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Introduction
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.
Methods
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.
Results
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%).
Discussion
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.
