V. Suresh1, M. Bishawi5, B. Bryner5, M. Manning4, C. Patel3, J. Rogers3, C. Milano5, J. Schroder5, M. Daneshmand5, C. A. Sommer2 1Duke University Medical Center,School Of Medicine,Durham, NC, USA 2Duke University Medical Center,Division Of Acute Care Surgery, Department Of Surgery,Durham, NC, USA 3Duke University Medical Center,Division Of Cardiology, Department Of Medicine,Durham, NC, USA 4Duke University Medical Center,Division Of Cardiac Anesthesia, Department Of Anesthesia,Durham, NC, USA 5Duke University Medical Center,Division Of Cardiothoracic Surgery, Department Of Surgery,Durham, NC, USA
Introduction: An increasing number of end-stage heart failure patients are supported with Left Ventricular Assist Device (LVAD) implantation and must be maintained on a consistent anticoagulation regimen. These patients are experiencing prolonged survival, and in some, the development of new biliary disease. Thus, the objective of this study was to describe the outcomes and management of LVAD patients undergoing laparoscopic cholecystectomy.
Methods: This study was a retrospective single center review. Adult patients supported on an implanted, continuous flow LVAD from January 1, 2007 to December 31, 2016 were included. Baseline characteristics were collected via retrospective chart review and the institutional LVAD registry. All laparoscopic cholecystectomies were performed in the operating room, utilizing cardiac anesthesia with endotracheal intubation, while LVAD settings were monitored by a trained perfusionist. Physical palpation and visual inspection were used to determine the course of the driveline and avoid driveline injury. Preoperative and postoperative hematology lab values, such as hemoglobin, international normalized ratio (INR), were collected via chart review. Continuous variables were presented as mean ± standard deviations, and compared using the Student t-test. Categorical variables were presented as proportions and percentages, and compared using chi-squared test or Fisher Exact test as appropriate. Statistical significance was established at a p < 0.05.
Results: After screening 798 patients, 5 (0.63%) were found to have undergone laparoscopic cholecystectomies after LVAD implantation. For 4 patients (80%), the indication was symptomatic cholelithiasis, and one patient (20%) had symptomatic acalculous cholecystitis. The average time from LVAD implantation to laparoscopic cholecystectomy was 254.4 ± 158.0 days. Average pre-operative INR was 1.34 ± 0.30. Average preoperative hemoglobin was 11.28 ± 2.41. Pre-operative FFP was administered to one patient. Preoperative Vitamin K was given to one patient. All patients were on Coumadin pre-operatively and admitted prior to their operations for bridging with a heparin drip. Average post-operative change in hemoglobin was -1.16 ± 1.97. The only major post-operative complication in this cohort was the development of an abdominal wall hematoma in one patient, which was treated with drainage in the operating room and post-operative blood transfusion. The average length of stay (LOS) was 13.2 ± 4.6 days. 3 patients (60%) took an average of 12 days to reach therapeutic INR as the main driver for prolonged hospitalization.
Conclusions: Laparoscopic cholecystectomies can be performed safely in LVAD patients. Prolonged hospital stay is mainly due to time to re-achieve INR goals.