J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://www.journalmc.org

Case Report

Volume 15, Number 6, June 2024, pages 97-101

Combined General and Regional Anesthesia for a Patient With Duchenne Muscle Dystrophy With an Implanted Left Ventricular Assisted Device Undergoing Orthopedic Surgery

**Table 1.** Reports Regarding Regional Anesthesia for LVAD Patients Undergoing Surgical Interventions
Author	Age/sex	Surgical procedure	Anesthesia type/comments
POD: postoperative day; LVAD: left ventricular assisted device; TKR: total knee replacement; TPVB: thoracic paravertebral block.
Gayam et al, 2020 [8]	24-year-old woman, 80 kg with LVAD (polysubstance abuse-related cardiomyopathy)	Induction of labor and Cesarean delivery	Epidural anesthesia. The last dose of enoxaparin (150 mg twice daily) was 24 h before admission. The epidural was incrementally dosed with 15 mL of 0.125% bupivacaine and 5 mL of 0.25% bupivacaine over a 1.5-h period of time. Analgesia was then maintained with an infusion of 0.1% bupivacaine and fentanyl 2 µg/mL. Cesarean delivery proceeded uneventfully. Anticoagulation was resumed on POD 1 using an unfractionated heparin infusion at 700 U/h and then transitioned to dabigatran. Bilateral transverse abdominis plane blocks using liposomal bupivacaine were performed on POD 1 and 6.
Fegley et al, 2021 [9]	72-year-old woman with LVAD for ischemic cardiomyopathy	Elective left TKR	Spinal anesthesia (L3 - 4) and adductor canal catheter. Sedation was provided using a propofol infusion. Warfarin was withheld 6 days before surgery and the patient was admitted to the hospital 2 days before surgery for maintenance of anticoagulation with intravenous unfractionated heparin. The heparin infusion was discontinued 4 - 6 h before the procedure. Anticoagulation was reinitiated on POD 2, after removal of the adductor canal catheter. The patient’s postoperative course was uncomplicated. She was discharged home on POD 5.
Okitsu et al, 2017 [10]	Case series of three patients (35 - 49 years of age). One male and two females with an LVAD for dilated cardiomyopathy	Surgical management of LVAD-related infections	Combined general and regional anesthesia (continuous TPVB). Warfarin therapy was not altered for catheter placement or removal. Levobupivacaine (10 mL of 0.25%) was administered during catheter insertion for the intraoperative analgesic and 0.125% levobupivacaine was continuously infused at a rate of 6 mL/h postoperatively for 3 days to 2 weeks. Satisfaction ranged from 5 - 8/10.

Table 1. Reports Regarding Regional Anesthesia for LVAD Patients Undergoing Surgical Interventions

Author

Age/sex

Surgical procedure

Anesthesia type/comments

POD: postoperative day; LVAD: left ventricular assisted device; TKR: total knee replacement; TPVB: thoracic paravertebral block.

Gayam et al, 2020 [8]

24-year-old woman, 80 kg with LVAD (polysubstance abuse-related cardiomyopathy)

Induction of labor and Cesarean delivery

Epidural anesthesia. The last dose of enoxaparin (150 mg twice daily) was 24 h before admission. The epidural was incrementally dosed with 15 mL of 0.125% bupivacaine and 5 mL of 0.25% bupivacaine over a 1.5-h period of time. Analgesia was then maintained with an infusion of 0.1% bupivacaine and fentanyl 2 µg/mL. Cesarean delivery proceeded uneventfully. Anticoagulation was resumed on POD 1 using an unfractionated heparin infusion at 700 U/h and then transitioned to dabigatran. Bilateral transverse abdominis plane blocks using liposomal bupivacaine were performed on POD 1 and 6.

Fegley et al, 2021 [9]

72-year-old woman with LVAD for ischemic cardiomyopathy

Elective left TKR

Spinal anesthesia (L3 - 4) and adductor canal catheter. Sedation was provided using a propofol infusion. Warfarin was withheld 6 days before surgery and the patient was admitted to the hospital 2 days before surgery for maintenance of anticoagulation with intravenous unfractionated heparin. The heparin infusion was discontinued 4 - 6 h before the procedure. Anticoagulation was reinitiated on POD 2, after removal of the adductor canal catheter. The patient’s postoperative course was uncomplicated. She was discharged home on POD 5.

Okitsu et al, 2017 [10]

Case series of three patients (35 - 49 years of age). One male and two females with an LVAD for dilated cardiomyopathy

Surgical management of LVAD-related infections

Combined general and regional anesthesia (continuous TPVB). Warfarin therapy was not altered for catheter placement or removal. Levobupivacaine (10 mL of 0.25%) was administered during catheter insertion for the intraoperative analgesic and 0.125% levobupivacaine was continuously infused at a rate of 6 mL/h postoperatively for 3 days to 2 weeks. Satisfaction ranged from 5 - 8/10.