Surviving the OR

Managing the Heart Failure Patient in the OR

What has to be managed:

1. Expectations - patient, family, surgeon, anesthesiologist

2. Medications - BB, RAA drugs, diuretics, vasoactive drugs
3. Fluids narrow therapeutic index
4. Devices ICD, LVAD

Understanding and Expectations

Heart failure (HF) is a common condition in our patients and is associated

with substantial morbidity and mortality. As such, it is imperative that the heart
failure patient, their family, their surgeon, and the anesthesia team understand the
implications of the disease in order to make good decisions. This will apply whether
the patient is undergoing cataract surgery, major non-cardiac surgery, left
ventricular assist device placement, or heart transplantation.
Heart failure is

Defined by the American College of Cardiology (ACC) as a complex clinical

syndrome that results from any structural or functional impairment of ventricular
filling or ejection of blood.(1)

Common: The prevalence of heart failure in the United States is estimated at 5.1
million, and is expected to increase to 6.4 million by 2030. There are approximately
650,000 patients diagnosed with HF every year, and the incidence increases with
age. The lifetime risk of developing heart failure for individuals over 40 is currently
20%.(1,2)
While that is all very interesting, data on the incidence and prevalence in the
community does not reflect our actual practice. Data from a large group of Medicare
patients undergoing a variety of non-cardiac surgeries demonstrated the prevalence
of heart failure to be 18%.(3) The incidence of all LV dysfunction in a group of
vascular surgery patients, including those without symptoms, was an impressive
50%!(4)

Not just systolic: Approximately half of patients with symptomatic heart failure
will have reduced left ventricular systolic function.(5) This is commonly referred to
as heart failure with reduced ejection fraction (HFrEF) and is defined as clinical
heart failure with a left ventricular ejection fraction (LVEF) 40%. On the other
hand, the other half of heart failure patients will have preserved ejection fraction
(HFpEF), defined as an LVEF 50%. It is important to note that, while there has
been less attention paid to patients with preserved EF, the mortality of HF is similar
whether the EF is preserved or not.(5)
Not just left sided: The vast majority of literature on heart failure relates to the left
ventricle, leading to the incorrect impression that right ventricular function and
dysfunction is of little importance. A working group of the National Heart, Lung, and
Blood institute concluded that the role of the right ventricle in a spectrum of
cardiovascular diseases has been relatively neglected proportionate to its central
importance.(6) An echocardiographic evaluation of multiple indices of RV function
demonstrated that both systolic and diastolic dysfunction of the right ventricle
negatively affect survival in heart failure.(7)

Expensive: The total cost of heat failure care in the US is in excess of $30 billion
dollars a year and is expected to rise to $70 billion by 2030.(2)

Lethal: Among patients with a new diagnosis of heart failure the outlook is poor.
The 1-year mortality is approximately 20% and the 5-year mortality is nearly
50%.(8) The need for hospitalization for heart failure portends an even worse
outcome.(9) These patients can expect a 1-year mortality of 30% and a 5 year
mortality of 70%.(10,11)
A patient with such high mortality should perhaps consider whether they
want to spend a significant proportion of their remaining days undergoing and
recovering from, for instance, a total hip arthroplasty. Though generally
underutilized for HF patients, palliative care teams can provide useful insight and
assistance with goals-of-care discussions.(12) The recent ACC guidelines suggest that
palliative and supportive care is effective for patients with symptomatic advanced
HF to improve quality of life.(1)

Associated with grim postoperative outcomes: Medicare patients with a

diagnosis of HF undergoing major non-cardiac surgery have a 30-day mortality of
8%, twice that of patients with coronary artery disease.(3)
A interesting study of patients with previous admissions for non-ischemic
heart failure showed a 9% 30-day mortality after all non-cardiac surgeries, an 8.5%
mortality for even minor surgeries, and an impressive 13% mortality if surgery was
performed within a month of a heart failure admission. (13) Postoperative outcomes
may also be worse in elderly HF patients, those with LVEF < 30%, and those with
diabetes.(14)

Fluids

Despite having been the focus of much research and discussion, the ideal
type and quantity of IV fluid to administer to any patient undergoing surgery still
remains a subject of debate. This is especially true of the heart failure patient, as
there has been little research directed solely at this population.
The first step in the management of these patients is to realize how small a
therapeutic index there is for IV fluids. For a healthy patient there is a wide range of
volume administration that, while perhaps not ideal, will not result in fulminant
heart failure from overload or renal failure from hypovolemia. In the typical heart
failure patient, however, this range will be dramatically smaller and in the end-stage
HF patient the optimal volume status will often be that which minimizes congestive
complications and renal failure, while avoiding neither.
I am not aware of any trials specifically designed to address the use of goal-
directed therapy (GDT) to guide fluid administration in the HF population, but a
recent meta-analysis suggested that GDT in the cardiac surgery population could
decrease both morbidity and length of stay.(15) It seems rational to apply concepts
of GDT to the HF population as well, namely:

