cardiac failure, routine ophthalmic or visual acuity screening may identify patients who can benefit from cataract surgery to maximize their ability to function. Inpatient rehabilitation of patients with LVADs has been shown to result in significant improvement in Functional Independence Measure scores12; however, many tasks measured in this validated 18-item scale, including feeding, grooming, dressing, and toileting, depend on adequate vision. Ophthalmic evaluation may allow patients with LVADs to reach their maximum functional potential. In summary, cataract surgery can be safely performed in patients with LVAD support in
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
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CASE REPORT: CATARACT SURGERY IN PATIENTS WITH LVADS
Figure 1. Points to watch in cataract surgery in patients with an LVAD.
settings with adequate monitoring (Figure 1) and the ability to intervene for maintenance of hemodynamic stability if necessary. REFERENCES 1. McKellar SH, Morris DS, Mauermann WJ, Park SJ, Zietlow SP. Evolution of general surgical problems in patients with left ventricular assist devices. Surgery 2012; 152:896–902 2. Hu SXH, Keogh AM, Macdonald PS, Kotlyar E, Robson D, Harkess M, Granger E, Dhital K, Jansz P, Spratt P, Hayward CS. Interaction between physical activity and continuous-flow left ventricular assist device function in outpatients. J Card Fail 2013; 19:169–175 3. Marcuccilli L, Casida J, Peters RM. Modification of self-concept in patients with a left-ventricular assist device: an initial exploration. J Clin Nurs 2013; 22:2456–2464 4. Goldstein DJ, Mullis SL, Delphin ES, El-Amir N, Ashton RC Jr, Gardocki M, Jordan DA, Catanese KA, Levin HR, Rose EA, Oz MC. Noncardiac surgery in long-term implantable left ventricular assist-device recipients. Ann Surg 1995; 222:203–207. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1234779/pdf/annsurg00042-0109.pdf. Accessed January 5, 2014 5. Schmid C, Wilhelm M, Dietl K-H, Schmidt C, Hammel D, Scheld HH. Noncardiac surgery in patients with left ventricular assist devices. Surgery 2001; 129:440–444 6. Garatti A, Bruschi G, Colombo T, Russo C, Milazzo F, Catena E, Lanfranconi M, Vitali E. Noncardiac surgical procedures in patient supported with long-term implantable left ventricular assist device. Am J Surg 2009; 197:710–714 7. Morgan JA, Paone G, Nemeh HW, Henry SE, Gerlach B, Williams CT, Lanfear DE, Tita C, Brewer RJ. Non-cardiac surgery in patients on long-term left ventricular assist device support. J Heart Lung Transplant 2012; 31:757–763
8. Ahmed M, Le H, Aranda JM Jr, Klodell CT. Elective noncardiac surgery in patients with left ventricular assist devices. J Card Surg 2012; 27:639–642 9. Connors CW, Poltak JM, Christie AA. Noncardiac surgery in the prone position in patients with ventricular assist devices [letter]. J Cardiothorac Vasc Anesth 2012; 26:e6–e7 10. Stone ME, Soong W, Krol M, Reich DL. The anesthetic considerations in patients with ventricular assist devices presenting for noncardiac surgery: a review of eight cases. Anesth Analg 2002; 95:42–49. Available at: http://journals.lww.com/anesthesiaanalgesia/Fulltext/2002/07000/The_Anesthetic_Considerations_ in_Patients_with.7.aspx. Accessed January 5, 2014 11. Ono M, Joshi B, Brady K, Easley RB, Kibler K, Conte J, Shah A, Russell SD, Hogue CW. Cerebral blood flow autoregulation is preserved after continuous-flow left ventricular assist device implantation. J Cardiothorac Vasc Anesth 2012; 26:1022–1028 12. Nguyen E, Stein J. Functional outcomes of adults with left ventricular assist devices receiving inpatient rehabilitation. PM&R 2013; 5:99–103
OTHER CITED MATERIAL A. Nelson DM, Healy AH, Eccles AL, Morley K, Wecker CR, Nelson KE, Long JW. Non-LVAD related surgery in LVAD patients [abstract]. ASAIO Cardiac Abstracts. In: ASAIO J 2005; 51(2):47A. Available at: http://journals.lww.com/asaiojournal/Fulltext/2005/ 03000/Non_Lvad_Related_Surgery_in_Lvad_Patients.184.aspx. Accessed January 5, 2014
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
First author: Allen O. Eghrari, MD Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Cataract surgery in patients with left ventricular assist device support Allen O. Eghrari, MD, Richard J. Rivers, MD, PhD, MBA, Majed Alkharashi, MB BS, Fatemeh Rajaii, MD, PhD, Daniel Nyhan, MB BCh, Shameema Sikder, MD
