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Denardo SJ, Vlachos PP, Meyers BA, Babakhani-Galangashi R, Wang L, Gao Z, Tcheng JE. Translating proof-of-concept for platelet slip into improved antithrombotic therapeutic regimens. Platelets 2024; 35:2353582. [PMID: 38773939 DOI: 10.1080/09537104.2024.2353582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/03/2024] [Indexed: 05/24/2024]
Abstract
Platelets are central to thrombosis. Research at the intersection of biological and physical sciences provides proof-of-concept for shear rate-dependent platelet slip at vascular stenosis and near device surfaces. Platelet slip extends the observed biological "slip-bonds" to the boundary of functional gliding without contact. As a result, there is diminished engagement of the coagulation cascade by platelets at these surfaces. Comprehending platelet slip would more precisely direct antithrombotic regimens for different shear environments, including for percutaneous coronary intervention (PCI). In this brief report we promote translation of the proof-of-concept for platelet slip into improved antithrombotic regimens by: (1) reviewing new supporting basic biological science and clinical research for platelet slip; (2) hypothesizing the principal variables that affect platelet slip; (3) applying the consequent construct model in support of-and in some cases to challenge-relevant contemporary guidelines and their foundations (including for urgent, higher-risk PCI); and (4) suggesting future research pathways (both basic and clinical). Should future research demonstrate, explain and control platelet slip, then a paradigm shift for choosing and recommending antithrombotic regimens based on predicted shear rate should follow. Improved clinical outcomes with decreased complications accompanying this paradigm shift for higher-risk PCI would also result in substantive cost savings.
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Affiliation(s)
- Scott J Denardo
- Medicine/Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Pavlos P Vlachos
- School of Mechanical Engineering, Purdue University, West Lafayette, IN, USA
| | - Brett A Meyers
- School of Mechanical Engineering, Purdue University, West Lafayette, IN, USA
| | | | - Lin Wang
- Department of Statistics, Purdue University, West Lafayette, IN, USA
| | - Zejin Gao
- Department of Statistics, Purdue University, West Lafayette, IN, USA
| | - James E Tcheng
- Medicine/Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
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2
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Hajduczok AG, Donald EM, Maning J, Youmans Q, Reza N. Can't Rain on Our Parade: Highlights from the Heart Failure Society of America (HFSA) Annual Scientific Meeting 2024. J Card Fail 2024:S1071-9164(24)00421-4. [PMID: 39395783 DOI: 10.1016/j.cardfail.2024.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Accepted: 10/03/2024] [Indexed: 10/14/2024]
Affiliation(s)
| | - Elena M Donald
- Department of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Jennifer Maning
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Quentin Youmans
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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3
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Estep JD, Salah HM, Kapadia SR, Burkhoff D, Lala A, Butler J, Hall S, Fudim M. HFSA Scientific Statement: Update on Device Based Therapies in Heart Failure. J Card Fail 2024:S1071-9164(24)00258-6. [PMID: 39261158 DOI: 10.1016/j.cardfail.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/16/2024] [Accepted: 07/16/2024] [Indexed: 09/13/2024]
Abstract
Heart failure (HF) is 1 of the major challenges of our time, given its increase in prevalence and related mortality rates. Foundational pharmacological therapies, including angiotensin receptor neprilysin inhibitors (ARNIs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose co-transporter inhibitors (SGLTis), have been established for HF with reduced ejection fraction (HFrEF). Moreover, recent trials have established the role of SGLTis in patients with HF with preserved ejection fraction (HFpEF). However, even with these therapies, a substantial residual risk persists in both HFrEF and HFpEF. Alongside pharmacological advancements, device-based therapies have shown efficacy in HF management, including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT). More recently, devices such as cardiac contractility modulation (CCM) and baroreflex activation therapy (BAT) have been approved by the FDA, although they lack comprehensive guideline recommendations. This scientific statement outlines the unmet needs in chronic HF, reviews contemporary data and provides a framework for integrating novel device-based therapies into current clinical workflows. It emphasizes the importance of early diagnosis and phenotyping, proper patient stratification and a personalized approach to combining pharmacological and device therapies. The document also highlights the need for further research into device interactions and patient selection to optimize outcomes, while recognizing the need for a more integrated approach to treatment so as to address the unmet needs and residual risks in HF management.
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Affiliation(s)
- Jerry D Estep
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, Weston, FL
| | - Husam M Salah
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Anuradha Lala
- Zena and Weil Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine, New York, NY
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX; Department of Medicine, University of Mississippi School of Medicine, Jackson, MI
| | | | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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4
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Blumer V, Looby M, Shah P. Periprocedural Bridging in Patients With Left Ventricular Assist Devices: Is it Necessary? J Card Fail 2024; 30:1120-1123. [PMID: 38782085 DOI: 10.1016/j.cardfail.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024]
Affiliation(s)
| | - Mary Looby
- Inova Schar Heart and Vascular, Falls Church, VA
| | - Palak Shah
- Inova Schar Heart and Vascular, Falls Church, VA.
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5
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Ando M, Ono M. Current issues of destination therapy in Japan: to achieve 5-year or even longer survival. J Artif Organs 2024; 27:203-211. [PMID: 38981996 PMCID: PMC11345326 DOI: 10.1007/s10047-024-01458-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 06/08/2024] [Indexed: 07/11/2024]
Abstract
In April 2021, destination therapy (DT) was finally approved in Japan. Since DT does not aim at heart transplantation (HT), our goal is to have a patient safely remain on an implantable ventricular assist device (VAD) for the rest of his/her life. To achieve this goal, similarly to bridge-to-transplant (BTT) patients, the authors believe the following six aspects are even more crucial in DT patients: (1) to appropriately assess risks before implantation, (2) to carefully determine the ability to manage the device by multidisciplinary discussions, (3) to prevent complications by improving the quality of care, (4) to expand the number of facilities that can take care of DT patients by improving collaboration among the facilities, (5) to reduce the burden of caregivers by utilizing social resources, and (6) to establish a home palliative care system based on advance care planning. In addition, for elderly DT patients to live happy and long lives, it is essential to help them to find a purpose of life and to keep activities of daily living, such as employment, schooling, and participation in social activities, just like the general elderly population. Our goals are not only to do our best for the patients just in front of us, but also to establish a system to follow up our DT cohort, same as BTT one, by all-Japan manner. In the present review, we discuss the current state of DT in Japan and what we need to focus on to maintain or improve its long-term performance.
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Affiliation(s)
- Masahiko Ando
- Department of Cardiovascular Surgery, The University of Tokyo Hospital, Hongo 7-3-1, Bunkyo, Tokyo, 113-8655, Japan.
| | - Minoru Ono
- Department of Cardiovascular Surgery, The University of Tokyo Hospital, Hongo 7-3-1, Bunkyo, Tokyo, 113-8655, Japan
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6
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Sylvester KW, Grandoni J, Rhoten M, Coakley L, Lyons-Matiello E, Frankel K, Fortin B, Jolley K, Park HS, Freedman RY, Mehra MR, Givertz MM, Connors JM. Assessment of Temporary Warfarin Reversal in Patients With Left Ventricular Assist Devices: the KVAD Study. J Card Fail 2024; 30:1111-1119. [PMID: 38521486 DOI: 10.1016/j.cardfail.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Patients with left ventricular assist devices (LVADs) require interruption of warfarin for invasive procedures, but parenteral bridging is associated with many complications. Four-factor prothrombin complex concentrate (4F-PCC) can temporarily restore hemostasis in patients undergoing anticoagulation with warfarin. OBJECTIVES This pilot study evaluated the strategy of using variable-dose 4F-PCC to immediately and temporarily reverse warfarin before invasive procedures without holding warfarin in patients with LVADs. The duration of effect of 4F-PCC on factor levels and time to reestablish therapeutic anticoagulation post procedure were assessed. METHODS Adult patients with LVADs and planned invasive procedures were enrolled from a single center. Warfarin was continued uninterrupted. The 4F-PCC dose administered immediately pre-procedure was based on study protocol. International normalized ratio (INR)- and vitamin K-dependent factor levels were collected before and during the 48 hours after 4F-PCC administration. The use of parenteral bridging, International Society for Thrombosis and Haemostasis major and clinically relevant nonmajor bleeding (CRNMB) and thromboembolic events at 7 and 30 days were collected. RESULTS In 21 episodes of 4F-PCC reversal, median baseline INR was 2.7 (IQR 2.2-3.2). The median dosage of 4F-PCC administered was 1794 units (IQR 1536-2130). At 24 and 48 hours post 4F-PCC administration, median INRs were 1.8 (IQR 1.7-2.0) and 2.0 (IQR 1.9-2.4). Two patients required postoperative bridging. One patient experienced major bleeding within 72 hours, and 2 experienced CRNMB within 30 days. There were no thromboembolic events. Baseline and post 4F-PCC vitamin K-dependent factor levels corresponded with changes in INR values. The median time to achieve therapeutic INR post-procedure was 2.5 days (IQR, 1-4). CONCLUSION Administration of 4F-PCC for temporary reversal of warfarin for invasive procedures in patients with LVADs allowed for continued warfarin dosing with minimal use of post-intervention bridging, limited bleeding and no thromboembolic events.