- Have a method to evaluate cardiac output/stroke volume

(I favor echocardiography)
- Assess dynamic indices that predict volume responsiveness
- Have a reason to administer fluids, generally to improve cardiac
output in a patient who is expected to be volume responsive. Do not
administer fluid based on formulaic indices
- Respect the complications of volume overload in the HF patient

Medications

There are three broad issues regarding medication management of the heart
failure patient: decisions regarding continuation of previously prescribed
medications, choices regarding the appropriate anesthetic agents, and choices
regarding appropriate vasoactive drugs.

Previously prescribed medications

The heart failure patient will often present on some combination of a loop
diuretic, an ACE-inhibitor or angiotensin receptor blocker, a beta blocker, an
aldosterone receptor antagonist, hydralazine with isosorbide dinitrate, and possibly
digoxin.(1) Each of these medications has potential perioperative implications, and
the continuation or discontinuation of each medication should be considered on a
case-by-base basis. In general, however, it is reasonable to continue the preoperative
regimen of a well-managed heart failure patient as withdrawl of any medication can
destabilize previously stable HF.

Anesthetic Agents
The heart failure patient is one that benefits from what is frequently
described as a cardiac anesthetic. As every cardiac anesthesiologist knows, this
means nothing more or less than an anesthetic designed with an understanding of a
patients physiologic state, the hemodynamic goals of their pathologies, and the
abilities of various anesthetic agents to accomplish those goals. As yet there is no
evidence that any given anesthetic plan is superior to another in the heart failure
patient.(16) These patients can be safely anesthetized with any of a variety of
combinations of agents. The key is to proceed slowly and to anticipate the effects of
the chosen agents on inotropy, preload, and afterload.
Vasoactive Drugs

The hemodynamic and adrenergic receptor effects of common vasoactive

drugs listed in the table below will be familiar to the cardiac anesthesiologist. It is
important to remember, however, that some patients with chronic heart failure will
have downregulated Beta-1 receptors and may respond better to inotropes such as
milrinone and levosimendan that act via alternative mechanisms.
Milrinone has been shown to decrease mortality in hospitalized nonischemic
cardiomyopathy patients, while increasing that in ischemic patients.(17)
Levosimendan, an inodilator which increases the sensitivity of troponin C to
calcium, has been associated with improved LV function in HF patients undergoing
non-cardiac surgery as well as with improved mortality in cardiac surgery and
hospitalized heart failure patients.(18-20) While levosimendan does not currently
have FDA approval for use in the United States, it is in phase III trials.

Devices

The HF patient frequently presents to the operating room with one or more
pieces of hardware, including:

Pacer/Implanted Cardiac Defibrillator/Cardiac Resynchronization

A large portion of HF patients also meet criteria for placement of an ICD or

CRT-D. Current class I indications for ICD placement include (among many others)
heart failure symptoms in patients with an LVEF < 35% from either ischemic or
nonischemic causes. Those patients will also have class I indications for cardiac
resynchronization therapy if they have a left bundle branch block with a QRS
complex greater than 150 ms.(21) While both ICD, CRT, and the two combined
improve outcome and decrease mortality in appropriately selected patients, they
require additional attention perioperatively.(22-24) A comprehensive review of
cardiovascular implanted electronic devices is beyond the scope of this review, but
the ASA along with the Heart Rhythm Society recently published an excellent
guideline for their management.(25) A few general suggestions include:
- Surgeries using bipolar cautery generally do not require device
reprogramming
- Surgeries below the umbilicus generally do not require reprogramming
- A magnet applied over an ICD will likely inactivate tachyarrhythmia therapy
but will not cause the device to enter an asynchronous mode
- These patients are at high risk of malignant arrhythmias (hence the
devices) and any patient with a deactivated ICD should be monitored closely and
should have an external defibrillator immediately available
- It is wise to involve the device team early in the process, as they can often
provide information about the device itself, its function, and its history

LVAD(26-28)

