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Anjum F, Gilani M, Latif M, Sattar A, Ashraf H, Rafaqat S. The Role of Coagulation in Heart Failure: A Literature Review. Curr Heart Fail Rep 2024; 21:277-291. [PMID: 38869806 DOI: 10.1007/s11897-024-00671-z] [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] [Accepted: 05/31/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE OF REVIEW This article summarizes the role of coagulation factors in the pathophysiology of heart failure including D-dimer, fibrinogen and fibrin, prothrombin, p-selectin, tissue factor, tissue plasminogen activator, von Willebrand factor, β-thromboglobulin, Factor XI, tissue thromboplastin, plasminogen activator inhibitor-1 (PAI-1), thrombomodulin, soluble urokinase-type plasminogen activator receptor (suPAR) and stuart-prower factor. RECENT FINDINGS The D-dimer, P-selectin, prothrombin, von Willebrand factor, tissue plasminogen activator, fibrinogen, suPAR, tissue factor, thrombomodulin and Factor XI play significant roles the pathophysiology of heart failure. However, no associations were found between β-thromboglobulin, tissue thromboplastin, PAI-1 and stuart-prower factor in the context of heart failure. Coagulation factors play significant role in the pathophysiology of heart failure. Consequently, the underlying pathophysiological mechanisms that explain changes in the cascade are closely related to the diagnostic, prognostic and therapeutic roles of coagulation cascade factors, which help physicians identify and treat heart failure.
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Affiliation(s)
- Farhan Anjum
- Institute of Zoology, University of Punjab, Quaid-I-Azam Campus, Lahore, Pakistan
| | - Mahrukh Gilani
- Department of the Zoology, Lahore College for Women University, Lahore, Pakistan
| | - Maryam Latif
- Institute of Zoology, University of Punjab, Quaid-I-Azam Campus, Lahore, Pakistan
| | - Aqsa Sattar
- Department of Zoology (Molecular Physiology), Lahore College for Women University, Lahore, Pakistan
| | - Habiba Ashraf
- Department of the Zoology, Lahore College for Women University, Lahore, Pakistan
| | - Saira Rafaqat
- Department of Zoology (Molecular Physiology), Lahore College for Women University, Lahore, Pakistan.
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Chan CHH, Passmore MR, Tronstad O, Seale H, Bouquet M, White N, Teruya J, Hogan A, Platts D, Chan W, Dashwood AM, McGiffin DC, Maiorana AJ, Hayward CS, Simmonds MJ, Tansley GD, Suen JY, Fraser JF, Meyns B, Fresiello L, Jacobs S. The Impact of Acute Exercise on Hemostasis and Angiogenesis Mediators in Patients With Continuous-Flow Left Ventricular Assist Devices: A Prospective Observational Pilot Study. ASAIO J 2024:00002480-990000000-00501. [PMID: 38833540 DOI: 10.1097/mat.0000000000002246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
Impaired primary hemostasis and dysregulated angiogenesis, known as a two-hit hypothesis, are associated with gastrointestinal (GI) bleeding in patients with continuous-flow left ventricular assist devices (CF-LVADs). Exercise is known to influence hemostasis and angiogenesis in healthy individuals; however, little is known about the effect in patients with CF-LVADs. The objective of this prospective observational study was to determine whether acute exercise modulates two-hit hypothesis mediators associated with GI bleeding in patients with a CF-LVAD. Twenty-two patients with CF-LVADs performed acute exercise either on a cycle ergometer for approximately 10 minutes or on a treadmill for 30 minutes. Blood samples were taken pre- and post-exercise to analyze hemostatic and angiogenic biomarkers. Acute exercise resulted in an increased platelet count (p < 0.00001) and platelet function (induced by adenosine diphosphate, p = 0.0087; TRAP-6, p = 0.0005; ristocetin, p = 0.0009). Additionally, high-molecular-weight vWF multimers (p < 0.00001), vWF collagen-binding activity (p = 0.0012), factor VIII (p = 0.034), angiopoietin-1 (p = 0.0026), and vascular endothelial growth factor (p = 0.0041) all increased after acute exercise. This pilot work demonstrates that acute exercise modulated two-hit hypothesis mediators associated with GI bleeding in patients with CF-LVADs.
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Affiliation(s)
- Chris H H Chan
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Innovative Device & Engineering Applications Laboratory, Texas Heart Institute, Houston, Texas
| | - Margaret R Passmore
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Oystein Tronstad
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Helen Seale
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Mahe Bouquet
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Nicole White
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Jun Teruya
- Departments of Pathology & Immunology, Pediatrics, and Medicine, Baylor College of Medicine, Houston, Texas
| | - Airlie Hogan
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - David Platts
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Wandy Chan
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
- Cardio-Vascular Molecular and Therapeutics Translational Research Group, University of Queensland, Brisbane, Australia
| | - Alexander M Dashwood
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
- Cardio-Vascular Molecular and Therapeutics Translational Research Group, University of Queensland, Brisbane, Australia
| | - David C McGiffin
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, Australia
- Department of Cardiothoracic Surgery, Monash University, Melbourne, Australia
| | - Andrew J Maiorana
- Allied Health Department, Fiona Stanley Hospital, Perth, Australia
- Curtin School of Allied Health, Curtin University, Perth, Australia
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, St. Vincent's Hospital, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Michael J Simmonds
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Geoff D Tansley
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Australia
| | - Jacky Y Suen
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - John F Fraser
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Bart Meyns
- Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium; and
| | - Libera Fresiello
- Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium; and
- Group of Cardiovascular and Respiratory Physiology, University of Twente, Enschede, The Netherlands
| | - Steven Jacobs
- Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium; and
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Kumar N, Fitzsimons MG, Iyer MH, Essandoh M, Kumar JE, Dalia AA, Osho A, Sawyer TR, Bardia A. Vasoplegic syndrome during heart transplantation: A systematic review and meta-analysis. J Heart Lung Transplant 2024; 43:931-943. [PMID: 38428755 DOI: 10.1016/j.healun.2024.02.1458] [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: 11/03/2023] [Revised: 12/20/2023] [Accepted: 02/19/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Vasoplegic syndrome (VS) is a common occurrence during heart transplantation (HT). It currently lacks a uniform definition between transplant centers, and its pathophysiology and treatment remain enigmatic. This systematic review summarizes the available published clinical data regarding VS during HT. METHODS We searched databases for all published reports on VS during HT. Data collected included the incidence of VS in the HT population, patient and intraoperative characteristics, and postoperative outcomes. RESULTS Twenty-two publications were included in this review. The prevalence of VS during HT was 28.72% (95% confidence interval: 27.37%, 30.10%). Factors associated with VS included male sex, higher body mass index, hypothyroidism, pre-HT left ventricular assist device or venoarterial extracorporeal membrane oxygenation (VA-ECMO), pre-HT calcium channel blocker or amiodarone usage, longer cardiopulmonary bypass time, and higher blood product transfusion requirement. Patients who developed VS were more likely to require postoperative VA-ECMO support, renal replacement therapy, reoperation for bleeding, longer mechanical ventilation, and a greater 30-day and 1-year mortality. CONCLUSIONS The results of our systematic review are an initial step for providing clinicians with data that can help identify high-risk patients and avenues for potential risk mitigation. Establishing guidelines that officially define VS will aid in the precise diagnosis of these patients during HT and guide treatment. Future studies of treatment strategies for refractory VS are needed in this high-risk patient population.