Left ventricular assist devices (LVADs) have been increasingly used for 20 years in terminally ill patients with advanced heart failure or awaiting cardiac transplantation. Despite improvement in morbidity and mortality from use of these devices, quality of life may be limited by cataract. Access to cataract surgery in this predominantly elderly population is essential but limited by unfamiliarity with these devices. We describe phacoemulsification and intraocular lens implantation in 2 patients with LVADs. The patients had extensive preoperative cardiology evaluations and were instructed to continue warfarin through the day of surgery. Monitored sedation was used with fentanyl and midazolam. Both patients experienced significant improvement in visual acuity and quality of life. Neither experienced intraoperative hemodynamic instability. Cataract surgery may be safely performed in patients with LVAD support when adequate monitoring resources are available. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:675–678 Q 2014 ASCRS and ESCRS
Since approval of the first generation of left ventricular assist devices (LVADs) in 1994 for left ventricular failure, these devices have offered patients with end-stage heart disease improvements in time-to-transplantation and quality of life. Subsequent generations of LVADs, now implanted in thousands of individuals, provide continuous flow of blood with minimal mechanical moving parts and portability, which allows mobility and improved quality of life. These advances have permitted the use of LVADs as destination therapy for patients with advanced heart failure. The increase in expected lifespan of LVADs has raised the need to address issues of chronic noncardiac disease in these patients.1 Our experience with
Submitted: November 10, 2013. Final revision submitted: December 14, 2013. Accepted: December 17, 2013. From the Department of Ophthalmology (Eghrari, Alkharashi, Rajaii, Sikder) and the Department of Anesthesia and Critical Care (Rivers, Nyhan), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Corresponding author: Shameema Sikder, MD, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 7315 Wisconsin Avenue, Suite 610 West Tower, Bethesda, Maryland 20814, USA. E-mail: [email protected]. Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
patients with LVADs and cataract reveals that many of these patients are unable to obtain cataract surgery because the implications for anesthesia and surgical approaches in this setting are unclear. We describe 2 cases of cataract surgery in patients with LVADs and review considerations for the cataract surgeon operating on a patient with an LVAD. CASE REPORTS Case 1 A 69-year-old man weighing 77.1 kg initially presented to an ophthalmologist for cataract evaluation 1 year after implantation of a Heartmate II LVAD (Novacor) for dilated cardiomyopathy and subsequent heart failure. The corrected distance visual acuity (CDVA) was 20/80 and counting fingers in the right right eye and left eye, respectively. Slitlamp examination was significant for nuclear sclerosis of both lenses, 3C in the right eye and 4C in the left eye. The patient took warfarin daily for an international normalized ratio (INR) goal of 2.0 to 2.5. Given the risks of surgery and the patient's ability to ambulate using vision from the right eye, surgery was deferred at the time. The patient presented again 3 years after implantation of the LVAD, referred by his cardiologist due to significant limitations to his quality of life. The patient remained on his couch unable to see his surroundings and asked to be placed on hospice care due to his limited vision. The visual acuity was 20/200 in the right eye and light perception in the left eye, with a corresponding increase in the severity of nuclear sclerosis since the previous examination. In the right eye, the 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.01.024
675
676
CASE REPORT: CATARACT SURGERY IN PATIENTS WITH LVADS
