Zusammenfassung
Der Linksherzersatz durch ein Unterstützungssystem [„left ventricular assist device“ (LVAD)] ist, abgesehen von der Herztransplantation, die einzig etablierte chirurgische Behandlung des therapierefraktären Endstadiums der Linksherzinsuffizienz. Das individuelle intensivmedizinische Management dieser Patienten ist vom Aufnahmegrund abhängig und bedarf einer Vorstellung von der spezifischen Hämodynamik und den Eigenheiten der derzeit am häufigsten implantierten Kunstherzen mit nichtpulsatilem Flussmuster. Hierzu gehören Kenntnisse des hämodynamischen Monitorings, der Pumpenspezifika, des Managements von Antikoagulation und Hämostase sowie der Bewältigung von Problemen wie Rechtsherzversagen, Aortenklappeninsuffizienz und Infektionen. Die Behandlung eines bewusstlosen LVAD-Patienten stellt eine klinische Herausforderung dar, die versierte Kenntnisse in der transthorakalen und transösophagealen Echokardiographie, eine gezielte Labordiagnostik und pathophysiologisches Wissen zur differenzialdiagnostischen Abklärung erfordert. Unumgänglich sind zudem eine professionelle, interdisziplinäre Zusammenarbeit sowie der Austausch aktueller kritischer Informationen.
Abstract
Apart from heart transplantation, implantation of a left ventricular assist device (LVAD) is the only established surgical treatment for therapy-refractory terminal left heart failure, The specific intensive care unit (ICU) management of these patients depends on the reason for the ICU admission and requires understanding of the characteristic hemodynamics of non-pulsatile LVADs as well as of the inherent problems. Knowledge about the specific features in hemodynamic monitoring, understanding of pump characteristics, management of anticoagulation and hemostasis and the handling of problems, such as right heart failure, aortic valve insufficiency and infections is essential. The management of unconscious LVAD patients can be challenging. It requires a sophisticated transthoracic and transesophageal echocardiography (TTE/TEE) examination, targeted laboratory diagnostics and consideration of possible alternative diagnoses. Professional interdisciplinary cooperation and exchange of current knowledge is crucial.
Literatur
Alatri A, Armstrong AE, Greinacher A et al (2012) Results of a consensus meeting on the use of argatroban in patients with heparin-induced thrombocytopenia requiring antithrombotic therapy – a European perspective. Thromb Res 129:426–433
Baumann Kreuziger LM (2015) Management of anticoagulation and antiplatelet therapy in patients with left ventricular assist devices. J Thromb Thrombolysis 39:337–344
Bunz M, Kerscher C, Foltan M et al (2015) Patienten mit implantierten Herzunterstützungssystemen. Herausforderung in der Notfallmedizin. Anaesthesist 64:396–402
Dalen M, Sartipy U, Lund LH et al (2013) Peripheral extracorporeal membrane oxygenation as short-term right ventricular support after HeartWare left ventricular assist device implantation. ASAIO J 59:523–525
Gopinathannair R, Birks EJ, Trivedi JR et al (2015) Impact of cardiac resynchronization therapy on clinical outcomes in patients with continuous-flow left ventricular assist devices. J Card Fail 21:226–232
Goudra BG, Singh PM (2013) Anesthesia for gastrointestinal endoscopy in patients with left ventricular assist devices: initial experience with 68 procedures. Ann Card Anaesth 16:250–256
Grant AD, Smedira NG, Starling RC et al (2012) Independent and incremental role of quantitative right ventricular evaluation for the prediction of right ventricular failure after left ventricular assist device implantation. J Am Coll Cardiol 60:521–528
Guha A, Eshelbrenner CL, Richards DM et al (2015) Gastrointestinal bleeding after continuous-flow left ventricular device implantation: review of pathophysiology and management. Methodist DeBakey Cardiovasc J 11:24–27
Heilmann C, Geisen U, Beyersdorf F et al (2011) Acquired Von Willebrand syndrome is an early-onset problem in ventricular assist device patients. Eur J Cardiothorac Surg 40:1328–1333. (Diskussion: 1233)