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Affiliation(s)
- Nicolas Kumar
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Michael G Fitzsimons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Manoj H Iyer
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julia E Kumar
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Adam A Dalia
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Asishana Osho
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tamara R Sawyer
- Central Michigan University College of Medicine, Mt. Pleasant, Michigan
| | - Amit Bardia
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Bae DJ, Willey JZ, Ibeh C, Yuzefpolskaya M, Colombo PC. Stroke and Mechanical Circulatory Support in Adults. Curr Cardiol Rep 2023; 25:1665-1675. [PMID: 37921947 DOI: 10.1007/s11886-023-01985-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 11/05/2023]
Abstract
PURPOSE OF THE REVIEW Short-term and durable mechanical circulatory support (MCS) devices represent life-saving interventions for patients with cardiogenic shock and end-stage heart failure. This review will cover the epidemiology, risk factors, and treatment of stroke in this patient population. RECENT FINDINGS Short-term devices such as intra-aortic balloon pump, Impella, TandemHeart, and Venoatrial Extracorporal Membrane Oxygenation, as well as durable continuous-flow left ventricular assist devices (LVADs), improve cardiac output and blood flow to the vital organs. However, MCS use is associated with high rates of complications, including ischemic and hemorrhagic strokes which carry a high risk for death and disability. Improvements in MCS technology have reduced but not eliminated the risk of stroke. Mitigation strategies focus on careful management of anti-thrombotic therapies. While data on therapeutic options for stroke are limited, several case series reported favorable outcomes with thrombectomy for ischemic stroke patients with large vessel occlusions, as well as with reversal of anticoagulation for those with hemorrhagic stroke. Stroke in patients treated with MCS is associated with high morbidity and mortality. Preventive strategies are targeted based on the specific form of MCS. Improvements in the design of the newest generation device have reduced the risk of ischemic stroke, though hemorrhagic stroke remains a serious complication.
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Affiliation(s)
- David J Bae
- Division of Medicine, Center for Advanced Cardiac Care, Columbia University, New York, NY, USA
| | - Joshua Z Willey
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Irving Medical Center, New York, NY, 10032, USA.
| | - Chinwe Ibeh
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Melana Yuzefpolskaya
- Division of Medicine, Center for Advanced Cardiac Care, Columbia University, New York, NY, USA
| | - Paolo C Colombo
- Division of Medicine, Center for Advanced Cardiac Care, Columbia University, New York, NY, USA
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Liesdek OCD, Urbanus RT, de Maat S, de Heer LM, Ramjankhan FZ, Sebastian SAE, Huisman A, de Jonge N, Vink A, Fischer K, Maas C, Suyker WJL, Schutgens REG. Insights in the Prothrombotic Changes After Implantation of a Left Ventricular Assist Device in Patients With End-Stage Heart Failure: A Longitudinal Observational Study. ASAIO J 2023; 69:438-444. [PMID: 36730294 DOI: 10.1097/mat.0000000000001855] [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: 02/03/2023] Open
Abstract
Thrombus formation is a common complication during left ventricular assist device (LVAD) therapy, despite anticoagulation with vitamin K antagonists (VKA) and a platelet inhibitor. Plasma levels of markers for primary and secondary hemostasis and contact activation were determined before LVAD implantation and 6 and 12 months thereafter in 37 adults with end-stage heart failure. Twelve patients received a HeartMate 3, 7 patients received a HeartWare, and 18 patients received a HeartMate II. At baseline, patients had elevated plasma levels of the platelet protein upon activation, β-thromboglobulin, and active von Willebrand factor in thrombogenic state (VWFa), which remained high after LVAD implantation. Von Willebrand factor levels and VWF activity were elevated at baseline but normalized 12 months after LVAD implantation. High D -dimer plasma levels, at baseline, remained elevated after 12 months. This was associated with an increase in plasma thrombin-antithrombin-complex levels and plasma levels of contact activation marker-cleaved H-kininogen after LVAD implantation. Considering these results it could be concluded that LVAD patients show significant coagulation activation despite antithrombotic therapy, which could explain why patients are at high risk for LVAD-induced thrombosis. Continuous low-grade systemic platelet activation and contact activation may contribute to prothrombotic effects of LVAD.
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Affiliation(s)
- Omayra C D Liesdek
- From the Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht University, the Netherlands
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Rolf T Urbanus
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Steven de Maat
- Central Diagnostic Laboratory, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Linda M de Heer
- From the Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Faiz Z Ramjankhan
- From the Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Silvie A E Sebastian
- Central Diagnostic Laboratory, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Albert Huisman
- Central Diagnostic Laboratory, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Aryan Vink
- Department of Pathology, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Coen Maas
- Central Diagnostic Laboratory, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Willem J L Suyker
- From the Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht University, the Netherlands
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Schlagenhauf A, Haidl H, Trummer G, Berchtold-Herz M, Pooth JS, Strini T, Geisen U, Beyersdorf F, Zieger B. The endogenous thrombin potential in patients with left ventricular assist device or heart transplant. Front Med (Lausanne) 2023; 10:1155496. [PMID: 37122335 PMCID: PMC10130672 DOI: 10.3389/fmed.2023.1155496] [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: 01/31/2023] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Background The Heartmate 3 (HM 3) is a left ventricular assist device featuring less shear stress, milder acquired von Willebrand syndrome, and fewer bleeding incidences than its predecessor the Heartmate II (HM II). The novel surface coating of the HM 3 suggests less contact activation of plasmatic coagulation. We hypothesized that patients with HM 3 exhibit fewer aberrations in their thrombin potential than patients with HM II. We compared these results with the thrombin potential of patients with heart transplantation (HTX). Methods Thrombin generation in plasma samples of patients with HM II (n = 16), HM 3 (n = 20), and HTX (n = 13) was analyzed 3 days after implantation/transplantation and after long-term support (3-24 months) with HM II (n = 16) or HM 3 (n = 12) using calibrated automated thrombography. Heparin in postoperative samples was antagonized with polybrene. Results Three days postoperatively HM II patients exhibited a lower endogenous thrombin potential (ETP) than HM 3 and HTX patients (HM II: 947 ± 291 nM*min; HM 3: 1231 ± 176 nM*min; HTX: 1376 ± 162 nM*min, p < 0.001) and a lower velocity index of thrombin generation (HM II: 18.74 ± 10.90 nM/min; HM 3: 32.41 ± 9.51 nM/min; HTX: 37.65 ± 9.41 nM/min, p < 0.01). Subtle differences in the thrombin generation profiles remained in HM II and HM 3 patients under long-term support (Velocity Index: HM II: 38.70 ± 28.46 nM/min; HM 3: 73.32 ± 32.83 nM/min, p < 0.05). Prothrombin fragments 1 + 2 were higher in HM II than in HM 3 patients (HM II: 377.7 ± 208.4 pM; HM 3: 202.1 ± 87.7 pM, p < 0.05) and correlated inversely with the ETP (r = -0.584, p < 0.05). Conclusion We observed a more aberrant thrombin generation in HM II than in HM 3 despite comparable anticoagulation and routine parameters. A trend toward lower values was still observable in HM 3 compared to HTX patients. Calibrated automated thrombography may be a good tool to monitor the coagulation state of these patients and guide anticoagulation in the future.