While there is a growing number (of millions) of Americans with heart

failure, the number of transplants has plateaued at approximately 2,200 for several
years.(29) In this gap are hundreds of thousands of patients with severe heart failure
who will not undergo transplantation. While optimal medical management can
improve their mortality slightly, the largest benefits have been seen with the
appropriate use of LVADs. Since the REMATCH trial in 2001, which evaluated the
first-generation pulsatile HeartMate I, each subsequent generation of LVAD has
shown improved survival and device durability.(30) The third-generation HeartWare
centrifugal LVAD is associated with a 1 year survival of approximately 85%,
particularly impressive given the severity of illness of the patients in which it was
studied.(31)
As the number of LVAD patients continues to rise, particularly with an
increase in LVAD as destination therapy, the cardiac (and non-cardiac)
anesthesiologist will encounter these patients in increasing numbers, for both
cardiac transplantation as well as non-cardiac surgery. In one series, as many as
24% of patients with an LVAD as a bridge to transplant required non-cardiac
surgery in the year before their transplant.(32)
The perioperative care of the patient with an LVAD can be complicated, and
should ideally be undertaken in centers accustomed to their management. A few of
the issues will include:
Anticoagulation: LVAD patients are generally anticoagulated with warfarin,
and the surgeon, LVAD team, and anesthesiologists should discuss the degree of
anticoagulation necessary during the procedure to balance the risk of bleeding and
pump thrombosis.(33)
Device monitoring: While LVADs can be powered by batteries, and adequate
battery backup should be available, it is preferable to use the devices base
connected to a standard power outlet in the OR. In addition to serving as a reliable
power power source, the base serves as a monitor which provides valuable
information. The monitors generally display the pump speed (fixed by the LVAD
team), power, flow (an estimate only, may not reliably reflect output), and
pulsatility index. The pulsatility index is a reflection of variations in flow caused by
LV contraction. Changes in pulsatility may reflect changes in LV contractility, RV
function, and/or volume status. Each manufacturer provides useful guidelines and
instructions on their websites.
Patient monitoring: Patients with continuous-flow LVADs (most current
devices) have reduced peripheral pulsatility, which can make routine monitoring
challenging. In most cases, automated non-invasive blood pressure cuffs will not
function adequately, necessitating the placement of an arterial catheter. Arterial
cannulation can be facilitated with the use of 2D and Doppler ultrasound if palpation
of an arterial pulse is difficult. Diminished pulsatility may also render pulse
oximetry inaccurate. In these cases cerebral oximetery along with frequent arterial
blood gas measurements can provide information on oxygenation. Perhaps the
most valuable monitor in the LVAD patient, however, will be the intraoperative
transesophageal echocardiogram (TEE.) The use of TEE allows the skilled
clinician to assess the position and function of the LVAD inflow and outflow,
function and filling of the right ventricle, and its effect on LV loading.
Hemodynamic management: LVADs have been accurately described as
preload dependant and afterload sensitive, a phrase which does well in guiding the
perioperative physician in their management. A decrease in LV loading (either from
right ventricular systolic dysfunction or decreased preload) will cause a drop in
LVAD output (and will often be reflected in a decreased pulsatility index.) And
while afterload should be maintained at a level appropriate to provide organ
perfusion (generally at a mean of 60-80 mmHg), excessive or rapid increases in
systemic vascular resistance will result in a drop in LVAD output. This may be
particularly true for the newer centrifugal devices.(34)
Right ventricular dysfunction: While right ventricular dysfunction is
common in the immediate post-LVAD implant period, it can present at any time.(35)
Close attention should be paid to right ventricular function during periods of
variable loading conditions and changing hemodynamic states, which includes many
surgical procedures and anesthetics. The management of RV dysfunction will be
similar whether or not the HF patient has an LVAD, and involves an optimization of
preload, afterload, and contractility.(36)
It is important to realize that optimization does not imply maximization
when it comes to RV preload. In the past the right ventricle was seen as a passive
conduit, and it was suggested that right ventricular dysfunction could be overcome
with further fluid administration. The idea was that given enough preload blood
could be forced past the sluggish RV, through the lungs, and into the left ventricle.
This is certainly not the case! If the RV has been forced off the Starling curve the
only way blood can be pushed past the right ventricle is through a ruptured
interatrial septum. As this is clearly not the goal, close attention should be paid to
right ventricular preload. If administration of fluid results in right atrial dilation,
bulging of the interatrial septum, or dilation of the right ventricle further fluid
should not be given without improving forward flow through alteration of RV
afterload or contractility.
Right ventricular afterload should first be optimized by treating conditions
that increase pulmonary vascular resistance. These include hypoxia, hypercarbia,
acidosis, hypothermia, light anesthesia, and unnecessarily high intrathoracic
pressures. Unfortunately this is rarely adequate to decrease PVR, and interventions
often need to be added to affect improvement. Generally this means the
administration of pulmonary vasodilator. While there is a growing number of oral
agents being used in the pulmonary hypertension population, for the
anesthesiologist pulmonary vasodilation will generally be accomplished with either
inhaled agents (such as nitric oxide, prostacyclin, or milrinone) or intravenous
agents (most commonly milrinone, nitroglycerin, or nitroprusside.) It is important
to monitor the right heart failure patient for inappropriate decreases in systemic
vascular resistance when administering pulmonary vasodilators, and to remember
that the right ventricular myocardial supply/demand balance is affected by both
PVR and SVR.
Ultimately, it may be necessary to augment contractility in the face of a
failing right ventricle. This can be accomplished with a number of agents, including
milrinone, epinephrine, dobutamine, and levosimendan.
Finally, the patient with right ventricular failure with or without and LVAD,
with our without left heart failure, is a very challenging patient to manage. In my
experience these patients receive significant benefit from management that is
guided by thoughtful application of preoperative (transthoracic) and intraoperative
(transesophageal) echocardiography.

