What is the management strategy for patients with perioperative left ventricular (LV) dysfunction?

Management of Perioperative Left Ventricular Dysfunction

The management of perioperative left ventricular (LV) dysfunction requires a tailored approach based on the type and severity of dysfunction, with optimization of guideline-directed medical therapy before surgery and careful perioperative hemodynamic monitoring to reduce morbidity and mortality. 1

Risk Assessment and Classification

• Patients with symptomatic heart failure (HF) have the highest perioperative risk (30-day cardiovascular event rate of 49%), followed by those with asymptomatic systolic LV dysfunction (23%), asymptomatic diastolic LV dysfunction (18%), and normal LV function (10%) 1
• Severely decreased LVEF (<30%) is an independent contributor to poor perioperative outcomes and long-term mortality in patients undergoing elevated-risk noncardiac surgery 1
• Survival after surgery is significantly worse for patients with LVEF ≤29% compared to those with LVEF >29% 1
• Diastolic dysfunction (with or without systolic dysfunction) is associated with higher rates of major adverse cardiovascular events (MACE), prolonged hospital stays, and increased postoperative HF 1

Preoperative Evaluation

• Preoperative evaluation of LV function is recommended for patients with:
  • New dyspnea, physical examination findings of HF, or suspected new/worsening ventricular dysfunction 1
  • Known HF with worsening symptoms or change in clinical status 1
• Routine preoperative evaluation of LV function is NOT recommended in asymptomatic and clinically stable patients due to lack of benefit 1
• Measurement of natriuretic peptides (BNP, NT-proBNP) can help risk stratify patients and improve the predictive performance of the Revised Cardiac Risk Index 1
• Preoperative BNP levels >385 pg/ml predict postoperative complications including need for intra-aortic balloon pump, prolonged hospital stay, and increased mortality 1

Management Strategies by Type of LV Dysfunction

Systolic Dysfunction

• Optimize guideline-directed medical therapy (GDMT) before surgery for patients with stable HF to improve perioperative outcomes 1
• For patients with severely reduced LVEF (<30%):
  • Consider postponing elective surgery until optimization of cardiac function 1
  • Ensure close hemodynamic monitoring during surgery 1
  • Be prepared for potential need for inotropic support 1

Diastolic Dysfunction

• Maintain appropriate preload and avoid tachycardia to optimize diastolic filling 1
• Monitor for fluid overload, which can precipitate acute pulmonary edema 1
• Grade 3 diastolic dysfunction carries higher risk than grades 1-2 and requires more careful management 1

Specific Cardiomyopathies

• Restrictive Cardiomyopathies (amyloidosis, hemochromatosis, sarcoidosis):

  • Cardiac output is both preload and heart rate dependent 1
  • Avoid significant reduction in blood volume or filling pressures 1
  • Prevent bradycardia or tachycardia 1
  • Manage atrial arrhythmias aggressively 1
  • Utilize a multidisciplinary approach with optimization of the underlying pathology 1

• Hypertrophic Obstructive Cardiomyopathy:

  • Avoid decreased systemic vascular resistance (arterial vasodilators) 1
  • Prevent volume loss or reduction in preload/LV filling 1
  • Avoid overdiuresis which can increase dynamic obstruction 1

Perioperative Management

• Hemodynamic Monitoring:

  • Use dynamic measurements to assess volume status 1
  • Employ echocardiography as first-line assessment of heart function 1
  • Consider pulmonary artery catheter especially in right heart dysfunction 1

• Pharmacological Support:

  • For myocardial dysfunction, consider:
    • Low-to-moderate doses of dobutamine and epinephrine 1
    • Milrinone or levosimendan (the latter has shown promising cardioprotective effects) 1
  • For vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure 1
  • Exclude hypovolemia in patients under vasopressors through repeated volume assessments 1

• Mechanical Support:

  • Consider intra-aortic balloon pump in heart dysfunction with suspected coronary hypoperfusion 1
  • Ventricular assist device should be considered before end-organ dysfunction becomes evident 1, 2
  • Extra-corporeal membrane oxygenation may serve as a bridge to recovery or decision-making 1

Special Considerations

• Patients with LVADs undergoing noncardiac surgery require specialized management:

  • Preoperative optimization by cardiologists familiar with LVADs 3
  • Careful management of anticoagulation (present in 73% of LVAD patients before surgery) 3
  • Monitoring for postoperative bleeding, which is a common complication 3

• Point-of-care echocardiographic assessment may help identify LV dysfunction when performed by trained individuals, but comprehensive TTE remains the standard of care 1, 4

Common Pitfalls to Avoid

• Failing to recognize the significance of asymptomatic LV dysfunction, which still carries increased risk compared to normal LV function 1
• Overdiuresis in patients with restrictive or hypertrophic cardiomyopathies 1
• Inappropriate use of vasodilators in hypertrophic obstructive cardiomyopathy 1
• Neglecting to monitor for and treat atrial arrhythmias, which can significantly worsen cardiac output in patients with LV dysfunction 1
• Underestimating the importance of maintaining appropriate heart rate and preload in patients with restrictive physiology 1