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Affiliation(s)
- Axel Schlagenhauf
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University Graz, Graz, Austria
| | - Harald Haidl
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University Graz, Graz, Austria
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan-Steffen Pooth
- Department of Emergency Medicine, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Tanja Strini
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University Graz, Graz, Austria
| | - Ulrich Geisen
- Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- *Correspondence: Barbara Zieger,
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Ivak P, Netuka I, Tucanova Z, Wohlfahrt P, Konarik M, Szarszoi O, Novakova S, Kubanek M, Lanska V, Pitha J. The Effect of Artificial Pulsatility on the Peripheral Vasculature in Patients with A Continuous-Flow Ventricular Assist Device. Can J Cardiol 2021; 37:1578-1585. [PMID: 34090978 DOI: 10.1016/j.cjca.2021.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 05/26/2021] [Accepted: 05/29/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Implantation of left ventricular assist systems (LVASs) has become the standard of care for advanced heart failure (HF). The absence of pulsatility in previous devices contributes to vascular and endothelial dysfunction, related to atherosclerotic or vascular complications. We hypothesized that the artificial pulsatility provided by the HeartMate 3 (HM3) LVAS would exert a favorable effect on the vasculature. METHODS In 32 patients implanted with HM3 (5 females; mean age 55±13.6 years), the reactive hyperemia index (RHI) and peripheral augmentation index (AI), markers of endothelial function and arterial stiffness, were measured with an Endo-PAT2000 prior to and in the 3rd and 6th months after implantation. RHI and AI data from 30 HeartMate II (HM II) recipients in the 3rd and 6th months after implantation, from 15 advanced HF patients without LVASs, and from 13 healthy volunteers were also analyzed. RESULTS In HM3 recipients, the mean RHI significantly decreased at 3rd and 6th months after implantation. The RHI was substantially lower at baseline than that of healthy or HF reference group. Increasing AI values, indicating worsening arterial stiffness, were also observed. Similar trends were observed in HM II recipients between the 3rd and 6th months, but with higher absolute values of RHI and AI. CONCLUSIONS We detected impaired vascular function in HM3 patients and provided additional evidence on the negative effect of low pulsatility on vascular function after LVAS implantation. The results suggest that the artificial pulsatility of the HM3 does not avert the progression of endothelial dysfunction.
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Affiliation(s)
- Peter Ivak
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Physiology, Third Faculty of Medicine, Charles University, Prague, Czech Republic; Second Department of Surgery, Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Second Department of Surgery, Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zuzana Tucanova
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Peter Wohlfahrt
- Laboratory for Atherosclerosis Research, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Miroslav Konarik
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondrej Szarszoi
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Sarka Novakova
- Laboratory for Atherosclerosis Research, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Milos Kubanek
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Vera Lanska
- Medical Statistics Unit, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Pitha
- Department of Physiology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Thromboembolic Events in Patients With Left Ventricular Assist Devices Are Related to Microparticle-Induced Coagulation. ASAIO J 2021; 67:59-66. [PMID: 33346991 DOI: 10.1097/mat.0000000000001200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Thromboembolic events (TEs) are a feared complication in patients supported by a continuous-flow left ventricular assist device (LVAD). The aim of the study was to analyze the role of circulating microparticles (MPs) in activating the coagulation system in LVAD patients, which might contribute to the occurrence of TEs. First, we analyzed the effect of LVAD support on endothelial function, on the levels of endothelial MPs (EMPs) and platelet MPs (PMPs), and on the procoagulative activity of circulating MPs (measured as MP-induced thrombin formation) before LVAD implantation, post-implantation, and at a 3 month follow-up (n = 15). Second, these parameters were analyzed in 43 patients with ongoing LVAD support who were followed up for the occurrence of TEs in the following 12 months. In patients undergoing LVAD implantation, the levels of PMPs and MP-induced thrombin formation increased post-LVAD implantation. The flow-mediated vasodilation (FMD) decreased, while the levels of EMPs increased post-LVAD implantation. TEs occurred in eight patients with ongoing LVAD support despite adequate coagulation. The levels of PMPs and MP-induced thrombin formation were higher in LVAD patients with TEs than in LVAD patients without TEs and were independent predictors for the risk of TEs under LVAD support. As conclusion, implantation of LVAD enhanced MP-induced coagulation, which was independently associated with the occurrence of TEs. These parameters may serve in risk stratification for early transplantation and individualized modification of standard LVAD therapy.
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9
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Carotid artery structure and hemodynamics and their association with adverse vascular events in left ventricular assist device patients. J Artif Organs 2021; 24:182-190. [PMID: 33459911 DOI: 10.1007/s10047-020-01229-1] [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: 06/19/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
Left ventricular assist devices (LVADs) are associated with major vascular complications including stroke and gastrointestinal bleeding (GIB). These adverse vascular events may be the result of widespread vascular dysfunction resulting from pre-LVAD abnormalities or continuous flow during LVAD therapy. We hypothesized that pre-existing large artery atherosclerosis and/or abnormal blood flow as measured in carotid arteries using ultrasonography are associated with a post-implantation composite adverse outcome including stroke, GIB, or death. We retrospectively studied 141 adult HeartMate II patients who had carotid ultrasound duplex exams performed before and/or after LVAD surgery. Structural parameters examined included plaque burden and stenosis. Hemodynamic parameters included peak-systolic, end-diastolic, and mean velocity as well as pulsatility index. We examined the association of these measures with the composite outcome as well as individual subcomponents such as stroke. After adjusting for established risk factors, the composite adverse outcome was associated with pre-operative moderate-to-severe carotid plaque (OR 5.08, 95% CI 1.67-15.52) as well as pre-operative internal carotid artery stenosis (OR 9.02, 95% CI 1.06-76.56). In contrast, altered hemodynamics during LVAD support were not associated with the composite outcome. Our findings suggest that pre-existing atherosclerosis possibly in combination with LVAD hemodynamics may be an important contributor to adverse vascular events during mechanical support. This encourages greater awareness of carotid morphology pre-operatively and further study of the interaction between hemodynamics, pulsatility, and structural arterial disease during LVAD support.
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Poredos P, Jezovnik MK, Radovancevic R, Gregoric ID. Endothelial Function in Patients With Continuous-Flow Left Ventricular Assist Devices. Angiology 2020; 72:9-15. [PMID: 32757767 DOI: 10.1177/0003319720946977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The endothelium plays a crucial role in maintaining cardiovascular homeostasis. Shear stress generated by flowing blood regulates the release of substances that provide adequate tissue perfusion. The extent of damage to endothelial cells depends on locally disturbed shear stress caused by the deteriorated flow. Patients with heart failure have reduced cardiac output, which results in reduced blood flow and negative shear stress. Reduced shear stress also affects microcirculation and reduces tissue perfusion. Consequently, the production of free oxygen radicals is increased and bioavailability of nitric oxide is additionally decreased. Therefore, endothelial dysfunction is involved in the progression of heart failure and cardiovascular events. Left ventricular assist devices (LVAD) are used for the treatment of patients with advanced heart failure. Older pulsatile flow LVADs were mostly substituted by continuous-flow LVADs (cf-LVADs). Despite the advantages of the cf-LVADs, the loss of pulsatility leads to different complications on the micro- and macrovascular levels. One of the pathogenetic mechanisms of cardiovascular complications with cf-LVADs may be endothelial dysfunction, which after the implantation of the device does not improve and may even deteriorate. In contrast, the pulsatile pattern of LVADs on blood flow could preserve endothelial function.
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Affiliation(s)
- Pavel Poredos
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA.,Department of Vascular Disease, 37663University Medical Center, Ljubljana, Slovenia
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
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11
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Michelhaugh SA, Camacho A, Ibrahim NE, Gaggin H, D’Alessandro D, Coglianese E, Lewis GD, Januzzi JL. Proteomic Signatures During Treatment in Different Stages of Heart Failure. Circ Heart Fail 2020; 13:e006794. [DOI: 10.1161/circheartfailure.119.006794] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background:
Proteomics have already provided novel insights into the pathophysiology of heart failure (HF) with reduced ejection fraction. Previous studies have evaluated cross-sectional protein signatures of HF, but few have characterized proteomic changes following HF with reduced ejection fraction treatment with ARNI (angiotensin receptor/neprilysin inhibitor) therapy or left ventricular assist devices.