Summary

Heart failure is a common diagnosis in the surgical population and it will only
become more so with time. The perioperative physician will have growing
opportunities to care for these patients, including those with right and left
ventricular dysfunction, systolic and diastolic dysfunction, those with end-stage
symptoms and those who are yet asymptomatic, those with LVADS and those
without, patients presenting for cardiac transplantation and those presenting for
elective surgeries. In addition to understanding the intraoperative management of
the heart failure patient, it will be important for all of us to be aware of the broader
implications of this common disease for our patients. For some of our patients we
will be the first physician to diagnosis heart failure, and as such we should be
familiar with the basics of prognosis and management.
References

1. Yancy CW, Jessup M, Bozkurt B et al. 2013 ACCF/AHA guideline for the
management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on practice guidelines.
Circulation, 2013:e240-319.

2. Go AS, Mozaffarian D, Roger VL et al. Heart disease and stroke statistics--2013

update: a report from the American Heart Association. Circulation 2013;127:e6-
e245.

3. Hammill BG, Curtis LH, Bennett-Guerrero E et al. Impact of heart failure on

patients undergoing major noncardiac surgery Anesthesiology, 2008:559-67.

4. Flu W-J, van Kuijk J-P, Hoeks SE et al. Prognostic implications of asymptomatic
left ventricular dysfunction in patients undergoing vascular surgery Anesthesiology,
2010:1316-24.

5. Bursi F, Weston SA, Redfield MM et al. Systolic and diastolic heart failure in the
community. JAMA, 2006:2209-16.

6. Voelkel NF, Quaife RA, Leinwand LA et al. Right Ventricular Function and Failure:
Report of a National Heart, Lung, and Blood Institute Working Group on Cellular and
Molecular Mechanisms of Right Heart Failure Circulation, 2006:1883-91.

7. Meluzin J, Spinarov L, Hude P et al. Prognostic importance of various

echocardiographic right ventricular functional parameters in patients with
symptomatic heart failure. Journal of the American Society of Echocardiography :
official publication of the American Society of Echocardiography, 2005:435-44.

8. Roger VL, Weston SA, Redfield MM et al. Trends in heart failure incidence and
survival in a community-based population. JAMA, 2004:344-50.

9. Solomon SD, Dobson J, Pocock S et al. Influence of nonfatal hospitalization for

heart failure on subsequent mortality in patients with chronic heart failure.
Circulation, 2007:1482-7.

10. Chen J, Normand S-LT, Wang Y, Krumholz HM. National and regional trends in
heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998-
2008. JAMA, 2011:1669-78.

11. Joffe SW, Webster K, McManus DD et al. Improved Survival After Heart Failure:
A Community-Based Perspective Journal of the American Heart Association,
2013:e000053-e.
12. Kavalieratos D, Mitchell EM, Carey TS et al. "Not the grim reaper service": an
assessment of provider knowledge, attitudes, and perceptions regarding palliative
care referral barriers in heart failure. Journal of the American Heart Association,
2014:e000544.

13. van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA. Mortality and Readmission
of Patients With Heart Failure, Atrial Fibrillation, or Coronary Artery Disease
Undergoing Noncardiac Surgery: An Analysis of 38 047 Patients Circulation,
2011:289-96.

14. Healy KO, Waksmonski CA, Altman RK et al. Perioperative outcome and long-
term mortality for heart failure patients undergoing intermediate- and high-risk
noncardiac surgery: impact of left ventricular ejection fraction. Congest Heart Fail,
2010:45-9.