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Affiliation(s)
- Katelyn W Sylvester
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA. https://twitter.com/KatelynSylvester4
| | - Jessica Grandoni
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Megan Rhoten
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Lara Coakley
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA
| | | | - Katie Frankel
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA
| | - Brooke Fortin
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Kate Jolley
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Hae Soo Park
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | | | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA. https://twitter.com/MRMehraMD
| | - Michael M Givertz
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA. https://twitter.com/GivertzMichael
| | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Boston, MA.
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7
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Shah P, Looby M, Dimond M, Bagchi P, Shah B, Isseh I, Rollins AT, Abdul-Aziz AA, Kennedy J, Tang DG, Klein KM, Casselman S, Vermeulen C, Sheaffer W, Snipes M, Sinha SS, O'Connor CM. Evaluation of the Hemocompatibility of the Direct Oral Anticoagulant Apixaban in Left Ventricular Assist Devices: The DOAC LVAD Study. JACC. HEART FAILURE 2024; 12:1540-1549. [PMID: 38795110 DOI: 10.1016/j.jchf.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND Patients receiving left ventricular assist device (LVAD) support require long-term anticoagulation to reduce the risk of thromboembolic complications. Apixaban is a direct oral anticoagulant that has become first-line therapy; however, its safety in LVAD recipients has not been well described. OBJECTIVES This study sought to investigate whether, in patients with a fully magnetically levitated LVAD, treatment with apixaban would be feasible and comparable with respect to safety and freedom from the primary composite outcome of death or major hemocompatibility-related adverse events (HRAEs) (stroke, device thrombosis, major bleeding, aortic root thrombus, and arterial non-central nervous system thromboembolism) as compared with treatment with warfarin. METHODS The DOAC LVAD (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices) trial was a phase 2, open label trial of LVAD recipients randomized 1:1 to either apixaban 5 mg twice daily or warfarin therapy. All patients were required to take low-dose aspirin. Patients were followed up for 24 weeks to evaluate the primary composite outcome. RESULTS A total of 30 patients were randomized: 14 patients to warfarin and 16 patients to apixaban. The median patient age was 60 years (Q1-Q3: 52-71 years), and 47% were Black patients. The median time from LVAD implantation to randomization was 115 days (Q1-Q3: 56-859 days). At 24 weeks, the primary composite outcome occurred in no patients receiving apixaban and in 2 patients (14%) receiving warfarin (P = 0.12); these 2 patients experienced major bleeding from gastrointestinal sources. CONCLUSIONS Anticoagulation with apixaban was feasible in patients with an LVAD without an excess of HRAEs or deaths. This study informs future pivotal clinical trials evaluating the safety and efficacy of apixaban in LVAD recipients. (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices [DOAC LVAD]; NCT04865978).
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Affiliation(s)
- Palak Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA.
| | - Mary Looby
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Matthew Dimond
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Pramita Bagchi
- Department of Biostatistics, George Washington University, Washington, DC, USA
| | - Bhruga Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Iyad Isseh
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Allman T Rollins
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Ahmad A Abdul-Aziz
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Jamie Kennedy
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Daniel G Tang
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Katherine M Klein
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Samantha Casselman
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Christen Vermeulen
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Wendy Sheaffer
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Meredith Snipes
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Shashank S Sinha
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
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8
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Pinney SP. DOAC Use in Durable Mechanical Circulatory Support: A Sign of Things to Come? JACC. HEART FAILURE 2024; 12:1550-1552. [PMID: 39237250 DOI: 10.1016/j.jchf.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 07/23/2024] [Indexed: 09/07/2024]
Affiliation(s)
- Sean P Pinney
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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9
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Simmonds MJ, Thamsen B, Olia SE, McNamee AP, Granegger M, Wurm H, Rajagopal K, McGiffin DC. Will blood-informed design signal the fourth generation of cardiac assist devices? J Heart Lung Transplant 2024:S1053-2498(24)01799-6. [PMID: 39182799 DOI: 10.1016/j.healun.2024.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/30/2024] [Accepted: 08/13/2024] [Indexed: 08/27/2024] Open
Abstract
Mechanical circulatory support devices have profoundly transformed the management of severe cardiothoracic disorders. While heart transplantation is the gold standard therapy for end-stage heart disease, long-term mechanical support devices are a viable alternative for those ineligible and/or those awaiting organ availability. Major technological advancements were made over first 5 decades of development, resulting in improved durability and survival with reduced adverse events. However, gains have tapered recently for various complications (e.g., internal bleeding, multisystem organ failure), which collectively represent a significant proportion of disability and/or mortality. Further, in light of mature ventricular assist devices failing during clinical trials or even after clinical approval (class I withdrawals), it is timely to consider: Are our preclinical assessment protocols vital in the design and development of mechanical circulatory support devices, providing a realistic and reliable profile of future clinical performance? This commentary explores this question and analyses development pathways through the lens of the various disciplines involved in the preclinical assessment of mechanical circulatory support technologies: Limitations in approaches to benchtop blood testing, computational design and simulation, and animal testing are discussed as likely contributors to some of the common hemocompatibility-related adverse events (HRAEs). While it is acknowledged that some shortcomings are pragmatic in nature, possible solutions are presented that will only be realized through truly transdisciplinary and open approaches that challenge the current nature of medical device development. We suggest that these can and must be overcome to diminish HRAEs and will potentially demarcate the fourth generation of cardiac assist devices.
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Affiliation(s)
- Michael J Simmonds
- Biorheology Research Laboratory, Griffith University, Gold Coast, Australia.
| | - Bente Thamsen
- Christian Doppler Laboratory for Mechanical Circulatory Support, Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Salim E Olia
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Antony P McNamee
- Biorheology Research Laboratory, Griffith University, Gold Coast, Australia
| | - Marcus Granegger
- Christian Doppler Laboratory for Mechanical Circulatory Support, Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Hendrik Wurm
- Faculty of Mechanical Engineering and Marine Technology, Institute of Turbomachinery, University of Rostock, Rostock, Germany
| | - Keshava Rajagopal
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David C McGiffin
- Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, Australia
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10
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Martínez León A, Bazal Chacón P, Herrador Galindo L, Ugarriza Ortueta J, Plaza Martín M, Pastor Pueyo P, Alonso Salinas GL. Review of Advancements in Managing Cardiogenic Shock: From Emergency Care Protocols to Long-Term Therapeutic Strategies. J Clin Med 2024; 13:4841. [PMID: 39200983 PMCID: PMC11355768 DOI: 10.3390/jcm13164841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/08/2024] [Accepted: 08/14/2024] [Indexed: 09/02/2024] Open
Abstract
Cardiogenic shock (CS) is a complex multifactorial clinical syndrome of end-organ hypoperfusion that could be associated with multisystem organ failure, presenting a diverse range of causes and symptoms. Despite improving survival in recent years due to new advancements, CS still carries a high risk of severe morbidity and mortality. Recent research has focused on improving early detection and understanding of CS through standardized team approaches, detailed hemodynamic assessment, and selective use of temporary mechanical circulatory support devices, leading to better patient outcomes. This review examines CS pathophysiology, emerging classifications, current drug and device therapies, standardized team management strategies, and regionalized care systems aimed at optimizing shock outcomes. Furthermore, we identify gaps in knowledge and outline future research needs.
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Affiliation(s)
- Amaia Martínez León
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain; (A.M.L.); (P.B.C.); (J.U.O.)
- Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Pablo Bazal Chacón
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain; (A.M.L.); (P.B.C.); (J.U.O.)
- Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
- Heath Sciences Department, Universidad Pública de Navarra (UPNA-NUP), 31006 Pamplona, Spain
| | - Lorena Herrador Galindo
- Advanced Heart Failure and Cardiology Department, Hospital Universitario de Bellvitge, Carrer de la Feixa Llarga s/n, 08907 L’Hospitalet de Llobregat, Spain;
| | - Julene Ugarriza Ortueta
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain; (A.M.L.); (P.B.C.); (J.U.O.)
- Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - María Plaza Martín
- Cardiology Department, Hospital Clínico Universitario de Valladolid, Av Ramón y Cajal 3, 47003 Valladolid, Spain;
| | - Pablo Pastor Pueyo
- Cardiology Department, Hospital Universitari Arnau de Vilanova, Av Alcalde Rovira Roure, 80, 25198 Lleida, Spain;
| | - Gonzalo Luis Alonso Salinas
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain; (A.M.L.); (P.B.C.); (J.U.O.)
- Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
- Heath Sciences Department, Universidad Pública de Navarra (UPNA-NUP), 31006 Pamplona, Spain
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11
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Cikes M, Yuzefpolskaya M, Gustafsson F, Mehra MR. Antithrombotic Strategies With Left Ventricular Assist Devices. J Card Fail 2024:S1071-9164(24)00318-X. [PMID: 39154903 DOI: 10.1016/j.cardfail.2024.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 08/20/2024]
Abstract
Long-term outcomes of patients with advanced heart failure treated with durable left ventricular assist devices (LVADs) have been augmented due to improved durability and hemocompatibility on the backbone of pump engineering enhancements. The incidence of hemocompatibility-related adverse events (pump thrombosis, stroke and nonsurgical bleeding events) are device specific and vary by type of engineered pump. A fully magnetically levitated rotor containing LVAD in concert with use of antithrombotic therapy has successfully overcome an increased risk of pump thrombosis and stroke-risk, albeit with only modest reduction in bleeding events. Modifications to antithrombotic strategies have focused on reduced-dose vitamin K antagonist use or use of direct oral anticoagulants with demonstration of safety and progress in reduction of mucosal bleeding episodes with elimination of antiplatelet agents. This review outlines the current landscape of advances in anticoagulation management in LVAD patients, highlighting the need for ongoing research and cautious application of emerging therapies and technologies.
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Affiliation(s)
- Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Melana Yuzefpolskaya
- Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Mandeep R Mehra
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
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12
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Akdogan RE, Check L, Houston BA, Carnicelli AP, Griffin JM, Atkins JL, Witer LJ, Kilic A, Tedford RJ, Baker G, Manger D, Hajj J, Rao VN. Aortic Root Thromboembolism and Associated Acute Myocardial Infarction in Patients With Contemporary Durable LVADs. JACC Case Rep 2024; 29:102441. [PMID: 39157541 PMCID: PMC11328753 DOI: 10.1016/j.jaccas.2024.102441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 08/20/2024]
Abstract
Patients with HeartMate 3 left ventricular assist devices may develop aortic root thrombus, yet its prevalence and associated risks are unknown. We present 2 patients who developed aortic root thromboembolism and acute coronary occlusions. We additionally present heart transplantation as viable treatment for thromboembolic disease and refractory right ventricular failure.
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Affiliation(s)
- Raziye Ecem Akdogan
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Larissa Check
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian A. Houston
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anthony P. Carnicelli
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jan M. Griffin
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jessica L. Atkins
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lucas J. Witer
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ryan J. Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Grace Baker
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Darian Manger
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jennifer Hajj
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vishal N. Rao
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
- The Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina, USA
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13
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Widhalm G, Aigner P, Gruber B, Moscato F, Moayedifar R, Schaefer AK, Dimitrov K, Zimpfer D, Riebandt J, Schlöglhofer T. Preoperative anatomical landmarks and longitudinal HeartMate 3 pump position in X-rays: Relevance for adverse events. Artif Organs 2024. [PMID: 39105573 DOI: 10.1111/aor.14837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/08/2024] [Accepted: 07/22/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Left ventricular assist device (LVAD) malposition has been linked to hemocompatibility-related adverse events (HRAEs). This study aimed to identify preoperative anatomical landmarks and postoperative pump position, associated with HRAEs during LVAD support. METHODS Pre- and postoperative chest X-ray measures (≤14 days pre-implantation, first postoperative standing, 6, 12, 18, and 24 months post-implantation) were analyzed for their association with HRAEs over 24 months in 33 HeartMate 3 (HM3) patients (15.2% female, age 66 (9.5) years). RESULTS HM3 patients with any HRAE showed significantly lower preoperative distances between left ventricle and thoracic outline (dLVT) (25.3 ± 10.2 mm vs. 40.3 ± 15.5 mm, p = 0.004). A ROC-derived cutoff dLVT ≤ 29.2 mm provided 85.7% sensitivity and 72.2% specificity predicting any HRAE during HM3 support (76.2% (>29.2 mm) vs. 16.7% (≤29.2 mm) freedom from HRAE, p < 0.001) and significant differences in cardiothoracic ratio (0.58 ± 0.04 vs. 0.62 ± 0.04, p = 0.045). Postoperative X-rays indicated lower pump depths in patients with ischemic strokes (9.1 ± 16.2 mm vs. 38.0 ± 18.5 mm, p = 0.007), reduced freedom from any neurological event (pump depth ≤ 28.7 mm: 45.5% vs. 94.1%, p = 0.004), and a significant correlation between pump depth and inflow cannula angle (r = 0.66, p < 0.001). Longitudinal changes were observed in heart-pump width (F(4,60) = 5.61, p < 0.001). CONCLUSION Preoperative X-ray markers are associated with postoperative HRAE occurrence. Applying this knowledge in clinical practice may enhance risk stratification, guide therapy optimization, and improve HM3 recipient management.
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Affiliation(s)
- Gregor Widhalm
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Aigner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Bernhard Gruber
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Roxana Moayedifar
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Kamen Dimitrov
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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14
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Netuka I, Tucanova Z, Ivak P, Gregor S, Kolesar DM, Marek T, Melenovsky V, Binova J, Dorazilova Z, Hegarova M, Podolec M, Riha H, Connors JM, Mehra MR. A Prospective Randomized Trial of Direct Oral Anticoagulant Therapy With a Fully Magnetically Levitated LVAD: The DOT-HM3 Study. Circulation 2024; 150:509-511. [PMID: 38594972 DOI: 10.1161/circulationaha.124.069726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Zuzana Tucanova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Peter Ivak
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Stanislav Gregor
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Dushan Michael Kolesar
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Tomas Marek
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Jana Binova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Zora Dorazilova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Marketa Hegarova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Martina Podolec
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Hynek Riha
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (I.N., Z.T., P.I., S.G., D.M.K., T.M., V.M., J.B., Z.D., M.H., M.P., H.R.)
| | - Jean M Connors
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.C., M.R.M.)
| | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.C., M.R.M.)
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15
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Schnegg B, Deveza R, Hayward C. Apixaban in bridge to transplant and destination LVAD - rationale and study design: the ApixiVAD trial. ESC Heart Fail 2024; 11:2387-2394. [PMID: 38650125 PMCID: PMC11287292 DOI: 10.1002/ehf2.14782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 02/19/2024] [Accepted: 03/16/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS Use of novel anticoagulation in mechanical circulatory support is controversial. We report the rationale and design of the ApixiVad pilot trial, a pilot study testing the safety of apixaban as an anticoagulant in patients bridged to transplant (BTT) or for destination (DT) with Heartmate 3 (HM3) left ventricular assist device (LVAD). METHODS AND RESULTS Apixaban has been used in small non-randomized cohorts in LVAD patients and shown to be effective in ex vivo studies. The ApixiVAD study examines apixaban use in a multicentre, international, open-label, randomized, controlled trial aiming to include 50 BTT or DT HM3 patients with a 1:1 randomization ratio. This event-driven study has a maximum follow-up period of 24 months with interim analysis at 6 months. The primary outcome is death, thromboembolic events and major bleeding, including operative bleeding and immediate transplant outcomes. The secondary outcome focuses on patients' quality of life related to anticoagulation. This investigator-driven pilot study is not powered to determine the non-inferiority of apixaban. An increase in primary outcome in the apixaban group of 20% will be considered a signal of harm. CONCLUSIONS A positive outcome in the ApixiVAD study would provide the basis for future, larger, pivotal anticoagulation trials in LVAD patients.