Methods:
In this retrospective omics study, we performed targeted proteomics (N=625) of whole blood sera from patients with American College of Cardiology/American Heart Association stage D (N=29) and stage C (N=12) HF using proximity extension assays. Samples were obtained before and after (median=82 days) left ventricular assist device implantation (stage D; primary analysis) and ARNI therapy initiation (stage C; matched reference). Oblique principal component analysis and point biserial correlations were used for feature extraction and selection; standardized mean differences were used to assess within and between-group differences; and enrichment analysis was used to generate and cluster Gene Ontology terms.
Results:
Core sets of proteins were identified for stage C (N=9 proteins) and stage D (N=18) HF; additionally, a core set of 5 shared HF proteins (NT-proBNP [N-terminal pro-B type natriuretic peptide], ESM [endothelial cell-specific molecule]-1, cathepsin L1, osteopontin, and MCSF-1) was also identified. For patients with stage D HF, moderate (δ, 0.40–0.60) and moderate-to-large (δ, 0.60–0.80) sized differences were observed in 8 of their 18 core proteins after left ventricular assist devices implantation. Additionally, specific protein groups reached concentration levels equivalent (
g
<0.10) to stage C HF after initiation on ARNI therapy.
Conclusions:
HF with reduced ejection fraction severity associates with distinct proteomic signatures that reflect underlying disease attributes; these core signatures may be useful for monitoring changes in cardiac function following initiation on ARNI or left ventricular assist device implantation.
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Affiliation(s)
- Sam A. Michelhaugh
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
| | - Alexander Camacho
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
| | - Nasrien E. Ibrahim
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
| | - Hanna Gaggin
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
| | - David D’Alessandro
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
| | - Erin Coglianese
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
| | - Gregory D. Lewis
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
| | - James L. Januzzi
- Massachusetts General Hospital, Boston (S.A.M., A.C., N.E.I., H.G., D.D., E.C., G.D.L., J.L.J.)
- Harvard Medical School, Boston, MA (N.E.I., H.G., E.G., G.D.L., J.L.J.)
- Baim Institute for Clinical Research, Boston, MA (J.L.J.)
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12
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Amili O, MacIver R, Coletti F. Magnetic Resonance Imaging Based Flow Field and Lagrangian Particle Tracking From a Left Ventricular Assist Device. J Biomech Eng 2020; 142:021007. [PMID: 31150534 DOI: 10.1115/1.4043939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Indexed: 11/08/2022]
Abstract
This study explores the optimal left ventricular assist device (LVAD) cannula outflow configuration in a patient-specific replica of the aorta. The volumetric velocity field is measured using phase-contrast magnetic resonance imaging (PC-MRI) under a physiologically relevant steady flow. The effect of the LVAD outflow graft insertion site and anastomosis angle on the transport of embolic particles to cranial vessels is studied by solving the particle equation of motion for spheres in the range of 0.1-1.0 mm using the measured three-dimensional (3D) velocity field. Results show that for a given aorta anatomy, it is possible to design the cannula graft location and terminal curvature so that the probability of embolic transport to the cranial vessels is significantly minimized. This is particularly important since the complex flow pattern in each cannula case affects the embolic trajectories differently, and hence the common assumption that particles distribute by the volumetric flow division does not hold.
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Affiliation(s)
- Omid Amili
- Department of Aerospace Engineering and Mechanics, University of Minnesota, Minneapolis, MN 55455
| | - Robroy MacIver
- Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404
| | - Filippo Coletti
- St. Anthony Falls Laboratory, Department of Aerospace Engineering and Mechanics, University of Minnesota, Minneapolis, MN 55455
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13
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Medical Management of Left Ventricular Assist Device Patients: A Practical Guide for the Nonexpert Clinician. Can J Cardiol 2019; 36:205-215. [PMID: 31879052 DOI: 10.1016/j.cjca.2019.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 01/09/2023] Open
Abstract
Left ventricular assist devices (LVADs) provide short- or long-term circulatory support to improve survival and reduce morbidity in selected patients with advanced heart failure. LVADs are being used increasingly and now have expanded indications. Health care providers across specialties will therefore not only encounter LVAD patients but play an integral role in their care. To accomplish that, they need to understand the elements of LVAD function, physiology and clinical use. This article provides a concise overview of the medical management of LVAD patients for nonexpert clinicians. Our presentation includes the basics of LVAD physiology, design, and operation, patient selection and assessment, medical management, adverse event identification and management, multidisciplinary care, and management of special circumstances, such as noncardiac surgery, cardiac arrest, and end-of-life care. The clinical examination of LVAD patients is unique in terms of blood pressure and heart rate assessment, LVAD "hum" auscultation, driveline and insertion site inspection, and device parameter recording. Important potential device-related adverse events include stroke, gastrointestinal bleeding, hematologic disorders, device infection, LVAD dysfunction, arrhythmias, and heart failure. Special considerations include the approach to the unconscious or pulseless patient, noncardiac surgery, and palliative care. An understanding of the principles presented in this paper will enable the nonexpert clinician to be effective in collaborating with an LVAD center in the assessment, medical management, and follow-up of LVAD patients. Future opportunities and challenges include the improvement of device designs, greater application of minimally invasive surgical implantation techniques, and management of health economics in cost-constrained systems like those of Canada and many other jurisdictions.
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14
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Bartoli CR, Zhang DM, Hennessy-Strahs S, Kang J, Restle DJ, Bermudez C, Atluri P, Acker MA. Clinical and In Vitro Evidence That Left Ventricular Assist Device-Induced von Willebrand Factor Degradation Alters Angiogenesis. Circ Heart Fail 2019; 11:e004638. [PMID: 30354363 DOI: 10.1161/circheartfailure.117.004638] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Gastrointestinal bleeding from angiodysplasia is a major problem in continuous-flow left ventricular assist device (LVAD) patients. LVAD shear stress causes pathologic degradation of VWF (von Willebrand factor). A mechanistic relationship between VWF degradation and angiodysplasia has not been explored. We tested 2 novel hypotheses: (1) clinical hypothesis: VWF fragments are elevated in LVAD patients that develop angiodysplasia and (2) in vitro hypothesis: VWF fragments generated during LVAD support alter angiogenesis, which may contribute to angiodysplasia. Methods and Results Clinical study: Paired blood samples were collected from continuous-flow LVAD patients (n=35). VWF was quantified with immunoblotting. In vitro experiments: (1) To investigate whether LVAD support alters angiogenesis, human endothelial cells were cultured with LVAD patient plasma (n=11). To investigate mechanism, endothelial cells were cultured with VWF fragments produced by exposing human VWF and ADAMTS-13 (VWF protease) to LVAD-like shear stress (175 dyne/cm2, n=8). Clinical study results: in all patients (n=35, mean support 666±430 days), LVAD support degraded high-molecular-weight VWF multimers ( P<0.0001) into low-molecular-weight VWF multimers ( P<0.0001) and VWF fragments ( P<0.0001). In patients with gastrointestinal bleeding from angiodysplasia (n=7), VWF fragments were elevated ( P=0.02) versus nonbleeders. In contrast, in patients with gastrointestinal bleeding without angiodysplasia, VWF fragments were not elevated versus nonbleeders ( P=0.96). In vitro experiments results: LVAD patient plasma caused abnormal angiogenesis with reduced tubule length ( P=0.04) and migration ( P=0.05). Similarly, endothelial cells grown with VWF degradation fragments exhibited reduced tubule length ( P<0.001) and migration ( P=0.01). Conclusions LVAD patients who bled from angiodysplasia had higher levels of VWF fragments than nonbleeders and gastrointestinal bleeders without angiodysplasia. VWF fragments caused abnormal angiogenesis in vitro. These findings suggest that VWF fragments may be a mechanistic link between LVAD support, abnormal angiogenesis, angiodysplasia, and gastrointestinal bleeding.