15. Aya HD, Cecconi M, Hamilton M, Rhodes A. Goal-directed therapy in cardiac

surgery: a systematic review and meta-analysis. Br J Anaesth, 2013:510-7.

16. Cohen MC, Pierce ET, Bode RH et al. Types of anesthesia and cardiovascular
outcomes in patients with congestive heart failure undergoing vascular surgery.
Congest Heart Fail 1999;5:248-53.

17. Felker GM, Benza RL, Chandler AB et al. Heart failure etiology and response to
milrinone in decompensated heart failure: results from the OPTIME-CHF study. J Am
Coll Cardiol, 2003:997-1003.

18. Katsaragakis S, Kapralou A, Markogiannakis H et al. Preoperative levosimendan

in heart failure patients undergoing noncardiac surgery. Neth J Med, 2008:154-9.

19. Landoni G, Biondi Zoccai G, Greco M et al. Effects of levosimendan on mortality

and hospitalization. A meta-analysis of randomized controlled studies. Crit Care
Med, 2012:634-46.

20. Nieminen MS, Fruhwald S, Heunks LMA et al. Levosimendan: current data,
clinical use and future development. Heart Lung Vessel, 2013:227-45.

21. Epstein AE, Dimarco JP, Ellenbogen KA et al. 2012 ACCF/AHA/HRS focused
update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based
therapy of cardiac rhythm abnormalities: a report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, 2013:e6-75.

22. Bardy GH, Lee KL, Mark DB et al. Amiodarone or an implantable cardioverter-
defibrillator for congestive heart failure. N Engl J Med, 2005:225-37.
23. Bradley DJ, Bradley EA, Baughman KL et al. Cardiac resynchronization and
death from progressive heart failure: a meta-analysis of randomized controlled
trials. JAMA, 2003:730-40.

24. Bristow MR, Saxon LA, Boehmer J et al. Cardiac-resynchronization therapy with
or without an implantable defibrillator in advanced chronic heart failure. N Engl J
Med, 2004:2140-50.

25. Crossley GH, Poole JE, Rozner MA et al. The Heart Rhythm Society
(HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on
the Perioperative Management of Patients with Implantable Defibrillators,
Pacemakers and Arrhythmia Monitors: Facilities and Patient Management Heart
Rhythm, 2011:1114-54.

26. Riha H, Netuka I, Kotulak T et al. Anesthesia management of a patient with a

ventricular assist device for noncardiac surgery. Seminars in Cardiothoracic and
Vascular Anesthesia, 2010:29-31.

27. Slininger KA, Haddadin AS, Mangi AA. Perioperative management of patients
with left ventricular assist devices undergoing noncardiac surgery. Journal of
Cardiothoracic and vascular anesthesia, 2013:752-9.

28. Thunberg CA, Gaitan BD, Arabia FA et al. Ventricular Assist Devices Today and
Tomorrow Journal of Cardiothoracic and vascular anesthesia, 2010:656-80.

29. Taylor DO, Stehlik J, Edwards LB et al. Registry of the International Society for
Heart and Lung Transplantation: Twenty-sixth Official Adult Heart Transplant
Report-2009. J Heart Lung Transplant, 2009:1007-22.

30. Rose EA, Gelijns AC, Moskowitz AJ et al. Long-term use of a left ventricular assist
device for end-stage heart failure. N Engl J Med, 2001:1435-43.

31. Aaronson KD, Slaughter MS, Miller LW et al. Use of an intrapericardial,

continuous-flow, centrifugal pump in patients awaiting heart transplantation.
Circulation, 2012:3191-200.

32. Stehlik J, Nelson DM, Kfoury AG et al. Outcome of noncardiac surgery in patients
with ventricular assist devices. Am J Cardiol, 2009:709-12.

33. Morgan JA, Paone G, Nemeh HW et al. Non-cardiac surgery in patients on long-
term left ventricular assist device support. J Heart Lung Transplant, 2012:757-63.

34. Lampert BC, Eckert C, Shullo MA et al. Differential Response to Afterload in Axial
and Centrifugal Continuous Flow Left Ventricular Assist Devices (CV-LVAD). The
Journal of heart and lung transplantation : the official publication of the
International Society for Heart Transplantation 2013;32:S57.
35. Dang NC, Topkara VK, Mercando M et al. Right heart failure after left ventricular
assist device implantation in patients with chronic congestive heart failure. J Heart
Lung Transplant, 2006:1-6.

36. Lahm T, McCaslin CA, Wozniak TC et al. Medical and Surgical Treatment of Acute
Right Ventricular Failure J Am Coll Cardiol, 2010:1435-46.