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Affiliation(s)
- Bruno Schnegg
- Department of Cardiology, Centre for Advanced Heart Failure, InselspitalBern University HospitalBernSwitzerland
| | - Ricardo Deveza
- Heart Failure and Transplant UnitSt Vincent's HospitalSydneyNew South WalesAustralia
| | - Christopher Hayward
- Heart Failure and Transplant UnitSt Vincent's HospitalSydneyNew South WalesAustralia
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16
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Mutschlechner D, Tscharre M, Wittmann F, Kitzmantl D, Schlöglhofer T, Wadowski PP, Laufer G, Eichelberger B, Lee S, Wiedemann D, Panzer S, Zimpfer D, Gremmel T. Platelet reactivity is associated with pump thrombosis in patients with left ventricular assist devices. Res Pract Thromb Haemost 2024; 8:102564. [PMID: 39391561 PMCID: PMC11466564 DOI: 10.1016/j.rpth.2024.102564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 07/28/2024] [Accepted: 08/30/2024] [Indexed: 10/12/2024] Open
Abstract
Background Patients with left ventricular assist devices (LVADs) are treated with a potent antithrombotic regimen to prevent pump thrombosis and thromboembolism. High on-treatment residual platelet reactivity (HRPR) is associated with ischemic outcomes in cardiovascular disease. Objectives In the current study, we investigated the prevalence and clinical impact of HRPR in stable LVAD patients. Methods Pump thrombosis, bleeding events, and death were assessed in 62 LVAD patients (19 HeartWare HVAD [Medtronic] and 43 HeartMate 3 [Abbott]) during a 2-year follow-up. Platelet aggregation was measured by multiple electrode aggregometry, and HRPR was defined as arachidonic acid (AA)-inducible platelet aggregation of ≥21 aggregation units. Soluble P-selectin was determined by enzyme-linked immunosorbent assay. Results Three patients (4.8%) had pump thrombosis and 10 patients (16.1%) suffered a bleeding complication. AA-inducible platelet aggregation was significantly higher in patients with pump thrombosis (P = .01), whereas platelet aggregation in response to adenosine diphosphate (ADP) and thrombin receptor-activating peptide (TRAP) was comparable between patients without and those with pump thrombosis (both P > .05). Platelet aggregation in response to AA, ADP, and TRAP was similar in patients without and with a bleeding event (all P > .05). HRPR was detected in 29 patients (46.8%) and was associated with significantly higher platelet aggregation in response to AA, ADP, and TRAP as well as higher levels of soluble P-selectin compared with patients without HRPR (all P < .05). All pump thromboses occurred in patients with HRPR (3 vs 0; P = .06) and HVAD. Conclusion Platelet reactivity is associated with pump thrombosis in LVAD patients. HRPR may represent a risk marker for pump thrombosis, particularly in HVAD patients.
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Affiliation(s)
- David Mutschlechner
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
- Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Maximilian Tscharre
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, St. Pölten, Austria
| | - Franziska Wittmann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniela Kitzmantl
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Günther Laufer
- Division of Cardiac Surgery, Department of Surgery, Medical University Graz, Graz, Austria
| | - Beate Eichelberger
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Silvia Lee
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Universitätsklinikum St. Pölten, St. Pölten, Austria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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17
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Kelleher JT, Givertz MM. Antithrombotic Therapy for Mechanical Circulatory Support: Time to Throw the Baby (Warfarin) Out With the Bathwater (Aspirin)? Circ Heart Fail 2024; 17:e011568. [PMID: 39051102 PMCID: PMC11335440 DOI: 10.1161/circheartfailure.124.011568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Affiliation(s)
| | - Michael M. Givertz
- Harvard Medical School, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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18
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Hollis IB, Jennings DL, Krim S, Ton VK, Ducharme A, Cowger J, Looby M, Eulert-Green JJ, Bansal N, Horn E, Byku M, Katz J, Michaud CJ, Rajapreyar I, Campbell P, Vale C, Cosgrove R, Hernandez-Montfort J, Otero J, Ingemi A, Raj S, Weeks P, Agarwal R, Martinez ES, Tops LF, Ahmed MM, Kiskaddon A, Kremer J, Keebler M, Ratnagiri RK. An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device. J Heart Lung Transplant 2024; 43:1199-1234. [PMID: 38878021 DOI: 10.1016/j.healun.2024.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 07/15/2024] Open
Abstract
Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.
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Affiliation(s)
- Ian B Hollis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina; University of North Carolina Medical Center, Chapel Hill, North Carolina.
| | - Douglas L Jennings
- New York Presbyterian Columbia Irving Medical Center/Long Island University College of Pharmacy, New York, New York
| | - Selim Krim
- John Ochsner Heart and Vascular Institute, New Orleans, Louisiana
| | - Van-Khue Ton
- Massachusetts General Hospital, Boston, Massachusetts
| | - Anique Ducharme
- Montreal Heart Institute/Université de Montréal, Montreal, Quebec, Canada
| | | | - Mary Looby
- Inova Fairfax Medical Campus, Falls Church, Virginia
| | | | - Neha Bansal
- Mount Sinai Kravis Children's Hospital, New York, New York
| | - Ed Horn
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mirnela Byku
- University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Jason Katz
- Division of Cardiology, NYU Grossman School of Medicine & Bellevue Hospital, New York, New York
| | | | | | | | - Cassandra Vale
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Richard Cosgrove
- Cornerstone Specialty Hospital/University of Arizona College of Pharmacy, Tucson, Arizona
| | | | - Jessica Otero
- AdventHealth Littleton Hospital, Littleton, Colorado
| | | | | | - Phillip Weeks
- Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | | | - Laurens F Tops
- Leiden University Medical Center, Leiden, the Netherlands
| | | | - Amy Kiskaddon
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mary Keebler
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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19
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Mondal A, Srikanth S, Aggarwal S, Alle NR, Odugbemi O, Ogbu I, Desai R. Coronary artery disease and heart failure: Late-breaking trials presented at American Heart Association scientific session 2023. World J Cardiol 2024; 16:389-396. [PMID: 39086888 PMCID: PMC11287454 DOI: 10.4330/wjc.v16.i7.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/21/2024] [Accepted: 06/05/2024] [Indexed: 07/23/2024] Open
Abstract
The late-breaking science presented at the 2023 scientific session of the American Heart Association paves the way for future pragmatic trials and provides meaningful information to guide management strategies in coronary artery disease and heart failure (HF). The dapagliflozin in patient with acute myocardial infarction (DAPA-MI) trial showed that dapagliflozin use among patients with acute MI without a history of diabetes mellitus or chronic HF has better cardiometabolic outcomes compared with placebo, with no difference in cardiovascular outcomes. The MINT trial showed that in patients with acute MI and anemia (Hgb < 10 g/dL), a liberal transfusion goal (Hgb ≥ 10 g/dL) was not superior to a restrictive strategy (Hgb 7-8 g/dL) with respect to 30-day all-cause death and recurrent MI. The ORBITA-2 trial showed that among patients with stable angina and coronary stenoses causing ischemia on little or no antianginal therapy, percutaneous coronary intervention results in greater improvements in anginal frequency and exercise times compared with a sham procedure. The ARIES-HM3 trial showed that in patients with advanced HF who received a HeartMate 3 levitated left ventricular assist device and were anticoagulated with a vitamin K antagonist, placebo was noninferior to daily aspirin with respect to the composite endpoint of bleeding and thrombotic events at 1 year. The TEAMMATE trial showed that everolimus with low-dose tacrolimus is safe in children and young adults when given ≥ 6 months after cardiac transplantation. Providing patients being treated for HF with reduced ejection fraction (HFrEF) with specific out-of-pocket (OOP) costs for multiple medication options at the time of the clinical encounter may reduce 'contingency planning' and increase the extent to which patients are taking the medications decided upon. The primary outcome, which was cost-informed decision-making, defined as the clinician or patient mentioning costs of HFrEF medication, occurred in 49% of encounters with the checklist only control group compared with 68% of encounters in the OOP cost group.
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Affiliation(s)
- Avilash Mondal
- Department of Internal Medicine, Nazareth Hospital, Philadelphia, PA 19152, United States
| | - Sashwath Srikanth
- Department of Internal Medicine, East Carolina University Greenville, Greenville, NC 27834, United States
| | - Sanjana Aggarwal
- Department of Internal Medicine, Hamdard Institute of Medical Sciences and Research, New Delhi 110062, India
| | - Naga R Alle
- Department of Medicine, Narayana Medical College, Nellore, Andhra Pradesh 524003, India
| | - Olufemi Odugbemi
- Department of Internal Medicine, Lincoln Medical Center, Bronx, NY 10451, United States
| | - Ikechukwu Ogbu
- Department of Internal Medicine, Mountainview Hospital Sunrise GME, Las Vegas, NV 89108, United States.