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Affiliation(s)
- Carlo R Bartoli
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B., S.H.-S., C.B., P.A., M.A.A.)
| | - David M Zhang
- Washington University, School of Medicine, St Louis, MO (D.M.Z.)
| | - Samson Hennessy-Strahs
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B., S.H.-S., C.B., P.A., M.A.A.)
| | - Jooeun Kang
- Vanderbilt University School of Medicine, Nashville, TN (J.K.)
| | | | - Christian Bermudez
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B., S.H.-S., C.B., P.A., M.A.A.)
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B., S.H.-S., C.B., P.A., M.A.A.)
| | - Michael A Acker
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B., S.H.-S., C.B., P.A., M.A.A.)
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15
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Usman MS, Ahmed S, Yamani N, Akhtar T, Asmi N, Siddiqi TJ, Khan SU, Doukky R, Khan MS. Meta-Analysis of the Effect of Preoperative Atrial Fibrillation on Outcomes After Left Ventricular Assist Device Implantation. Am J Cardiol 2019; 124:158-162. [PMID: 31047654 DOI: 10.1016/j.amjcard.2019.03.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 11/28/2022]
Abstract
The effect of preoperative atrial fibrillation (AF) on clinical outcomes after left ventricular assist device (LVAD) implantation remains uncertain. We sought to conduct a meta-analysis to assess the safety and efficacy of LVAD implantation in AF patients. Medline and Scopus were searched for studies that assessed the effect of preoperative AF on clinical outcomes in patients who underwent LVAD implantation. Outcomes of interest included all-cause mortality, thromboembolic events, and bleeding. Estimates were combined using random effects model to calculate risk ratios (RRs) with 95% confidence intervals. In this meta-analysis of 7 studies including 5,658 patients, preoperative AF was not associated with increased risk of all-cause mortality at 30 days (RR = 0.84 [0.51, 1.37]; p = 0.49; I2 = 0%), 6 months (RR = 1.17 [0.96, 1.14]; p = 0.11; I2 = 21%), 1 year (RR = 1.16 [0.84, 1.60]; p = 0.37; I2 = 53%) and 2 years (RR = 1.14 [0.96, 1.36]; p = 0.12; I2 = 23%). Preoperative AF did not increase the risk of thromboembolism (RR = 0.86 [0.38, 1.92]; p = 0.71; I2 = 26%), pump thrombosis (RR = 1.22 [0.88, 1.68]; p = 0.23; I2 = 49%), stroke (RR = 1.02 [0.87, 1.19]; p = 0.79; I2 = 11%), or major bleeding (RR = 0.86 [0.38, 1.92]; p = 0.71; I2 = 26%) after LVAD implantation. However, AF was associated with significantly increased risk of gastro-intestinal bleeding in patients receiving LVADs (RR = 1.27 [1.05, 1.55]; p = 0.014; I2 = 0%). In conclusion, this meta-analysis reports a significantly increased risk of gastrointestinal (GI) bleeding in LVADs recipients having concomitant AF. However, AF had no significant effect on all-cause mortality, stroke, or thromboembolic events in these patients. Further well-conducted studies are needed to validate these results.
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Affiliation(s)
| | - Saba Ahmed
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Naser Yamani
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Tauseef Akhtar
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Nisar Asmi
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, Illinois
| | | | - Safi U Khan
- Department of Internal Medicine, West Virginia University, Morgantown, West Virginia
| | - Rami Doukky
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, Illinois; Division of Cardiology, Rush University Medical Center, Chicago, Illinois
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16
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Tsiouris A, Heliopoulos I, Mikroulis D, Mitsias PD. Stroke after implantation of continuous flow left ventricular assist devices. J Card Surg 2019; 34:541-548. [DOI: 10.1111/jocs.14079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/13/2019] [Accepted: 04/18/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Athanasios Tsiouris
- Department of Cardiothoracic SurgeryProvidence Medical CenterKansas City Kansas
| | - Ioannis Heliopoulos
- Department of Neurology, University Hospital of AlexandroupolisSchool of MedicineDemocritus University of ThraceAlexandroupolis Greece
| | - Dimitrios Mikroulis
- Department of Cardiothoracic Surgery, University Hospital of Alexandroupolis, School of MedicineDemocritus University of ThraceAlexandroupolis Greece
| | - Panayiotis D. Mitsias
- Department of Neurology, University Hospital of HeraklionUniversity of Crete Greece
- Department of Neurology & Comprehensive Stroke CenterHenry Ford HospitalDetroit Michigan
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17
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Deshmukh A, Bhatia A, Sayer GT, Kim G, Raikhelkar J, Imamura T, Ozcan C, Ota T, Jeevanandam V, Uriel N. Left Atrial Appendage Occlusion With Left Ventricular Assist Device Decreases Thromboembolic Events. Ann Thorac Surg 2019; 107:1181-1186. [DOI: 10.1016/j.athoracsur.2018.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/30/2018] [Accepted: 09/05/2018] [Indexed: 02/06/2023]
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18
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Fatal Neurologic Dysfunction During Continuous-Flow Left Ventricular Assist Device Support. Ann Thorac Surg 2019; 107:1132-1138. [DOI: 10.1016/j.athoracsur.2018.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 09/14/2018] [Accepted: 10/01/2018] [Indexed: 01/24/2023]
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19
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Chen Z, Zhang J, Kareem K, Tran D, Conway RG, Arias K, Griffith BP, Wu ZJ. Device-induced platelet dysfunction in mechanically assisted circulation increases the risks of thrombosis and bleeding. Artif Organs 2019; 43:745-755. [PMID: 30805954 DOI: 10.1111/aor.13445] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/28/2019] [Accepted: 02/21/2019] [Indexed: 12/24/2022]
Abstract
Thrombotic and bleeding complications are the major obstacles for expanding mechanical circulatory support (MCS) beyond the current use. While providing the needed hemodynamic support, those devices can induce damage to blood, particularly to platelets. In this study, we investigated device-induced alteration of three major platelet surface receptors, von Willebrand factor (VWF) and associated hemostatic functions relevant to thrombosis and bleeding. Fresh human whole blood was circulated in an extracorporeal circuit with a clinical rotary blood pump (CentriMag, Abbott, Chicago, IL, USA) under the clinically relevant operating condition for 4 hours. Blood samples were examined every hour for glycoprotein (GP) IIb/IIIa activation and receptor loss of GPVI and GPIbα on the platelet surface with flow cytometry. Soluble P-selectin in hourly collected blood samples was measured by enzyme linked immunosorbent assay to characterize platelet activation. Adhesion of device-injured platelets to fibrinogen, collagen, and VWF was quantified with fluorescent microscopy. Device-induced damage to VWF was characterized with western blotting. The CentriMag blood pump induced progressive platelet activation with blood circulating time. Particularly, GPIIb/IIIa activation increased from 1.1% (Base) to 11% (4 hours) and soluble P-selectin concentration increased from 14.1 ng/mL (Base) to 26.5 ng/mL (4 hours). Those device-activated platelets exhibited increased adhesion capacity to fibrinogen. Concurrently, the CentriMag blood pump caused progressive platelet receptor loss (GPVI and GPIbα) with blood circulating time. Specifically, MFI of the GPVI and GPIbα receptors decreased by 17.2% and 16.1% for the 4-hours sample compared to the baseline samples, respectively. The device-injured platelets exhibited reduced adhesion capacities to collagen and VWF. The high molecular weight multimers (HMWM) of VWF in the blood disappeared within the first hour of the circulation. Thereafter the multimeric patterns of VWF were stable. The change in the VWF multimeric pattern was different from the progressive structural and functional changes of platelets with the circulation time. This study suggested that the CentriMag blood pump could induce two opposite effects on platelets and associated hemostatic functions under a clinically relevant operating condition. The device-altered hemostatic function may contribute to thrombosis and bleeding simultaneously as occurring in patients supported by a rotary blood pump. Device-induced damage of platelets may be an important cause for bleeding in patients supported with rotary blood pump MCS systems relative to device-induced loss of HMWM-VWF.