optic disc appeared healthy with a cup-to-disc ratio of 0.25 and intact macula and periphery. The B-scan of the left eye was within normal limits. The patient chose to have phacoemulsification in the worse-seeing left eye and provided informed consent to proceed. A consultation from anesthesiology was obtained. It was decided that for maximum safety, surgery should be performed in the presence of a perfusionist. As routine for cataract surgery, the case was performed using monitored anesthesia care. The patient was supine, and monitors for oxygen saturation and expired CO2 were placed. Despite LVAD support, the patient had sufficient pulsatile waveform for the automatic noninvasive blood pressure (NIBP) monitor to collect values. The blood pressure was recorded as the mean pressure. The heart was paced at its normal setting of 78 bpm. Supplemental oxygen was administered by nasal cannula at 3 L/min to ensure blood oxygen saturation was maintained between 97% and 100% throughout. A total of 25 mg fentanyl and 1 mg of midazolam was administered for sedation at the beginning of the case. The LVAD values during the case were speed, 9200 rpm; flow, 4.8 L/min; pulsatility index, 4.3. The mean blood pressure ranged between 81 mm Hg and 95 mm Hg; 400 mL of saline were infused during the case. A timeout was held, consent reviewed, and operative eye confirmed. After lidocaine jelly was applied to the ocular surface, 2 cc of lidocaine 2% and bupivacaine (Marcaine) 0.75% were administered to the inferotemporal sub-Tenon space. A modified Van Lint block was applied temporal to the eyelids because of significant squeezing. Trypan blue was used to stain the anterior capsule, and the anterior chamber was filled with an ophthalmic viscosurgical device in a soft-shell technique. Liquefied cortical material was aspirated and a stop-and-chop approach used for nuclear disassembly. The lens demonstrated a significant leathery posterior plate but was extracted without complication. A single-piece intraocular lens (IOL) (Acrysof SA60AT, Alcon Laboratories, Inc.) was placed in the bag and acetylcholine chloride (Miochol) used to induce miosis. Surgical time was 127 minutes, room time was 151 minutes, and anesthesia time was 161 minutes. Postoperatively, moxifloxacin 0.5% (Vigamox) and prednisolone acetate 1.0% were administered 4 times daily and tapered over 1 month. Visual acuity improved from light perception to uncorrected 20/60 on the first postoperative day and 20/50 at 1 week. The patient, who lived out of state, did not return for his 1-month appointment. He and his family communicated that he had since taken a multistate road trip and engaged in boating and fishing, activities that he had been unable to perform before the surgery.
Case 2 A 60-year-old man presented with decreased vision secondary to cataract in his left eye. He visited his local ophthalmology service but was declined surgery because of the LVAD. The patient had ischemic cardiomyopathy with an ejection fraction of 10% to 15%; a HeartMate II LVAD had been implanted 5 years before presentation. The electrocardiogram (EKG) showed left bundle branch block. The medical history included hypertension, dyslipidemia, depression, bilateral knee replacements, sigmoid colon polyp, adenocarcinoma, and gout. The patient had been on warfarin for 5 years with a target INR of 2.0 to 2.5.
On examination, the CDVA was 20/30 and 20/50 in the right eye and left eye, respectively. The left eye demonstrated 2C nuclear sclerotic and anterior cortical cataract. After discussion of the risks and benefits of surgery, the patient elected to proceed. The surgery was performed in the presence of a perfusionist using monitored anesthesia care. The patient was supine and monitored for oxygen saturation, expired CO2. The blood pressure was measured using a manual cuff with Doppler assistance and was recorded as systolic pressure. A total of 25 mg of fentanyl and 1 mg midazolam were administered intravenously at the beginning of the case, the latter in two 0.5 mg doses 13 minutes apart. Supplemental oxygen was provided by nasal cannula at 4 L/min and blood oxygen saturation maintained between 98% and 100%. Systolic values remained above 100 mm Hg for the entire case. The surgical time was 30 minutes, room time was 77 minutes, and anesthesia time was 93 minutes. Intraoperatively, lidocaine jelly was applied to the ocular surface, and then preservative-free lidocaine and epinephrine (1:10 000) were infused into the anterior chamber through a side-port incision. The nucleus was removed using a pop-and-chop technique. A single-piece IOL (Acrysof SA60AT) was placed in the bag. The eye was dressed at the end of the case with topical betaxolol, prednisolone acetate 1.0%, moxifloxacin, and gentamicin and prednisolone acetate ointment (Pred-G). Postoperatively, the uncorrected distance visual acuity was 20/20 3 in the left eye at day 1 and remained at 20/20 at 4 months. The patient elected to defer surgery in the right eye.