| | - Rupak Desai
- Independent Researcher, Atlanta, GA 30079, United States
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20
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Shah P, Sayer G, Sinha SS, Kanwar MK, Cowger JA, Pagani FD, Nayak A, Mehra MR, Cleveland JC, Psotka MA, Singh R, Desai SS, Lu Q, Hu Y, Connolly A, Kormos RL, Uriel N. Dynamic Risk Estimation of Adverse Events in Ambulatory LVAD Patients: A MOMENTUM 3 Analysis. JACC. HEART FAILURE 2024:S2213-1779(24)00486-4. [PMID: 39066758 DOI: 10.1016/j.jchf.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/26/2024] [Accepted: 05/21/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Hemocompatibility-related adverse events affect patients after left ventricular assist device (LVAD) implantation but are hard to predict. OBJECTIVES Dynamic risk modeling with a multistate model can predict risk of gastrointestinal bleeding (GIB), stroke, or death in ambulatory patients. METHODS This was a secondary analysis of the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) trial. HeartMate 3 LVAD recipients who survived to hospital discharge and were followed for up to 2 years. A total of 145 variables were included in the multistate model with multivariate logistic regression. Model performance was assessed with the area under the curve in a holdout validation cohort. A risk stratification tool was created by dividing patients into categories of predicted risk using the final model variables and associated OR. RESULTS Among 2,056 LVAD patients, the median age was 59.4 years (20.4% women, 28.6% Black). At 2 years, the incidence of GIB, stroke, and death was 25.6%, 6.0%, and 12.3%, respectively. The multistate model included 39 total variables to predict risk of GIB (16 variables), stroke (10 variables), and death (19 variables). When ambulatory patients were classified according to their risk category, the 30-day observed event rate in the highest risk group for GIB, stroke, or death was 26.9%, 1.8%, and 4.8%, respectively. The multistate model predicted GIB, stroke, and death at any 30-day period with an area under the curve of 0.70, 0.69, and 0.86, respectively. CONCLUSIONS The multistate model informs 30-day risk in ambulatory LVAD recipients and allows recalculation of risk as new patient-specific data become available. The model allows for accurate risk stratification that predicts impending adverse events and may guide clinical decision making. (MOMENTUM 3 IDE Clinical Study Protocol; NCT02224755).
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Affiliation(s)
- Palak Shah
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA.
| | - Gabriel Sayer
- Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, New York, USA
| | | | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | | | | | - Aditi Nayak
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Ramesh Singh
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | | | | | | | | | | | - Nir Uriel
- Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, New York, USA
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21
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Kikoïne J, Nowacka A, Schukraft S, Abdurashidova T, Yerly P, Tozzi P, Ltaief Z, Rosner L, Hullin R, Kirsch M. Clinical outcomes of HeartMate 3 left ventricular assist device support with a Bridge to Transplant vs a Destination Therapy strategy: a single-centre retrospective cohort. Swiss Med Wkly 2024; 154:3529. [PMID: 39137373 DOI: 10.57187/s.3529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
INTRODUCTION Real-world outcomes with the HeartMate 3 left ventricular assist device (LVAD) depending on whether it's a bridge to transplantation (BTT) or destination therapy (DT) are poorly studied. We aimed to compare the profile and clinical outcomes of patients supported with HeartMate 3 according to a BTT or a DT pre-implantation strategy. METHODS All patients consecutively implanted with HeartMate 3 at our centre (University Hospital of Lausanne, Switzerland) in 2015-2022 were analysed in a retrospective observational study. Indications for HeartMate 3 implantation were advanced heart failure despite optimal medical treatment. Patients were treated with a vitamin K antagonist anticoagulant combined with antiplatelet therapy after HeartMate 3 implantation and were followed up monthly at our institution. RESULTS Among 71 patients implanted with HeartMate 3 between 2015 and 2022, 51 (71.8%) were implanted as a BTT and 20 (28.2%) as DT. Their median age was 58 (IQR: 52-69) years and 84% of patients were classified as INTERMACS profiles 2-4. The median follow-up duration was 18.3 (IQR: 7.5-33.9) months. Patients in the DT group were older than those in the BTT group (p <0.001) and had more chronic renal failure (p <0.001). They also had a lower 5-year survival rate (mean ± standard error: 87.3 ± 5.6% vs 49.4 ± 15.1%) and more adverse events such as renal dysfunction requiring temporary perioperative dialysis (p = 0.08) or bleeding (p = 0.06). CONCLUSION Although patients supported with HeartMate 3 have favourable survival, those with LVAD-DT have poorer outcomes. There is a need to better select patients eligible for LVAD-DT in order to limit the burden of adverse events and improve their prognosis.
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Affiliation(s)
- John Kikoïne
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Anna Nowacka
- Department of Cardiac Surgery, University Hospital, Lausanne, Switzerland
| | - Sara Schukraft
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | | | - Patrick Yerly
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Piergiorgio Tozzi
- Department of Cardiac Surgery, University Hospital, Lausanne, Switzerland
| | - Zied Ltaief
- Department of Intensive Care Medicine, University Hospital, Lausanne, Switzerland
| | - Lorenzo Rosner
- Department of Anaesthesiology, University Hospital, Lausanne, Switzerland
| | - Roger Hullin
- Department of Cardiology, University Hospital, Lausanne, Switzerland
| | - Matthias Kirsch
- Department of Cardiac Surgery, University Hospital, Lausanne, Switzerland
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22
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Flieder T, Blaesen S, Schulte K, Blasberg J, Lauenroth V, Knabbe C, Schramm R, Morshuis M, Gummert J, Birschmann I. Aspirin resistance in patients with ventricular assist devices: A follow-up study. Artif Organs 2024; 48:781-788. [PMID: 38553978 DOI: 10.1111/aor.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/07/2024] [Accepted: 02/26/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Despite combined anticoagulation therapy consisting of a vitamin K antagonist and an antiplatelet agent, thromboembolic complications often occur in patients with a left ventricular assist device (LVAD). In addition, bleeding events are also common. Resistance to antiplatelet drugs is a well-known phenomenon; however, the utilization of laboratory chemistry testing for the presence of such resistance, and then switching therapy, is controversial. METHODS We tested 132 patients with LVAD (HeartWare n = 57, HeartMate II n = 22, HeartMate 3 n = 53) on acetylsalicylic acid (ASA) therapy for resistance and followed them for a maximum of 7 years regarding pump thrombosis. Light transmission aggregometry (LTA) and impedance aggregometry (IPA) were performed for testing platelet function. RESULTS We could show that patients with ASA resistance displayed an increased risk of pump thrombosis, regardless of the test used (LTA: OR = 6.20, CI [1.86-20.64], p = 0.003; IPA: OR = 12.14, CI [3.00-49.07], p < 0.001). In patients with a HeartMate 3, we could not detect any pump thrombosis associated with aspirin resistance. Furthermore, there was no significant difference in bleeding events between patients with ASA resistance and ASA responders. CONCLUSION Laboratory testing of ASA resistance seems to be a good tool to detect an increased risk of pump thrombosis, at least for patients with a HeartWare or HeartMate II. The extent to which these thromboses can be prevented with a change of medication has to be investigated in further studies. No pump thrombosis was detected in patients with a HeartMate 3, and the question should be asked as to what constellation of underlying and concomitant diseases must be present to justify ASA therapy for these patients.
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Affiliation(s)
- Tobias Flieder
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Bad Oeynhausen, Germany
| | - Sonja Blaesen
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Bad Oeynhausen, Germany
| | - Katrin Schulte
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Bad Oeynhausen, Germany
| | - Jost Blasberg
- Institut für Psychosoziale Medizin, Psychotherapie und Psychoonkologie, Universitätsklinikum Jena, Friedrich-Schiller-Universität, Jena, Germany
| | - Volker Lauenroth
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Klinik für Thorax- und Kardiovaskularchirurgie, Bad Oeynhausen, Germany
| | - Cornelius Knabbe
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Bad Oeynhausen, Germany
| | - René Schramm
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Klinik für Thorax- und Kardiovaskularchirurgie, Bad Oeynhausen, Germany
| | - Michiel Morshuis
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Klinik für Thorax- und Kardiovaskularchirurgie, Bad Oeynhausen, Germany
| | - Jan Gummert
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Klinik für Thorax- und Kardiovaskularchirurgie, Bad Oeynhausen, Germany
| | - Ingvild Birschmann
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Bad Oeynhausen, Germany
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23
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Derzi SH, Dewidar O, Sabri H, Tran D, Wells GA. Antithrombotic therapy for durable left ventricular assist devices: protocol for a living systematic review with indirect comparison/network meta-analysis. BMJ Open 2024; 14:e080110. [PMID: 38925683 PMCID: PMC11202742 DOI: 10.1136/bmjopen-2023-080110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Left ventricular assist devices (LVADs) have emerged as a successful treatment option for patients with end-stage heart failure. Compared with the best medical therapy, LVADs improve survival and enhance functional capacity and quality of life. However, two major complications compromise this patient population's outcomes: thrombosis and bleeding. Despite technological innovations and better hemocompatibility, these devices alter the rheology, triggering the coagulation cascade and, therefore, require antithrombotic therapy. Anticoagulation and antiplatelet therapies represent the current standard of care. Still, inconsistency in the literature exists, especially whether antiplatelet therapy is required, whether direct oral anticoagulants can replace vitamin K antagonists and even whether phosphodiesterase type 5 inhibitors with their antithrombotic effects could be added to the regimen of anticoagulation. METHODS AND ANALYSIS We will perform a living systematic review with network meta-analysis and indirect comparison between current antithrombotic therapies, which have and have not been directly compared within clinical trials and observational studies. We will systematically search the following electronic sources: Cochrane Central Register of Controlled Trials (CENTRAL), Medical Literature Analysis and Retrieval System Online (MEDLINE) and Excerpta Medica Database (EMBASE). We will exclusively examine studies published in English from 2016 to the present. Studies conducted before 2016 will be omitted since our primary focus is evaluating continuous flow devices. Two independent reviewers will assess the articles by title, abstract and full text; any disagreement will be resolved through discussion, and a third reviewer will be involved if necessary. The Cochrane Risk of Bias tool will be used to assess the risk of bias. We will then conduct a pairwise meta-analysis; if the assumption of transitivity is satisfied, we will proceed with network meta-analysis using Bayesian methodology. ETHICS AND DISSEMINATION Formal ethical approval is not required as no primary data are collected. This systematic review and network meta-analysis will delineate the risks of stroke, thromboembolic events, pump thrombosis, gastrointestinal bleeding and mortality in patients equipped with LVADs who are subjected to various antithrombotic regimens. The findings will be disseminated via a peer-reviewed publication and presented at conference meetings. This will enhance clinical practice and guide future research on anticoagulation strategies within this distinct patient cohort. PROSPERO REGISTRATION NUMBER CRD42023465288.