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Affiliation(s)
- Zengsheng Chen
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jiafeng Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kafayat Kareem
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Douglas Tran
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert G Conway
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherin Arias
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
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20
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Ventricular Assist Device Patients Have Different Clinical Outcomes and Altered Patterns of Bleeding with Intracranial Hemorrhage. ASAIO J 2019; 64:e55-e60. [PMID: 29432298 DOI: 10.1097/mat.0000000000000744] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Intracranial hemorrhage (ICH) is one of the most feared complications of left ventricular assist device (LVAD) support. However, outcomes in this group have not been well described. We therefore sought to examine clinical outcomes in this patient population in comparison to those with heart failure (HF) and no LVAD, as well as those without HF or LVAD. The National Inpatient Sample database, years 2002-2012, was queried to classify patients into 3 groups: any ICH (group 1), any HF with any ICH (group 2), and any LVAD with any ICH (group 3). Clinical outcomes, hemorrhage type, neurosurgical intervention rates, and hospital factors were collected and analyzed. Group 1 consisted of 419,264 patients, group 2 had 41,186, and group 3 had 118 patients. Group 3 patients were more likely to be in large, academic medical centers, with longer length of stay and higher hospital charges. Inpatient mortality was highest in this group at 39%; however, 46.2% were ultimately discharged to home. Patients in group 3 were more likely to have a subarachnoid or intracerebral hemorrhage versus a subdural or epidural hemorrhage. Neurosurgical intervention rates did not differ between the groups. Although LVAD patients with ICH have worse clinical outcomes, the majority survived their event and nearly half were able to be discharged home. Left ventricular assist device patients also have a distinct pattern of bleeding with ICH. Additional study is required to understand risk factors for the development of ICH in this population and ideal management strategies.
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21
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Early Gastrointestinal Complications From Ventricular Assist Devices is Increased by Non-Pulsatile Flow. Heart Lung Circ 2019; 29:295-300. [PMID: 30827856 DOI: 10.1016/j.hlc.2019.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 12/20/2018] [Accepted: 01/19/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Measurements of organ flow and perfusion during cardiopulmonary bypass suggest that perfusion of the splanchnic bed can be impaired by non-pulsatile flow. We postulated that non-pulsatile flow from centrifugal ventricular assist devices might also compromise splanchnic blood flow and cause bowel ischaemia especially in the period of circulatory instability early post-implant. The aim of the present studies was to compare the incidence of gastrointestinal (GI) complications in patients having a non-pulsatile device with the incidence in those having a pulsatile device. METHODS In a pilot study, the initial 12 patients who received the Ventrassist (Ventracor, Sydney, NSW, Australia) centrifugal, non-pulsatile device during the period from June 2003 to September 2005 at the Alfred Hospital, Melbourne were compared with 11 patients who received a Thoratec (Thoratec, Pleasanton, CA, USA), pulsatile, positive displacement device and the incidence was recorded of GI complications requiring an intervention either surgical, endoscopic or by interventional radiology. This was followed by a larger (full) study of a second cohort of similar ventricular assist device (VAD) patients from January 1992 until December 2012 comparing 53 patients having non-pulsatile devices and 110 having pulsatile devices. RESULTS In the pilot study, the overall incidence of complications in the non-pulsatile group (67%) was almost double that in the pulsatile group (36%) but the difference was not statistically significant (p = 0.15) because of the small number (n = 23) of participants. In the full study, all GI complications with either device occurred within the first 3 weeks post-implant. In the non-pulsatile patients, there was a higher incidence of GI bleeding, 23% vs 4% (p = 0.002), endoscopies, 24% vs 12% (p = 0.049). More patients with a non-pulsatile flow device had delayed absorption of nasogastric feeds than their pulsatile counterparts, 35% vs 7% (p < 0.0001). Patients with a non-pulsatile flow device had a higher overall rate of gastrointestinal complications than patients had with a pulsatile flow device, 56% vs 20% (p < 0.0001). After correcting for the other predictors, the odds of developing a gastrointestinal complication in the pulsatile group was significantly lower (odds ratio 0.07) than in the non-pulsatile device group (p < 0.0001). CONCLUSIONS We conclude that the use of non-pulsatile centrifugal VADs compared with pulsatile positive displacement VADs is associated with a higher incidence of both haemorrhagic and ischaemic complications in the gastro-intestinal system especially in the very early post-implant period. Whether these complications could be reduced in centrifugal devices by increasing their pulsatility is not clear and merits further research.
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22
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Apostoli A, Bianchi V, Bono N, Dimasi A, Ammann KR, Moiia YR, Montisci A, Sheriff J, Bluestein D, Fiore GB, Pappalardo F, Candiani G, Redaelli A, Slepian MJ, Consolo F. Prothrombotic activity of cytokine-activated endothelial cells and shear-activated platelets in the setting of ventricular assist device support. J Heart Lung Transplant 2019; 38:658-667. [PMID: 30846234 DOI: 10.1016/j.healun.2019.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND We systematically analyzed the synergistic effect of: (i) cytokine-mediated inflammatory activation of endothelial cells (ECs) with and (ii) shear-mediated platelet activation (SMPA) as a potential contributory mechanism to intraventricular thrombus formation in the setting of left ventricular assist device (LVAD) support. METHODS Intact and shear-activated human platelets were exposed to non-activated and cytokine-activated ECs. To modulate the level of LVAD-related shear activation, platelets were exposed to shear stress patterns of varying magnitude (30, 50, and 70 dynes/cm2, 10 minutes) via a hemodynamic shearing device. ECs were activated via exposure to inflammatory tumor necrosis factor-α (TNF-α 10 and 100 ng/ml, 24 hours), consistent with inflammatory activation recorded in patients on LVAD circulatory support. RESULTS Adhesivity of shear-activated platelets to ECs was significantly higher than that of intact/unactivated platelets, regardless of the initial activation level (70 dynes/cm2 shear-activated platelets vs intact platelets: +80%, p < 0.001). Importantly, inflammatory activation of ECs amplified platelet prothrombinase activity progressively with increasing shear stress magnitude and TNF-α concentration: thrombin generation of 70 dynes/cm2 shear-activated platelets was 2.6-fold higher after exposure and adhesion to 100 ng/ml TNF-α‒activated ECs (p < 0.0001). CONCLUSIONS We demonstrated synergistic effect of SMPA and cytokine-mediated EC inflammatory activation to enhance EC‒platelet adhesion and platelet prothrombotic function. These mechanisms may contribute to intraventricular thrombosis in the setting of mechanical circulatory support.
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Affiliation(s)
- Alice Apostoli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Valentina Bianchi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Nina Bono
- Politecnico di Milano Research Unit, National Interuniversity Consortium of Materials Science and Technology, Milano, Italy
| | - Annalisa Dimasi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Kaitlyn R Ammann
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona, USA
| | - Yana Roka Moiia
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona, USA
| | - Andrea Montisci
- Anesthesia and Intensive Care, Sant'Ambrogio Cardiothoracic Center, Milano, Italy
| | - Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Gianfranco B Fiore
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Scientific Institute, Milano, Italy; Università Vita Salute San Raffaele, Milano, Italy
| | - Gabriele Candiani
- Biocompatibility and Cell Culture Laboratory "BioCell," Department of Chemistry, Materials and Chemical Engineering "Giulio Natta," Politecnico di Milano, Milano, Italy
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Marvin J Slepian
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona, USA
| | - Filippo Consolo
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy; Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Scientific Institute, Milano, Italy; Università Vita Salute San Raffaele, Milano, Italy.
