End-stage cardiac failure patients presenting for LVAD implantation are often dependent on high circulating concentrations of catecholamines to maintain vasoconstriction. Acute decreases in LV preload or increases in LV afterload are poorly tolerated and should be avoided on anesthetic induction. Decreases in heart rate (HR) are especially deleterious, as these patients cannot compensate by increasing stroke volume [1]. Thus, these patients may benefit from low-dose norepinephrine or epinephrine infusion at the time of induction in order to maintain HR and CO .

Lidocaine and fentanyl are often given to blunt the sympathetic response to laryngoscopy. Etomidate is the most commonly used induction agent, but it comes with a risk of adrenal insufficiency. If this is a concern, ketamine can be used. Esmolol should be available to manage any tachycardia resulting from laryngoscopy. Increased time for circulation is required for onset of all intravenous medications, and intraoperative awareness is more frequent in patients undergoing cardiac surgery [15]. Maintaining cardiac output while restricting fluids to avoid unnecessary increases in RV end-diastolic pressure and maintaining adequate anesthetic depth are the pre-CBP goals.

Baseline labs including basic chemistry panel, arterial blood gas, and ACT should be obtained following induction. Hypokalemia and hyperglycemia should be addressed immediately. Antibiotics should be initiated at the time of skin prep (or earlier with vancomycin) and redosed accordingly during the procedure. Leukocyte-reduced blood should be available to reduce anti-HLA antibody production [16]. Replacement products for patients with an iatrogenic antithrombin III deficiency should be available.

Patients should be anticoagulated with heparin (300–400 units/kg) and an appropriate ACT (>350 s) confirmed with the surgeon and perfusionist prior to initiating CPB [17]. For patients with a suspected heparin resistance manifested by inappropriate ACT elevation, an additional dose of heparin may be administered. If this is unsuccessful, a presumed antithrombin III deficiency can be treated with antithrombin III concentrate or FFP if the former is unavailable. If the patient remains refractory to heparin or there is a contraindication to heparin, bivalirudin is the preferred substitute for use on CPB.

The American Society of Echocardiography recommends a TEE checklist for both pre- and postimplantation (Table 7.2). TEE evaluation of the RV should begin with a qualitative assessment of size, tricuspid regurgitation (TR) severity, TR etiology (iatrogenic or secondary to dilated annulus), and ventricular motion from the tricuspid annulus to the apex, inclusive of the free wall [3, 18]. Systolic function and dilatation should be noted, as RV end-diastolic diameter was one of the two echocardiographic variables recently identified as independently predictive of RV failure [3, 19]. 3D volume assessment, tricuspid annular plane systolic excursion (TAPSE), global and regional RV fractional change area, and the maximum derivative of the RV pressure (dP/dt max) have also been mentioned as quantitative options for evaluating systolic function [3, 18]. However, these tools are not always available, and the techniques are challenging in this population [3]. At present there is no consensus on reliable predictors of RV failure following LVAD placement, but given the high morbidity and mortality associated with that event, thorough pre-bypass and postimplant examinations of both ventricles are imperative.