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Affiliation(s)
- Simone Helena Derzi
- Anesthesiology, University of Alberta, Edmonton, Alberta, Canada
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Omar Dewidar
- Center for Global Health, Bruyere Research Institute, Ottawa, Ontario, Canada
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Hind Sabri
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Diem Tran
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George A Wells
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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24
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Nakamura M, Imamura T, Hida Y, Izumida T, Nakagaito M, Nagura S, Doi T, Fukahara K, Kinugawa K. A case of destination therapy for post-fulminant myocarditis with myelodysplastic syndrome. J Artif Organs 2024:10.1007/s10047-024-01455-x. [PMID: 38862744 DOI: 10.1007/s10047-024-01455-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 06/02/2024] [Indexed: 06/13/2024]
Abstract
We encountered a 64-year-old woman who experienced fulminant myocarditis and underwent treatment with veno-arterial extracorporeal membrane oxygenation and Impella CP support. Subsequently, she underwent a device upgrade to Impella 5.5 and received continuous hemodiafiltration for 3 months. During mechanical circulatory support, she developed refractory anemia and thrombocytopenia, leading to a diagnosis of myelodysplastic syndrome. Following the removal of the devices, she no longer required blood transfusions. She received HeartMate 3 left ventricular assist device implantation as a destination therapy indication despite the presence of myelodysplastic syndrome. She was successfully managed by aspirin-free antithrombotic therapy without any hemocompatibility-related adverse events for 4 months after index discharge on foot. We present a patient with a unique and rare presentation, wherein HeartMate 3 was implanted and successfully managed without aspirin to prevent bleeding complications associated with myelodysplastic syndrome.
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Affiliation(s)
- Makiko Nakamura
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan.
| | - Yuki Hida
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Toshihide Izumida
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Masaki Nakagaito
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Saori Nagura
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Toyama, Japan
| | - Toshio Doi
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Toyama, Japan
| | - Kazuaki Fukahara
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
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25
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Ghannam A, Check L, Akdogan E, Hajj J, Houston B, Rao V, Tedford R, Kilic A. Early inflow pannus development requiring left ventricular assist device exchange: More to come? JTCVS Tech 2024; 25:97-99. [PMID: 38899099 PMCID: PMC11184665 DOI: 10.1016/j.xjtc.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Alexander Ghannam
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Larissa Check
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Ecem Akdogan
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Jennifer Hajj
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Brian Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Vishal Rao
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Ryan Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
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26
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Bernhardt AM, Reichenspurner H. Anticoagulation in LVAD recipients and thrombembolic complications: Where do we stand? Where are we going to? J Heart Lung Transplant 2024; 43:876-877. [PMID: 38431240 DOI: 10.1016/j.healun.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 03/05/2024] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
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27
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Netuka I, Tucanova Z, Mehra MR. Direct Oral Anticoagulant Therapy With A Fully Magnetically Levitated LVAD and Bridging to Heart Transplantation: A DOT-HM3 Study Analysis. J Card Fail 2024:S1071-9164(24)00193-3. [PMID: 38825175 DOI: 10.1016/j.cardfail.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/04/2024]
Affiliation(s)
- Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Zuzana Tucanova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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28
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Beghini A, Sammartino AM, Papp Z, von Haehling S, Biegus J, Ponikowski P, Adamo M, Falco L, Lombardi CM, Pagnesi M, Savarese G, Metra M, Tomasoni D. 2024 update in heart failure. ESC Heart Fail 2024. [PMID: 38806171 DOI: 10.1002/ehf2.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/30/2024] Open
Abstract
In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.
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Affiliation(s)
- Alberto Beghini
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gianluigi Savarese
- Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
- Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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29
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Kirov H, Caldonazo T, Mukharyamov M, Toshmatov S, Fischer J, Schneider U, Siemeni T, Doenst T. Cardiac Surgery 2023 Reviewed. Thorac Cardiovasc Surg 2024. [PMID: 38740368 DOI: 10.1055/s-0044-1786758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
We reviewed the cardiac surgical literature for 2023. PubMed displayed almost 34,000 hits for the search term "cardiac surgery AND 2023." We used a PRISMA approach for a results-oriented summary. Key manuscripts addressed the mid- and long-term effects of invasive treatment options in patient populations with coronary artery disease (CAD), comparing interventional therapy (percutaneous coronary intervention [PCI]) with surgery (coronary artery bypass graft [CABG]). The literature in 2023 again confirmed the excellent long-term outcomes of CABG compared with PCI in patients with left main stenosis, specifically in anatomically complex chronic CAD, but even in elderly patients, generating further support for an infarct-preventative effect as a prognostic mechanism of CABG. For aortic stenosis, a previous trend of an early advantage for transcatheter (transcatheter aortic valve implantation [TAVI]) and a later advantage for surgical (surgical aortic valve replacement) treatment was also re-confirmed by many studies. Only the Evolut Low Risk trial maintained an early advantage of TAVI over 4 years. In the mitral and tricuspid field, the number of interventional publications increased tremendously. A pattern emerges that clinical benefits are associated with repair quality, making residual regurgitation not irrelevant. While surgery is more invasive, it currently generates the highest repair rates and longest durability. For terminal heart failure treatment, donor pool expansion for transplantation and reducing adverse events in assist device therapy were issues in 2023. Finally, the aortic diameter related to adverse events and technical aspects of surgery dominated in aortic surgery. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation, but provides up-to-date information for patient-specific decision-making.
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Affiliation(s)
- Hristo Kirov
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, University Hospital Jena, Jena, Germany
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, University Hospital Jena, Jena, Germany
| | - Murat Mukharyamov
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, University Hospital Jena, Jena, Germany
| | - Sultonbek Toshmatov
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, University Hospital Jena, Jena, Germany
| | - Johannes Fischer
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, University Hospital Jena, Jena, Germany
| | - Ulrich Schneider
- Department of Cardiac Surgery, Saarland University Medical Center, Homburg Saar, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, University Hospital Jena, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University of Jena, University Hospital Jena, Jena, Germany
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30
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Wang X, Zhou X, Chen H, Du J, Qing P, Zou L, Chen Y, Duan F, Yuan S, Shi J, Ji B, Wu R, Zhang Y, Jin Y, Hu S. Long-term outcomes of a novel fully magnetically levitated ventricular assist device for the treatment of advanced heart failure in China. J Heart Lung Transplant 2024:S1053-2498(24)01664-4. [PMID: 38740078 DOI: 10.1016/j.healun.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/28/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024] Open
Abstract
PURPOSE Left ventricular assist devices (LVADs) are well-established for treating end-stage heart failure, but this therapy is only available to Chinese patients in recent years. The CH-VAD is the first used fully magnetically levitated pump and the most widely used device in China. This study reports the long-term outcomes of a cohort supported by the CH-VAD for the first time. METHODS From June 2017 to August 2023, 50 consecutive patients received CH-VAD implantation in Fuwai Hospital. Clinical data were collected during follow-up and retrospectively analyzed. RESULTS Baseline characteristics included a mean age of 47.9±13.9 years, 90% male, and 26% ischemic etiology. The INTERMACS profile revealed 12% Profile 1, 56% Profile 2, 26% Profile 3 and 6% Profile 4. Mean support duration was 868 ± 630 days (range 33 days-6.4 years). Kaplan-Meier survival rate was 96% (95% confidence interval [CI], 85 to 99) at 6 months, 93% (95% CI, 79-98) at 1 year, 93% (95% CI, 79-98) at 2 years and 89% (95% CI, 71-96) at 3 years. 40 patients (80%) currently remain on support, 3 were bridged to recovery, 2 received transplant, and 5 expired during support. Major adverse events included right heart failure (10%), surgical related bleeding (8%), arrhythmia (8%) and driveline infection (16%). Major hemocompatibility-related adverse events were limited to 3 non-disabling strokes and 1 gastrointestinal bleeding. There was no major device malfunction during the follow-up period. CONCLUSIONS The largest single-center experience with the leading LVAD in China shows high survival with low complication rates, demonstrating the CH-VAD is safe and efficient in providing long-term support for end-stage heart failure patients.
