ASAIO Journal 2015
Clinical Cardiovascular
Periprocedural Management of 172 Gastrointestinal Endoscopies in Patients with Left Ventricular Assist Devices David W. Barbara,* David A. Olsen,* Juan N. Pulido,* Barry A. Boilson,† David H. Bruining,‡ John M. Stulak,§ and William J. Mauermann*
The number of patients with left ventricular assist devices (LVADs) continues to increase, and gastrointestinal (GI) endoscopy is commonly required in this patient population. We retrospectively reviewed the experience of a single tertiary care center in managing patients with LVADs undergoing GI endoscopy between 2006 and 2013. After hospital dismissal from the LVAD placement, 53 patients underwent 172 GI endoscopic procedures. Gastrointestinal bleeding was the indication for endoscopy in 73.8% of patients. Median age at endoscopy was 66 years, and median time from LVAD implantation to initial endoscopy was 271 days (range, 31–1681 days). Anticoagulation or antiplatelet therapy was present within 1 week before 120 of 172 endoscopies (70%) and was withheld or actively reversed in 91 of 120 cases (76%). For sedation/anesthesia during endoscopy, 63 involved care by an anesthesiology team and 109 were performed with nursing sedation protocols. Noninvasive blood pressure techniques (conventional automated cuffs or Doppler pulses) were used for hemodynamic monitoring in 84%, arterial lines in 10%, and no blood pressure recordings documented/charted as inaccurate in 6%. Six patients died within 30 days of endoscopy with one death because of aspiration of blood and multiorgan failure. Patients with LVADs may safely undergo GI endoscopy with various individualized anesthetic/sedation models. Complications after endoscopy likely represent the acuity of this patient population. ASAIO Journal 2015; 61:670–675.
managed, and when compared with the pulsatile-flow LVADs, patients with current generation CF LVADs experience higher rates of gastrointestinal (GI) bleeding.3,4 It follows that patients with LVADs commonly present for gastrointestinal endoscopy. Previous series have described the perioperative management of patients with LVAD undergoing noncardiac surgery, some of which have included GI endoscopies.5–13 However, publications on patients with LVADs exclusively undergoing GI endoscopies are limited to one retrospective series that did not include postprocedure outcomes.14 The purpose of this study was to retrospectively review the periprocedural management and postprocedure complications of patients with LVADs undergoing GI endoscopies at a single, large tertiary referral center. Materials and Methods This study was approved by the Mayo Foundation Institutional Review Board, and all patients had consented to review of their electronic medical records for research purposes. An electronic database of adult (age ≥ 18 years) patients with LVADs was searched to identify those patients who underwent GI endoscopy between February 2006 and June 2013. Patients undergoing GI endoscopy during their index hospitalization for LVAD implantation were excluded, because this population differs in acuity from patients who have recovered from initial LVAD placement. In addition, patients undergoing GI capsule endoscopy or those with pulsatile LVADs were not included. Multiple planned endoscopies performed during the same anesthetic (e.g., esophagogastroduodenoscopy immediately followed by colonoscopy) were counted as one combined procedure. A portion of the resulting patient population included a subset of previously reported LVAD patients undergoing noncardiac surgery under general anesthesia.5 The electronic anesthesia and medical records for each patient were retrospectively reviewed to obtain demographic and periprocedural information including patient age, gender, LVAD type, indication for LVAD placement (i.e., etiology of heart failure and whether the LVAD was placed for bridge to transplantation or destination therapy), time from LVAD implant to GI endoscopy procedure, anticoagulation/antiplatelet medications within 7 days of endoscopy, active reversal of anticoagulation, and preprocedural support including mechanical ventilation or ionotropic medications. Procedural information collected included endoscopy type, indication, anesthetic type (i.e., general anesthesia, monitored anesthesia care, or moderate sedation), anesthetic provider (i.e., certified registered nurse anesthetist and anesthesiologist, intensive care unit (ICU) physician, or sedation nurse under gastroenterologist’s supervision), sedative medications administered, type of blood pressure (BP) monitoring technique, procedural duration (defined as the time between initial GI endoscope insertion and
Key Words: left ventricular assist device, LVAD, g astrointestinal, GI, endoscopy, bleeding, complication, death, mortality
The
national registry of mechanical circulatory support devices in the United States reported the implantation of more than 12,000 devices from 2006 to 2013, with the majority of these devices consisting of continuous-flow (CF) left ventricular assist devices (LVADs.)1 Despite improvements in survival and functional status, patients with LVADs often require subsequent hospital readmissions after implant.2 Specifically, patients with LVADs have more bleeding complications than those medically From the Departments of *Anesthesiology, †Cardiovascular D iseases, ‡Gastroenterology, and §Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota. Submitted for consideration March 2015; accepted for publication in revised form July 2015. Disclosure: The authors have no conflicts of interest to report. Correspondence: William J. Mauermann, Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street S.W., Rochester, MN 55905. Email: [email protected]. Copyright © 2015 by the American Society for Artificial Internal Organs DOI: 10.1097/MAT.0000000000000269
670
Copyright © American Society of Artificial Internal Organs. Unauthorized reproduction of this article is prohibited.
