NEW YORK (Reuters Health) – Patients with ventricular assist devices (VAD) can safely undergo abdominal surgery, suggests a new report on 57 patients.
The study, done at three tertiary referral centers in Boston, is the largest to date of outcomes in elective surgery in this small but growing patient population. “Our numbers were low just because there are not that many VAD patients in the world,” Dr. Nelya Melnitchouk of Brigham and Women’s Hospital in Boston told Reuters Health in a telephone interview.
An increasing number of people with end-stage heart disease are undergoing VAD implantation, either as a bridge to transplant or as destination therapy, Dr. Melnitchouk and her colleagues note in their report, online September 6 in the Annals of Surgery. As patients live longer with VADs, they add, the number who may require abdominal surgery is growing.
In the new study, the researchers reviewed the charts of 468 patients with VADs, identifying 57 who underwent 63 abdominal operations in 2003-2015 at the three Boston hospitals. Twenty-three operations were elective, 24 were emergent, and 16 were emergently performed immediately after VAD placement and not included in the main analysis.
Perioperative anticoagulation most frequently involved holding warfarin and starting a heparin/enoxaparin/bivalirudin bridge. Median estimated blood loss was 50 mL in the elective surgery group and 100 mL in the emergent group.
Thirteen percent of the elective patents and 8% of the emergent patients required transfusion to treat postoperative bleeding. Four percent of patients in each group had an ischemic cerebrovascular accident.
None of the elective surgery group and 13% of the emergent group had venous thromboembolism. The mortality rate at 30 days was 4% with elective surgery and 17% with emergent surgery.
Among the 16 patients who underwent emergent abdominal surgery in the setting of cardiogenic shock soon after device placement, 11 required transfusion to treat postoperative bleeding, 44% died within 24 hours, and 30-day mortality was 75%.
This high mortality rate “is likely more reflective of their critical illness than the operation itself,” the authors note. “The clinicians making decisions to perform abdominal operation in the setting of a cardiogenic shock should take into consideration extremely high mortality and bleeding risk in this subset of patients,” they add.
Device thrombosis is a major concern when shifting a VAD patient’s anticoagulation regimen, but it did not occur in any of the study patients, Dr. Melnitchouk noted.
She and her colleagues conclude: “Larger, prospective multi-institutional studies are needed to further elucidate risk factors that affect surgical outcomes and provide more-standardized guidelines of anticoagulation management to provide better care and counseling for our patients.”
SOURCE: http://bit.ly/2xxy7sh
Ann Surg 2017.
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