DISCUSSION In this case series, 2 patients with cataracts of varying density had cataract extraction and IOL implantation with significant improvement in visual acuity and function. This is important to allow patients with LVADs to maximize their functional potential. As studies suggest, many of these patients live a relatively sedentary lifestyle.2 The goal of cataract surgery in patients with LVADs is to improve daily activity. A study of self-concept in patients after LVAD implantation found a common perception of “feeling alive” and a desire to integrate into mainstream society.3 The patient in Case 1 gained the ability to walk independently and travel away from home. In both cases, only 1 eye was operated on, as this provided the patient with the desired functional improvement and balanced the benefits with the surgical risk. Although surgical risks from anesthesia may cause individuals to wait until cataracts have significantly advanced before having cataract extraction, our evaluation of case time and risk for complications between cases leads us to recommend operating while the lens is of moderate density. Our cases were performed in the presence of a perfusionist, and the possible need for vitreoretinal surgery must be taken into account as complications can arise with a denser lens. Such risk must take into account that cataract surgery is elective;
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
CASE REPORT: CATARACT SURGERY IN PATIENTS WITH LVADS
as such, it has rarely been performed in this cohort. Studies of surgery among cohorts of LVAD patients reveal low but steadily increasing rates of noncardiac surgery at all time periods, including 8 of 28 patients from 1990 to 1994,4 14 of 71 patients from 1993 to 1999,5 11 of 77 patients from 1988 to 2007,6 and 20 of 86 patients from 2006 to 2011.7 Most of these cases were abdominal cases and not elective; none were ophthalmic. Additionally, in a recent 10-year study of elective noncardiac surgery in patients with LVADs, no ophthalmic procedures were conducted among 6 of 141 consecutive patients who had LVAD implantation and subsequently had elective surgery.8 To date, only 1 case of cataract surgery in a patient with LVAD support is known, presented as part of a series of noncardiac cases.A To reduce the number of surgeries for the patient, simultaneous binocular surgery can be considered under special circumstances. A patient who is able to tolerate surgery with little to no sedation or with mild cataract in the second eye would clearly benefit from sequential surgery. We believe most patients would fall into this category. However, in a patient with bilateral dense cataracts and unfavorable expectations for cardiovascular outcomes, simultaneous binocular surgery can be performed if the patient clearly understands the risks. In this scenario, waiting to perform cataract surgery in the second eye will likely increase surgical complexity in the future due to lens density and the immediate benefit of some stereopsis to aid mobility and minimize fall risk is worthwhile. Overall, cataract surgery provides minimal hemodynamic instability in the setting of an LVAD, but close monitoring is essential. We recommend that patients be maintained on anticoagulation throughout the surgery. Patients are generally supine, which is preferred due to the effect of position on venous return.9 Ensuring proper nothing-by-mouth status is essential as long-term LVADs with peritoneal-placed pumps may take up intraabdominal volume and precautions should be taken against pulmonary aspiration.10 Blood pressure was measured with cuff and Doppler scan in 1 of our cases; in the other case, pulsations were adequate for the NIBP monitor. An arterial catheter could be placed if desired, but no clear indication existed during these 2 cases. Notably, the monitored pulse rate will reflect LVAD ejection and may not necessarily be the same as the EKG.10 Intraoperatively, our first case was safely conducted with sub-Tenon block comprising lidocaine and bupivacaine and our second case was performed with topical and intracameral anesthesia. Preoperatively, the surgeon must evaluate the patient's ability to tolerate the procedure under sedation and consider
677
the possible need to convert to general anesthesia. Use of electrocautery must be judicious, and bipolar tips are preferred; whereas external devices such as the Abiomed and Thoratec are isolated and Novacor devices are well-shielded, the Heartmate is not wellshielded and may be reset to a fixed-rate mode by the electrocautery.10 Betaxolol was used at the completion of the first case due to its selectivity among betaadrenergic receptors and was well-tolerated. In the first case, the lengthened surgical time reflected several factors particular to operating on a patient with LVAD support. First, given the extreme density of the lens and the patient's hemodynamic state, utmost care was taken to avoid complications and the necessity of a second surgery. We would recommend operating earlier in the course of the disease to limit case time and risk for complications. Second, we experienced malfunction of the phacoemulsification unit, requiring real-time troubleshooting in a room designed for cardiac procedures. In anticipation of such a scenario, we used a superior approach and were prepared to convert to a smallincision extracapsular cataract surgery if necessary, thereby allowing us to rely on minimal equipment. Although this malfunction was resolved in our case, we recommend that surgeons be prepared with an alternate approach should they encounter difficulties with equipment. Prior to surgery, we used standard preoperative screening protocols for cataract evaluation. Visual potential should be assessed by the potential acuity meter or similar device to ascertain potential benefit from surgery. Although vision loss from previous intraoperative ischemia or decreased perfusion should be considered in patients who have had LVAD implantation, vascular studies suggest that cerebral blood flow autoregulation is preserved during and after LVAD insertion.11 Ischemic optic neuropathy should remain, however, on the differential if vision loss does not appear to be directly attributable to the cataract. Given the promise of improvement in daily function afforded by an LVAD for patients in cardiac failure, routine ophthalmic or visual acuity screening may identify patients who can benefit from cataract surgery to maximize their ability to function. Inpatient rehabilitation of patients with LVADs has been shown to result in significant improvement in Functional Independence Measure scores12; however, many tasks measured in this validated 18-item scale, including feeding, grooming, dressing, and toileting, depend on adequate vision. Ophthalmic evaluation may allow patients with LVADs to reach their maximum functional potential. In summary, cataract surgery can be safely performed in patients with LVAD support in
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
678
CASE REPORT: CATARACT SURGERY IN PATIENTS WITH LVADS
Figure 1. Points to watch in cataract surgery in patients with an LVAD.
