Anesthetic management of the patient with low ejection fraction

The number of patients with heart failure presenting for surgery continues to rise, and anesthesiologists are increasingly being called upon to provide quality, safe care in the operating room for patients with low ejection fraction (EF). Perioperative goals in the management of these patients include maintaining forward flow, promoting inotropy without inducing or exacerbating ischemia, and returning patients to their preoperative level of function after surgery. Oftentimes, these goals can be met with pharmacologic support, including the use of calcium channel blockers, phosphodiesterase inhibitors, and novel agents, such as nesiritide and levosimendan. Many patients with diminished EF have implantable cardioverter-defibrillators (ICDs) in place. These devices can be complex to manage, and concern often arises regarding electromagnetic interference from monopolar cautery. Although simply placing a magnet on the device will often disable the antitachycardia interventions of an ICD, this is not always the case. The safest way to manage an ICD in the perioperative period is to interrogate and reprogram the device before and after surgery. Another helpful device in dealing with patients with low EF, particularly those in acute cardiogenic shock, is the intra-aortic balloon pump. These devices can serve a critical role in managing patients who have inadequate responses to pharmacologic therapy or in whom vasopressor and inotropic support are suboptimal because of concerns for increasing myocardial work. With full understanding of available pharmacologic agents, and an appreciation of the capabilities of ICDs and intra-aortic balloon pumps, anesthesiologists will be better equipped to meet the perioperative needs of the patient with low EF.