Anesthetic considerations for the patient undergoing therapy for advanced heart failure

Advanced heart failure (AHF) affects a growing percentage of our population. The anesthesiologist must be cognizant of the perioperative considerations of patients undergoing state-of-the-art therapy for AHF. These therapies include classic and novel agents to improve systolic function, neurohormonal modulators, heart rhythm and synchronization management and mechanical support of the circulation. The perioperative considerations and recommendations may range from invasive hemodynamic monitoring, management of proper inotropic support to maintain left ventricular and right ventricular systolic function, isolation from electromagnetic interference in patients with rhythm management devices, maintenance of appropriate systemic and pulmonary vascular resistance, and surgical planning and anticoagulant management.

Studies of the efficacy and hemodynamic changes of patients on inotropic therapy (milrinone, levosimendan, and istaroxime) and neuropeptide (nesiritide) therapy will be reviewed. Perioperative considerations of patients on mechanical circulatory support will be discussed. The need for implementation of temporary mechanical support for noncardiac surgery will be discussed.

A working knowledge of AHF treatments and perioperative considerations is necessary for all anesthesiologists as more patients receiving therapy will be presenting for all types of surgical procedures.