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Affiliation(s)
- Xianqiang Wang
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xingtong Zhou
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haibo Chen
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juan Du
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ping Qing
- Emergency and Critical Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liang Zou
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Chen
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fujian Duan
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Shi
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rong Wu
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanming Zhang
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Jin
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Center of Cardiac Surgery in Adults, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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31
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Tscharre M, Mutschlechner D, Schlöglhofer T, Wiedemann D, Zimpfer D, Gremmel T. Omission of Antiplatelet Therapy in Patients With HeartMate 3 Left Ventricular Assist Devices: A Systematic Review and Meta-Analysis. ASAIO J 2024:00002480-990000000-00479. [PMID: 38728742 DOI: 10.1097/mat.0000000000002225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
The HeartMate 3 (HM3) left ventricular assist device has decreased thromboembolic events and minimized the risk of pump thrombosis. However, bleeding complications due to combined antithrombotic therapy with a vitamin K antagonist (VKA) and aspirin remain high. Only limited data on the safety of VKA monotherapy in HM3 patients are available. A systematic search on the main databases was performed. Observational data and randomized trials were eligible for this analysis. As primary endpoint, we analyzed hemocompatibility-related adverse events (HRAE). As secondary endpoints, we investigated the individual components of the primary endpoint. The analysis was carried out using the odds ratio (OR) as outcome measure. A random-effects model was fitted to the data. Five manuscripts fulfilled the inclusion criteria. These trials included 785 patients (381 on VKA monotherapy, 404 on VKA and aspirin). VKA monotherapy significantly reduced HRAE (OR: 0.11 [95% confidence interval {CI}: 0.02-0.59], p = 0.01, I2 = 87%). The reduction was driven by a decrease in bleeding complications (OR: 0.12 [95% CI: 0.02-0.62], p = 0.01, I2 = 86%) without increasing the rates of thromboembolic events (OR: 0.69 [95% CI: 0.26-1.81], p = 0.45, I = 0%). Vitamin K antagonist monotherapy is associated with a significant reduction of bleeding events without increasing the risk of thromboembolic complications in HM3 patients.
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Affiliation(s)
- Maximilian Tscharre
- From the Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, St. Pölten, Austria
| | - David Mutschlechner
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
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van der Horst S, de Jong Y, van Rein N, Jukema J, Palmen M, Janssen E, Bonneville E, Klok F, Huisman M, Tops L, den Exter P. Performance of risk scores in predicting major bleeding in left ventricular assist device recipients: a comparative external validation. Res Pract Thromb Haemost 2024; 8:102437. [PMID: 38953051 PMCID: PMC11215111 DOI: 10.1016/j.rpth.2024.102437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 07/03/2024] Open
Abstract
Background Implantation of a left ventricular assist device (LVAD) is a crucial therapeutic option for selected end-stage heart failure patients. However, major bleeding (MB) complications postimplantation are a significant concern. Objectives We evaluated current risk scores' predictive accuracy for MB in LVAD recipients. Methods We conducted an observational, single-center study of LVAD recipients (HeartWare or HeartMate-3, November 2010-December 2022) in the Netherlands. The primary outcome was the first post-LVAD MB (according to the International Society on Thrombosis and Haemostasis [ISTH] and Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS], and INTERMACS combined with intracranial bleeding [INTERMACS+] criteria). Mortality prior to MB was considered a competing event. Discrimination (C-statistic) and calibration were evaluated for the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly score, Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk and Stroke score, Anticoagulation and Risk Factors in Atrial Fibrillation score, Outpatient Bleeding Risk Index, venous thromboembolism score, atrial fibrillation score, and Utah Bleeding Risk Score (UBRS). Results One hundred four patients were included (median age, 64 years; female, 20.2%; HeartWare, 90.4%; HeartMate-3, 9.6%). The cumulative MB incidence was 75.7% (95% CI 65.5%-85.9%) by ISTH and INTERMACS+ criteria and 67.0% (95% CI 56.0%-78.0%) per INTERMACS criteria over a median event-free follow-up time of 1916 days (range, 59-4521). All scores had poor discriminative ability on their intended prediction timeframe. Cumulative area under the receiving operator characteristic curve ranged from 0.49 (95% CI 0.35-0.63, venous thromboembolism-BLEED) to 0.56 (95% CI 0.47-0.65, UBRS) according to ISTH and INTERMACS+ criteria and from 0.48 (95% CI 0.40-0.56, Anticoagulation and Risk Factors in Atrial Fibrillation) to 0.56 (95% CI 0.47-0.65, UBRS) per INTERMACS criteria. All models showed poor calibration, largely underestimating MB risk. Conclusion Current bleeding risk scores exhibit inadequate predictive accuracy for LVAD recipients. There is a need for an accurate risk score to identify LVAD patients at high risk of MB who may benefit from patient-tailored antithrombotic therapy.
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Affiliation(s)
- S.F.B. van der Horst
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Y. de Jong
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - N. van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - J.W. Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - M. Palmen
- Department of Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - E. Janssen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E.F. Bonneville
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - F.A. Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - M.V. Huisman
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - L.F. Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - P.L. den Exter
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Roesel MJ, Nersesian G, Neuber S, Thau H, Wolff von Gudenberg R, Lanmueller P, Hennig F, Falk V, Potapov E, Knosalla C, Iske J. LVAD as a Bridge to Transplantation-Current Status and Future Perspectives. Rev Cardiovasc Med 2024; 25:176. [PMID: 39076481 PMCID: PMC11267215 DOI: 10.31083/j.rcm2505176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/15/2024] [Accepted: 02/26/2024] [Indexed: 07/31/2024] Open
Abstract
Heart failure (HF) is a common disease associated with high morbidity and mortality rates despite advanced pharmacological therapies. Heart transplantation remains the gold standard therapy for end-stage heart failure; however, its application is curtailed by the persistent shortage of donor organs. Over the past two decades, mechanical circulatory support, notably Left Ventricular Assist Devices (LVADs), have been established as an option for patients waiting for a donor organ. This comprehensive review focuses on elucidating the benefits and barriers associated with this application. We provide an overview of landmark clinical trials that have evaluated the use of LVADs as a bridge to transplantation therapy, with a particular focus on post-transplant outcomes. We discuss the benefits of stabilizing patients with these systems, weighing associated complications and limitations. Further technical advancements and research on optimal implantation timing are critical to ultimately improve outcomes and securing quality of life. In a world where the availability of donor organs remains constrained, LVADs are an increasingly important piece of patient care, bridging the critical gap to transplantation in advanced heart failure management.
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Affiliation(s)
- Maximilian J. Roesel
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Gaik Nersesian
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Sebastian Neuber
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Henriette Thau
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Rosalie Wolff von Gudenberg
- Department of Cardio-, Thoracic-, Transplantation-, and Vascular Surgery, Medizinische Hochschule Hannover, 30625 Hannover, Germany
| | - Pia Lanmueller
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Felix Hennig
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Berlin Institutes of Health at Charité - Universitätsmedizin Berlin, 10178 Berlin, Germany
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Jasper Iske
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Berlin Institutes of Health at Charité - Universitätsmedizin Berlin, 10178 Berlin, Germany
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Hammer Y, Xie J, Yang G, Bitar A, Haft JW, Cascino TM, Likosky DS, Pagani FD, Zhang M, Aaronson KD. Gastrointestinal bleeding following Heartmate 3 left ventricular assist device implantation: The Michigan Bleeding Risk Model. J Heart Lung Transplant 2024; 43:604-614. [PMID: 38065237 DOI: 10.1016/j.healun.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) results in frequent hospitalizations and impairs quality of life in durable left ventricular assist device (LVAD) recipients. Anticipation of these events before implantation could have important implications for patient selection and management. METHODS The study population included all adult HeartMate 3 (HM3) primary LVAD recipients enrolled in the STS Intermacs registry from January 2017 to December 2020. Using multivariable modeling methodologies, we investigated the relationships between preimplantation characteristics and postimplant bleeding, bleeding and death, and additional bleeding episodes on subsequent bleeding episodes and created a risk score to predict the likelihood of post-LVAD GIB based solely on preimplantation factors. RESULTS Of 6,425 patients who received an HM3 LVAD, 1,010 (15.7%) patients experienced GIB. Thirteen preimplantation factors were independent predictors of post-LVAD GIB. A risk score was created from these factors and calculated for each patient. By 3 years postimplant, GIB occurred in 11%, 26%, and 43% of low-, medium- and high-risk patients, respectively. Experiencing 1 post-LVAD GIB event was associated with an increased risk for further GIB events, with 33.9% of patients experiencing at least 1 recurrence. While post-LVAD GIB was associated with mortality, there was no relationship between number of GIB events and death. CONCLUSIONS The Michigan Bleeding Risk Model is a simple tool, which facilitates the prediction of post-LVAD GIB in HM3 recipients using 13 preimplant variables. The implementation of this tool may help in the risk stratification process and may have therapeutic and clinical implications in HM3 LVAD recipients.