Hellman Y, Malik AS, Lin H et al (2015) B-type natriuretic peptide-guided therapy and length of hospital stay post left ventricular assist device implantation. ASAIO J 61:156–160
Karhausen J, Dudaryk R, Phillips-Bute B et al (2012) Three-dimensional transesophageal echocardiography for perioperative right ventricular assessment. Ann Thorac Surg 94:468–474
Kellman SE, Feider AJ, Jeevanandam V et al (2015) Can intraoperative transesophageal echocardiography predict postoperative aortic insufficiency in patients receiving implantable left ventricular assist devices? J Cardiothorac Vasc Anesth (im Druck)
Kirklin JK, Naftel DC, Pagani FD et al (2014) Sixth INTERMACS annual report: a 10,000-patient database. J Heart Lung Transplant 33:555–564
Kolde HJ, Habrecht U, Von Hesberg J et al (2014) Multicentric validation of a rapid assay for heparin-induced thrombocytopenia with different specimen types. Blood Coagul Fibrinolysis 25:6–9
Lang RM, Bierig M, Devereux RB et al (2005) Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18:1440–1463
Lopilato AC, Doligalski CT, Caldeira C (2015) Incidence and risk factor analysis for gastrointestinal bleeding and pump thrombosis in left ventricular assist device recipients. Artif Organs (im Druck)
Maldonado Y, Singh S, Taylor MA (2014) Cerebral near-infrared spectroscopy in perioperative management of left ventricular assist device and extracorporeal membrane oxygenation patients. Curr Opin Anaesthesiol 27:81–88
Martina JR, Westerhof BE, De Jonge N et al (2014) Noninvasive arterial blood pressure waveforms in patients with continuous-flow left ventricular assist devices. ASAIO J 60:154–161
Martina JR, Westerhof BE, Van Goudoever J et al (2010) Noninvasive blood pressure measurement by the Nexfin monitor during reduced arterial pulsatility: a feasibility study. ASAIO J 56:221–227
Mauermann WJ, Rehfeldt KH, Park SJ (2008) Transesophageal echocardiography in a patient in hemodynamic compromise after Jarvik 2000 implantation: the suckdown effect. Anesth Analg 107:791–792
McMurray JJ, Adamopoulos S, Anker SD et al (2012) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 33:1787–1847
Rossi M, Serraino GF, Jiritano F et al (2012) What is the optimal anticoagulation in patients with a left ventricular assist device? Interact Cardiovasc Thorac Surg 15:733–740
Ryan T, Petrovic O, Dillon JC et al (1985) An echocardiographic index for separation of right ventricular volume and pressure overload. J Am Coll Cardiol 5:918–927
Sandner SE, Zimpfer D, Zrunek P et al (2008) Low molecular weight heparin as an alternative to unfractionated heparin in the immediate postoperative period after left ventricular assist device implantation. Artif Organs 32:819–822
Sheu R, Joshi B, High K et al (2015) Perioperative management of patients with left ventricular assist devices undergoing noncardiac procedures: a survey of current practices. J Cardiothorac Vasc Anesth 29:17–26
Theiss HD, Grabmaier U, Kreissl N et al (2014) Preconditioning with levosimendan before implantation of left ventricular assist devices. Artif Organs 38:231–234
Topkara VK, Kondareddy S, Malik F et al (2010) Infectious complications in patients with left ventricular assist device: etiology and outcomes in the continuous-flow era. Ann Thorac Surg 90:1270–1277
Weber CF, Gorlinger K, Meininger D et al (2012) Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 117:531–547
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
B. Steinlechner, D. Zimpfer, A. Schiferer, N. Heinrich, T. Schlöglhofer, A. Rajek, M. Dworschak und M. Hiesmayr geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
Additional information
Redaktion
A. Geppert, Wien
G. Heinz, Wien
Rights and permissions
About this article
Cite this article
Steinlechner, B., Zimpfer, D., Schiferer, A. et al. Intensivbehandlung von Kranken mit Linksherzersatz. Med Klin Intensivmed Notfmed 110, 421–430 (2015). https://doi.org/10.1007/s00063-015-0063-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00063-015-0063-6