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23
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Sheriff F, Hirsch J, Shelton K, D'Alessandro D, Stapleton C, Koch M, Rabinov J, Jassar A, Patel A, Leslie-Mazwi T. Large-vessel occlusion stroke after cardiothoracic surgery: Expanding time windows offer new salvage opportunities. J Thorac Cardiovasc Surg 2018; 158:186-196.e2. [PMID: 30685180 DOI: 10.1016/j.jtcvs.2018.11.106] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 10/09/2018] [Accepted: 11/25/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Ischemic stroke due to large-vessel occlusion (LVO) is a complication after cardiothoracic surgery (CTS). Recently published endovascular stroke trials have major implications for treating LVO strokes; we evaluated our experience in patients undergoing CTS. METHODS Our prospective institutional CTS database was reviewed between July 2013 and April 2018 for ischemic strokes. Patients with LVO were identified and their course and outcomes analyzed. RESULTS A total of 5947 patients were reviewed; 148 (2.48%) had a cerebrovascular complication; 92.5% were ischemic. Of these 10.9% had an LVO. Prolonged aortic crossclamp was associated with LVO (odds ratio, 1.012 for every minute of prolonged aortic crossclamp time; confidence interval, 1.001-1.023) and remained significant in patients with ejection fraction >45%; prolonged cardiac bypass time was only associated with LVO in patients with ejection fraction >45% (odds ratio, 1.012 for every minute of prolonged cardiac bypass time; confidence interval, 1.003-1.021). Patients fell into 2 categories: detection of neurologic deficit in the stable postoperative patient or detection of deficit on emergence from anesthesia. Seven patients met criteria for emergent revascularization, with median National Institutes of Health Stroke Scale score 15, and shorter times from last seen well to deficit detection compared with patients not meeting criteria (P = .032). Median National Institutes of Health Stroke Scale day 7 score improved to 5. There was a trend toward better modified Rankin Scale scores at 3 months in patients who underwent thrombectomy. CONCLUSIONS LVO complicates a small proportion of patients after CTS and may be more likely with prolonged aortic crossclamp and cardiac bypass times. Both early and late window endovascular stroke treatment has the potential to positively modify the complication profile of CTS. Greater awareness of this treatment option is needed.
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Affiliation(s)
- Faheem Sheriff
- Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Mass
| | - Joshua Hirsch
- Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, Mass
| | - Kenneth Shelton
- Cardiac Critical Care, Department of Anesthesia, Massachusetts General Hospital, Boston, Mass
| | - David D'Alessandro
- Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Chris Stapleton
- Neuroendovascular, Department of Neurosurgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew Koch
- Neuroendovascular, Department of Neurosurgery, Massachusetts General Hospital, Boston, Mass
| | - James Rabinov
- Neuroendovascular, Department of Neurosurgery, Massachusetts General Hospital, Boston, Mass
| | - Arminder Jassar
- Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Aman Patel
- Neuroendovascular, Department of Neurosurgery, Massachusetts General Hospital, Boston, Mass
| | - Thabele Leslie-Mazwi
- Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Mass; Neuroendovascular, Department of Neurosurgery, Massachusetts General Hospital, Boston, Mass.
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24
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Hamdan A, Ortuno S, Guerot E, Aissaoui N. L’assistance monoventriculaire gauche de longue durée : indications, management et complications. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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25
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The Physiological Rationale for Incorporating Pulsatility in Continuous-Flow Left Ventricular Assist Devices. Cardiol Rev 2018; 26:294-301. [DOI: 10.1097/crd.0000000000000202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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26
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Abstract
Despite improvements in left ventricular assist device (LVAD) technology, bleeding and thrombotic complications are major concerns that adversely influence morbidity and mortality. Current antithrombotic therapy recommendations for LVAD thrombosis prophylaxis are largely derived from clinical device trials that implement a one-size-fits-all strategy. Objective serial laboratory-based assessment of thrombogenicity is needed to balance the risk of bleeding and thrombotic complications. Finally, the newest-generation device, the HeartMate 3, has been associated with lower levels of shear and reduced hemolysis that may mitigate thrombotic event occurrences.
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27
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Nakagita K, Wada K, Mukai Y, Uno T, Nishino R, Matsuda S, Takenaka H, Terakawa N, Oita A, Takada M. Effects of vitamin K epoxide reductase complex 1 gene polymorphisms on warfarin control in Japanese patients with left ventricular assist devices (LVAD). Eur J Clin Pharmacol 2018; 74:885-894. [PMID: 29781049 DOI: 10.1007/s00228-018-2483-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/10/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE This study aimed to investigate relationships between times in therapeutic range (TTR) or warfarin sensitivity indexes (WSI) and VKORC1-1639G>A and CYP2C9 polymorphisms in patients with left ventricular assist devices (LVAD). METHODS Severe heart failure patients who received LVAD from January 1, 2013 to October 31, 2017 were recruited. Relationships between TTR or WSI and VKORC1-1639G>A and CYP2C9 gene polymorphisms were investigated immediately after LVAD implantation (period 1) and immediately prior to hospital discharge (period 2). RESULTS Among 54 patients, 31 (72.1%) had VKORC1-1639AA and CYP2C9*1/*1 (AA group) polymorphisms and 12 (27.9%) had VKORC1-1639GA and CYP2C9*1/*1 (GA group) polymorphisms. During period 1, mean prothrombin time-international normalized ratio (PT-INR) values were significantly higher in the AA group than in the GA group (2.21 vs. 2.05, p < 0.0001). Mean WSI values were 1.68-fold greater in the AA group than in the GA group (1.14 vs. 0.68, p < 0.0001). In addition, times below the therapeutic range (TBTR) in the GA group were significantly greater than in the AA group during period 1 (39.8 vs. 28.3%, p = 0.032), and insufficient PT-INR was more frequent in the GA group than in the AA group. However, mean PT-INR values during period 2 did not differ and no significant differences in TTR, TATR, and TBTR values were identified. In subsequent multivariable logistic regression analyses, the VKORC1-1639GA allele was significantly associated with insufficient anticoagulation. CONCLUSION Patients with the VKORC1-1639GA and CYP2C9*1/*1 alleles may receive insufficient anticoagulation therapy during the early stages after implantation of LVAD, and VKORC1-1639G>A and CYP2C9 genotyping may contribute to more appropriate anticoagulant therapy after implantation of LVAD.
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Affiliation(s)
- Kazuki Nakagita
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan.,Division of Clinical Drug Informatics, Kindai University School of Pharmacy, 577-8502, 3-4-1, Kowakae, Higashi-osaka, Osaka, 577-8502, Japan
| | - Kyoichi Wada
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yutaro Mukai
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan.,Division of Clinical Drug Informatics, Kindai University School of Pharmacy, 577-8502, 3-4-1, Kowakae, Higashi-osaka, Osaka, 577-8502, Japan
| | - Takaya Uno
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan.,Division of Clinical Drug Informatics, Kindai University School of Pharmacy, 577-8502, 3-4-1, Kowakae, Higashi-osaka, Osaka, 577-8502, Japan
| | - Ryoji Nishino
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sachi Matsuda
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiromi Takenaka
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobue Terakawa
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akira Oita
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, Kindai University School of Pharmacy, 577-8502, 3-4-1, Kowakae, Higashi-osaka, Osaka, 577-8502, Japan.