settings with adequate monitoring (Figure 1) and the ability to intervene for maintenance of hemodynamic stability if necessary. REFERENCES 1. McKellar SH, Morris DS, Mauermann WJ, Park SJ, Zietlow SP. Evolution of general surgical problems in patients with left ventricular assist devices. Surgery 2012; 152:896–902 2. Hu SXH, Keogh AM, Macdonald PS, Kotlyar E, Robson D, Harkess M, Granger E, Dhital K, Jansz P, Spratt P, Hayward CS. Interaction between physical activity and continuous-flow left ventricular assist device function in outpatients. J Card Fail 2013; 19:169–175 3. Marcuccilli L, Casida J, Peters RM. Modification of self-concept in patients with a left-ventricular assist device: an initial exploration. J Clin Nurs 2013; 22:2456–2464 4. Goldstein DJ, Mullis SL, Delphin ES, El-Amir N, Ashton RC Jr, Gardocki M, Jordan DA, Catanese KA, Levin HR, Rose EA, Oz MC. Noncardiac surgery in long-term implantable left ventricular assist-device recipients. Ann Surg 1995; 222:203–207. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1234779/pdf/annsurg00042-0109.pdf. Accessed January 5, 2014 5. Schmid C, Wilhelm M, Dietl K-H, Schmidt C, Hammel D, Scheld HH. Noncardiac surgery in patients with left ventricular assist devices. Surgery 2001; 129:440–444 6. Garatti A, Bruschi G, Colombo T, Russo C, Milazzo F, Catena E, Lanfranconi M, Vitali E. Noncardiac surgical procedures in patient supported with long-term implantable left ventricular assist device. Am J Surg 2009; 197:710–714 7. Morgan JA, Paone G, Nemeh HW, Henry SE, Gerlach B, Williams CT, Lanfear DE, Tita C, Brewer RJ. Non-cardiac surgery in patients on long-term left ventricular assist device support. J Heart Lung Transplant 2012; 31:757–763
8. Ahmed M, Le H, Aranda JM Jr, Klodell CT. Elective noncardiac surgery in patients with left ventricular assist devices. J Card Surg 2012; 27:639–642 9. Connors CW, Poltak JM, Christie AA. Noncardiac surgery in the prone position in patients with ventricular assist devices [letter]. J Cardiothorac Vasc Anesth 2012; 26:e6–e7 10. Stone ME, Soong W, Krol M, Reich DL. The anesthetic considerations in patients with ventricular assist devices presenting for noncardiac surgery: a review of eight cases. Anesth Analg 2002; 95:42–49. Available at: http://journals.lww.com/anesthesiaanalgesia/Fulltext/2002/07000/The_Anesthetic_Considerations_ in_Patients_with.7.aspx. Accessed January 5, 2014 11. Ono M, Joshi B, Brady K, Easley RB, Kibler K, Conte J, Shah A, Russell SD, Hogue CW. Cerebral blood flow autoregulation is preserved after continuous-flow left ventricular assist device implantation. J Cardiothorac Vasc Anesth 2012; 26:1022–1028 12. Nguyen E, Stein J. Functional outcomes of adults with left ventricular assist devices receiving inpatient rehabilitation. PM&R 2013; 5:99–103
OTHER CITED MATERIAL A. Nelson DM, Healy AH, Eccles AL, Morley K, Wecker CR, Nelson KE, Long JW. Non-LVAD related surgery in LVAD patients [abstract]. ASAIO Cardiac Abstracts. In: ASAIO J 2005; 51(2):47A. Available at: http://journals.lww.com/asaiojournal/Fulltext/2005/ 03000/Non_Lvad_Related_Surgery_in_Lvad_Patients.184.aspx. Accessed January 5, 2014
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
First author: Allen O. Eghrari, MD Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
