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The PERSUADE survey was designed to explore real world practices for anaesthesia and intensive care management during left ventricular assist device (LVAD) implantation in European cardiac centres.
Of 202 European LVAD centres invited to participate, 91 centres expressed an initial interest and received a link to the survey, which targeted information regarding 1) institutional organisation and experience, 2) hemodynamic monitoring, 3) inotropic and medical management and 4) post-operative intensive care aspects.
Seventy-four European centres from 23 countries completed the survey (response rate 36.6%). Most LVAD implantations were performed in university hospitals (n = 55, 74.3%). 50% of the centres had 10-20-year experience with at least 10 implantations (n = 45, 60.8%) in 2019.
Extended hemodynamic monitoring included: CVP (n=67, 90.5%), pulmonary artery catheter (PAC) (n=64, 86.5%), CCO (n=42, 56.8%), TEE (n=74, 100%), NIRS (n=56, 75.7%) and BIS-index (n=44, 59.5%).
First choice induction agents were propofol (n=31, 43.2%), etomidate (n=24, 32.4%) and midazolam (n=11, 14.9%), and sufentanil (n=39, 52.7%) and fentanyl (n=23, 31.1%).
Hemodynamic parameters used to define right ventricular (RV) failure were: CVP (n=52, 70.3%), MPAP-CVP gradient (n=25, 33.8%), CVP/PCWP ratio (n=25, 33.8%) and RVSWI (n=22, 29.7%), while TEE parameters used were eyeballing (n=52, 70.3%), TAPSE<16 mm (n=38, 51.4%), RVEDD-LVEDD ratio>1.0 (n=26, 35.1%), interatrial septum constantly bowing (n=41, 55.4%), hypovolemic left atrium and ventricle (n=11, 14.9%), dilated right atrium and ventricle (n=41, 55.4%) and inferior vena cava collapsibility (n=4, 5.4%).
Primary inotropic support before induction consisted of dobutamine (n=45, 60.8%), levosimendan (n=40, 54.1%), norepinephrine (n=30, 40.5%), and PDE3-inhibitors (n=28, 37.8%), or a combination. Prophylactic inotropic support prior to extracorporeal circulation included: continuation of preoperative inotropic support (n=25, 33.8%), norepinephrine (n=35, 47.3%), dobutamine (n=30, 40.5%), epinephrine (n=29, 39.2%), PDE3-inhibitors (n=26, 35.1%), levosimendan (n=13, 17.6%) and NO (n=8, 10.8%). If RV-function worsened during weaning from extracorporeal circulation, the primary therapeutic strategy was change in inotropes (n=44, 59.5%), RVAD implantation (n=13, 17.6%), ECMO (n=10, 13.5%) or use of NO (n=5, 6.8%).
Vasoplegia was monitored by a combination of parameters: clinical judgement (n=32, 43.2%), use of norepinephrine>100 ng/kg/min (n=43, 58.1%), MAP<50 mmHg (n=36, 48.6%) and SVR<800 dynes/sec/cm5 (n=40, 54.1%) for several hours.
The estimated postoperative complication rate was 27.5% for vasoplegia, 10% for RV-failure requiring mechanical circulatory support, 20% for developing renal failure requiring renal replacement therapy and 5% for gastrointestinal bleeding. Two thirds of the centres started anticoagulation on the day of LVAD implantation, with preference of intravenous heparin (n= 69, 93.2%).
These data demonstrate that the majority of LVAD implantations were performed by an experienced team of surgeons and anaesthesiologists at university hospitals. There was sizeable practice variation in the choice of induction, maintenance, and inotropic agents. In particular only the minority of hospitals utilized inhaled NO therapy. While all centres employed TEE monitoring, PAC was less universal and only half of the centres used continuous hemodynamic monitoring. Finally, various parameters were used to define RV-failure or vasoplegia. These findings demonstrate the need for international consensus to guide perioperative monitoring and pharmacological support.
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© 2021 Published by Elsevier Inc.