671
ENDOSCOPY IN LVAD PATIENTS
final removal), procedural location, and procedural complications (refractory hypotension defined as three sequential mean arterial BP readings
Clinical Cardiovascular
Periprocedural Management of 172 Gastrointestinal Endoscopies in Patients with Left Ventricular Assist Devices David W. Barbara,* David A. Olsen,* Juan N. Pulido,* Barry A. Boilson,† David H. Bruining,‡ John M. Stulak,§ and William J. Mauermann*
The number of patients with left ventricular assist devices (LVADs) continues to increase, and gastrointestinal (GI) endoscopy is commonly required in this patient population. We retrospectively reviewed the experience of a single tertiary care center in managing patients with LVADs undergoing GI endoscopy between 2006 and 2013. After hospital dismissal from the LVAD placement, 53 patients underwent 172 GI endoscopic procedures. Gastrointestinal bleeding was the indication for endoscopy in 73.8% of patients. Median age at endoscopy was 66 years, and median time from LVAD implantation to initial endoscopy was 271 days (range, 31–1681 days). Anticoagulation or antiplatelet therapy was present within 1 week before 120 of 172 endoscopies (70%) and was withheld or actively reversed in 91 of 120 cases (76%). For sedation/anesthesia during endoscopy, 63 involved care by an anesthesiology team and 109 were performed with nursing sedation protocols. Noninvasive blood pressure techniques (conventional automated cuffs or Doppler pulses) were used for hemodynamic monitoring in 84%, arterial lines in 10%, and no blood pressure recordings documented/charted as inaccurate in 6%. Six patients died within 30 days of endoscopy with one death because of aspiration of blood and multiorgan failure. Patients with LVADs may safely undergo GI endoscopy with various individualized anesthetic/sedation models. Complications after endoscopy likely represent the acuity of this patient population. ASAIO Journal 2015; 61:670–675.
managed, and when compared with the pulsatile-flow LVADs, patients with current generation CF LVADs experience higher rates of gastrointestinal (GI) bleeding.3,4 It follows that patients with LVADs commonly present for gastrointestinal endoscopy. Previous series have described the perioperative management of patients with LVAD undergoing noncardiac surgery, some of which have included GI endoscopies.5–13 However, publications on patients with LVADs exclusively undergoing GI endoscopies are limited to one retrospective series that did not include postprocedure outcomes.14 The purpose of this study was to retrospectively review the periprocedural management and postprocedure complications of patients with LVADs undergoing GI endoscopies at a single, large tertiary referral center. Materials and Methods This study was approved by the Mayo Foundation Institutional Review Board, and all patients had consented to review of their electronic medical records for research purposes. An electronic database of adult (age ≥ 18 years) patients with LVADs was searched to identify those patients who underwent GI endoscopy between February 2006 and June 2013. Patients undergoing GI endoscopy during their index hospitalization for LVAD implantation were excluded, because this population differs in acuity from patients who have recovered from initial LVAD placement. In addition, patients undergoing GI capsule endoscopy or those with pulsatile LVADs were not included. Multiple planned endoscopies performed during the same anesthetic (e.g., esophagogastroduodenoscopy immediately followed by colonoscopy) were counted as one combined procedure. A portion of the resulting patient population included a subset of previously reported LVAD patients undergoing noncardiac surgery under general anesthesia.5 The electronic anesthesia and medical records for each patient were retrospectively reviewed to obtain demographic and periprocedural information including patient age, gender, LVAD type, indication for LVAD placement (i.e., etiology of heart failure and whether the LVAD was placed for bridge to transplantation or destination therapy), time from LVAD implant to GI endoscopy procedure, anticoagulation/antiplatelet medications within 7 days of endoscopy, active reversal of anticoagulation, and preprocedural support including mechanical ventilation or ionotropic medications. Procedural information collected included endoscopy type, indication, anesthetic type (i.e., general anesthesia, monitored anesthesia care, or moderate sedation), anesthetic provider (i.e., certified registered nurse anesthetist and anesthesiologist, intensive care unit (ICU) physician, or sedation nurse under gastroenterologist’s supervision), sedative medications administered, type of blood pressure (BP) monitoring technique, procedural duration (defined as the time between initial GI endoscope insertion and
Key Words: left ventricular assist device, LVAD, g astrointestinal, GI, endoscopy, bleeding, complication, death, mortality
The
national registry of mechanical circulatory support devices in the United States reported the implantation of more than 12,000 devices from 2006 to 2013, with the majority of these devices consisting of continuous-flow (CF) left ventricular assist devices (LVADs.)1 Despite improvements in survival and functional status, patients with LVADs often require subsequent hospital readmissions after implant.2 Specifically, patients with LVADs have more bleeding complications than those medically From the Departments of *Anesthesiology, †Cardiovascular D iseases, ‡Gastroenterology, and §Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota. Submitted for consideration March 2015; accepted for publication in revised form July 2015. Disclosure: The authors have no conflicts of interest to report. Correspondence: William J. Mauermann, Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street S.W., Rochester, MN 55905. Email: [email protected]. Copyright © 2015 by the American Society for Artificial Internal Organs DOI: 10.1097/MAT.0000000000000269
670
Copyright © American Society of Artificial Internal Organs. Unauthorized reproduction of this article is prohibited.
671
ENDOSCOPY IN LVAD PATIENTS
final removal), procedural location, and procedural complications (refractory hypotension defined as three sequential mean arterial BP readings