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Affiliation(s)
- Yoav Hammer
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan.
| | - Jiaheng Xie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Guangyu Yang
- Institute of Statistics and Big Data, Renmin University of China, Beijing, China
| | - Abbas Bitar
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Jonathan W Haft
- Department of Cardiac Surgery, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Thomas M Cascino
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Min Zhang
- Tsinghua Univeristy, Vanke School of Public Health, Beijing, China
| | - Keith D Aaronson
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
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Antonopoulos M, Bonios MJ, Dimopoulos S, Leontiadis E, Gouziouta A, Kogerakis N, Koliopoulou A, Elaiopoulos D, Vlahodimitris I, Chronaki M, Chamogeorgakis T, Drakos SG, Adamopoulos S. Advanced Heart Failure: Therapeutic Options and Challenges in the Evolving Field of Left Ventricular Assist Devices. J Cardiovasc Dev Dis 2024; 11:61. [PMID: 38392275 PMCID: PMC10888700 DOI: 10.3390/jcdd11020061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Heart Failure is a chronic and progressively deteriorating syndrome that has reached epidemic proportions worldwide. Improved outcomes have been achieved with novel drugs and devices. However, the number of patients refractory to conventional medical therapy is growing. These advanced heart failure patients suffer from severe symptoms and frequent hospitalizations and have a dismal prognosis, with a significant socioeconomic burden in health care systems. Patients in this group may be eligible for advanced heart failure therapies, including heart transplantation and chronic mechanical circulatory support with left ventricular assist devices (LVADs). Heart transplantation remains the treatment of choice for eligible candidates, but the number of transplants worldwide has reached a plateau and is limited by the shortage of donor organs and prolonged wait times. Therefore, LVADs have emerged as an effective and durable form of therapy, and they are currently being used as a bridge to heart transplant, destination lifetime therapy, and cardiac recovery in selected patients. Although this field is evolving rapidly, LVADs are not free of complications, making appropriate patient selection and management by experienced centers imperative for successful therapy. Here, we review current LVAD technology, indications for durable MCS therapy, and strategies for timely referral to advanced heart failure centers before irreversible end-organ abnormalities.
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Affiliation(s)
- Michael Antonopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Michael J Bonios
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stavros Dimopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Evangelos Leontiadis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Aggeliki Gouziouta
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Nektarios Kogerakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Antigone Koliopoulou
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Dimitris Elaiopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Ioannis Vlahodimitris
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Maria Chronaki
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Themistocles Chamogeorgakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stamatis Adamopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
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Balcioglu O, Ozgocmen C, Ozsahin DU, Yagdi T. The Role of Artificial Intelligence and Machine Learning in the Prediction of Right Heart Failure after Left Ventricular Assist Device Implantation: A Comprehensive Review. Diagnostics (Basel) 2024; 14:380. [PMID: 38396419 PMCID: PMC10888030 DOI: 10.3390/diagnostics14040380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
One of the most challenging and prevalent side effects of LVAD implantation is that of right heart failure (RHF) that may develop afterwards. The purpose of this study is to review and highlight recent advances in the uses of AI in evaluating RHF after LVAD implantation. The available literature was scanned using certain key words (artificial intelligence, machine learning, left ventricular assist device, prediction of right heart failure after LVAD) was scanned within Pubmed, Web of Science, and Google Scholar databases. Conventional risk scoring systems were also summarized, with their pros and cons being included in the results section of this study in order to provide a useful contrast with AI-based models. There are certain interesting and innovative ML approaches towards RHF prediction among the studies reviewed as well as more straightforward approaches that identified certain important predictive clinical parameters. Despite their accomplishments, the resulting AUC scores were far from ideal for these methods to be considered fully sufficient. The reasons for this include the low number of studies, standardized data availability, and lack of prospective studies. Another topic briefly discussed in this study is that relating to the ethical and legal considerations of using AI-based systems in healthcare. In the end, we believe that it would be beneficial for clinicians to not ignore these developments despite the current research indicating more time is needed for AI-based prediction models to achieve a better performance.
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Affiliation(s)
- Ozlem Balcioglu
- Department of Cardiovascular Surgery, Faculty of Medicine, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
- Operational Research Center in Healthcare, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
| | - Cemre Ozgocmen
- Department of Biomedical Engineering, Faculty of Engineering, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
| | - Dilber Uzun Ozsahin
- Operational Research Center in Healthcare, Near East University, TRNC Mersin 10, Nicosia 99138, Turkey;
- Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Tahir Yagdi
- Department of Cardiovascular Surgery, Faculty of Medicine, Ege University, Izmir 35100, Turkey
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37
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Morris KL. Sex Does Matter: Risk of Stroke in LVAD Recipients. JACC. ADVANCES 2024; 3:100816. [PMID: 38939400 PMCID: PMC11198400 DOI: 10.1016/j.jacadv.2023.100816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Kathleen L. Morris
- Division of Cardiology, Department of Advanced Heart Failure and Transplant Cardiology, Ascension St Vincent Hospital, Indianapolis, Indiana, USA
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38
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Lim GB. Aspirin exclusion in patients with an LVAD. Nat Rev Cardiol 2024; 21:72. [PMID: 38012304 DOI: 10.1038/s41569-023-00965-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
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39
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Bandaru RR, Rawat A, Jalali I, Isaak AK, Alrahahleh AA, Bataineh SM, Wei CR, Hirani S. Comparing the Efficacy and Safety of Warfarin Monotherapy vs. Warfarin and Aspirin for Adult Patients With Left Ventricular Assist Devices: A Meta-Analysis. Cureus 2024; 16:e53101. [PMID: 38414699 PMCID: PMC10897739 DOI: 10.7759/cureus.53101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2024] [Indexed: 02/29/2024] Open
Abstract
The aim of this meta-analysis was to assess the safety and efficacy of warfarin plus aspirin versus warfarin monotherapy in patients with left ventricular assist devices (LVAD). The present meta-analysis was conducted using the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two authors systematically searched online databases, including PubMed, EMBASE, the Cochrane Library, and Web of Science from inception to December 31, 2023. Outcomes assessed in this meta-analysis included any thrombotic event, bleeding events, and all-cause mortality. A total of five articles were included in the meta-analysis, enrolling a pooled sample size of 876 patients, including 405 in the warfarin monotherapy group and 471 in the warfarin plus aspirin group. Pooled analysis showed that the risk of thrombotic events was not significantly different between the two groups (risk ratio (RR): 0.46, 95% confidence interval (CI): 0.15-1.37). The risk of bleeding events was significantly lower in patients receiving warfarin alone compared to patients receiving aspirin plus warfarin (RR: 0.67, 95% CI: 0.53-0.85). The risk of all-cause mortality was not significantly different between patients receiving warfarin alone and patients receiving aspirin plus warfarin (RR: 0.92, 95% CI: 0.65-1.30). Despite the potential benefits of discontinuing aspirin, the decision should be approached cautiously, considering the undefined risks of discontinuing anticoagulation in LVAD patients.
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Affiliation(s)
| | - Anurag Rawat
- Interventional Cardiology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Illahay Jalali
- Medicine, Tehran University of Medical Sciences, Tehran, IRN
| | - Abraham K Isaak
- Telemetry, Sharp Memorial Hospital, San Diego, USA
- Internal Medicine, Orotta School of Medicine and Dentistry, Asmara, ERI
| | | | | | - Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
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40
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Brown MT, Wenger NK. Less is More in Antithrombotic Therapy for Durable Left Ventricular Assist Devices. Curr Cardiol Rev 2024; 20:e150424228882. [PMID: 38623981 PMCID: PMC11440322 DOI: 10.2174/011573403x307310240404062647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024] Open
Affiliation(s)
- Matthew T. Brown
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Nanette K. Wenger
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
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