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28
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McClane N, Jeske W, Walenga JM, Escalante V, Hoppensteadt D, Schwartz J, Bakhos M. Identification of Novel Hemostatic Biomarkers of Adverse Clinical Events in Patients Implanted With a Continuous-Flow Left Ventricular Assist Device. Clin Appl Thromb Hemost 2018; 24:965-972. [PMID: 29552914 PMCID: PMC6714718 DOI: 10.1177/1076029618760235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Heart failure affects over 5 million people in the United States. Its rising prevalence and the limited supply of donor hearts is increasing the use of mechanical cardiac support with the implantation of continuous-flow ventricular assist devices (CF-VAD). Patients with CF-VAD implants are at risk of complications, specifically adverse hemostatic events such as nonsurgical bleeding and thrombosis. Development of a pump thrombus requires clinical intervention and/or surgical replacement significantly increasing the risk of patient morbidity and mortality. Identification of biomarkers for these events could improve current risk assessment models, subsequent treatment, and quality of life prognoses for VAD-implanted patients. The standard means for identifying thrombus in VAD patients is currently limited to monitoring levels of lactate dehydrogenase (>2× upper limit of normal), which is incapable of predicting a future event, but describes the risk of a present thrombus. Surface-enhanced laser desorption ionization time-of-flight mass spectrometry is a technique used to identify biomarkers. In this study, 3 groups of unique peaks were identified in plasma from patients with left ventricular assist devices: 8.1-kDa, 11.7-kDa, and a 15.2-/16.1-kDa pair. Unique correlations were found for each peak, respectively, with microparticles (MPs) and MP procoagulant activity, C-reactive protein, and MP-tissue factor. Furthermore, the use of 8.1-kDa peaks may be able to differentiate thrombotic events from other hemostatic events.
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Affiliation(s)
- Nathan McClane
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Walter Jeske
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Jeanine M Walenga
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Vicki Escalante
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Debra Hoppensteadt
- 2 Health Sciences Division, Department of Pathology, Loyola University Chicago, Maywood, IL, USA
| | - Jeffrey Schwartz
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Mamdouh Bakhos
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
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29
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Beyazpınar DS, Ersoy Ö, Gültekin B, Aliyev A, Avsever M, Akay HT, Özkan M, Sezgin A, Aşlamacı S. Treatment of Left Ventricular Assist Device Thrombosis: Single-Center Experience. EXP CLIN TRANSPLANT 2018. [PMID: 29528019 DOI: 10.6002/ect.tond-tdtd2017.p47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Heart failure is the one of the biggest health problem in the world. Because of limited donors for heart transplant procedures, the ventricular assist device has become a solution for heart failure therapy. With the increase in number of ventricular assist devices, the incidence of complications has also increased. One of the most important life-threatening complications is ventricular assist device thrombosis. Medical therapy and changes in the ventricular assist device are the main therapy methods for ventricular assist device thrombosis. In this study, we showed our clinical experience with treatment of ventricular assist device thrombosis.
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Affiliation(s)
- D Sarp Beyazpınar
- From the Department of Family Medicine, Baskent University Faculty of Medicine, Ankara, Turkey
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30
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Miyamoto T, Karimov JH, Fukamachi K. Effects of continuous and pulsatile flows generated by ventricular assist devices on renal function and pathology. Expert Rev Med Devices 2018; 15:171-182. [DOI: 10.1080/17434440.2018.1437346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Jamshid H. Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, U.S.A
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31
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Kwak J, Majewski M, LeVan PT. Heart Transplantation in an Era of Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2018; 32:19-31. [DOI: 10.1053/j.jvca.2017.09.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Indexed: 11/11/2022]
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32
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Shahreyar M, Bob-Manuel T, Khouzam RN, Bashir MW, Sulaiman S, Akinseye O, Sharma A, Carter A, Latham S, Bhandari S, Jahangir A. Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:5. [PMID: 29404351 DOI: 10.21037/atm.2017.12.23] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients. Methods All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. Results Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance. Conclusions Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4- and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS.
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Affiliation(s)
- Muhammad Shahreyar
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Cardiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Rami N Khouzam
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Cardiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Samian Sulaiman
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Oluwaseun Akinseye
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Cardiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Arindam Sharma
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - April Carter
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Samuel Latham
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sanjay Bhandari
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Arshad Jahangir
- Aurora Cardiovascular Services, Aurora St. Luke's Medical Center, Milwaukee, WI, USA.,Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora St. Luke's Medical Center, Aurora Health Care, Milwaukee, WI, USA
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33
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Patricia Massicotte M, Bauman ME. Developmental hemostasis and ventricular assist devices: A troubled relationship. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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34
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Abstract
Left ventricular assist devices (LVADs) are an effective therapy for a growing and aging population in the background of limited donor supply. Selecting the proper patient involves assessment of indications, risk factors, scores for overall outcomes, assessment for right ventricular failure, and optimal timing of implantation. LVAD complications have a 5% to 10% perioperative mortality and complications of bleeding, thrombosis, stroke, infection, right ventricular failure, and device failure. As LVAD engineering technology evolves, so will the risk-prediction scores. Hence, more large-scale prospective data from multicenters will continually be required to aid in patient selection, reduce complications, and improve long-term outcomes.
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35
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Shroff GS, Ocazionez D, Akkanti B, Vargas D, Garza A, Gupta P, Patel JA, Patel MK, Gregoric ID. CT Imaging of Complications Associated with Continuous-Flow Left Ventricular Assist Devices (LVADs). Semin Ultrasound CT MR 2017; 38:616-628. [PMID: 29179901 DOI: 10.1053/j.sult.2017.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Heart failure is becoming increasingly prevalent, and more patients are being treated with left ventricular assist devices (LVADs), either as a bridge to transplant or as destination therapy. The use of continuous-flow LVADs is on the rise. LVAD therapy is associated with several classes of complications, including bleeding, thrombosis, and infection. CT imaging can be used effectively to diagnose LVAD complications, including mediastinal hematomas and pericardial, abdominal wall, and retroperitoneal hemorrhage, inflow and outflow graft and aortic thrombi, and driveline and pump pocket infections. CT can also be helpful in cases of device malfunction and can detect outflow graft kinking and inflow cannula misalignment. When interpreting CT scans in patients with LVADs, accessory materials implanted with the device should not be mistaken for hemorrhage or calcification. With training in recognizing LVAD complications, radiologists can play an important role in the evaluation of patients with heart failure.
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Affiliation(s)
- Girish S Shroff
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Daniel Ocazionez
- Department of Diagnostic and Interventional Imaging, The University of Texas Medical School at Houston, Houston, TX
| | - Bindu Akkanti
- Critical Care Medicine, Pulmonary and Sleep Medicine, The University of Texas Medical School at Houston, Houston, TX
| | - Daniel Vargas
- Department of Radiology, University of Colorado Hospital, Denver, CO
| | - Alheli Garza
- Department of Diagnostic and Interventional Imaging, The University of Texas Medical School at Houston, Houston, TX
| | - Pushpender Gupta
- Department of Radiology, Wake Forest Baptist Health, Winston-Salem, NC
| | - Jayeshkumar A Patel
- Department of Cardiothoracic and Vascular Surgery, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Houston, TX
| | - Manish K Patel
- Department of Cardiothoracic and Vascular Surgery, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Houston, TX
| | - Igor D Gregoric
- Department of Cardiothoracic and Vascular Surgery, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston/Memorial Hermann Hospital, Houston, TX
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36
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Gurvits GE, Fradkov E. Bleeding with the artificial heart: Gastrointestinal hemorrhage in CF-LVAD patients. World J Gastroenterol 2017; 23:3945-3953. [PMID: 28652649 PMCID: PMC5473115 DOI: 10.3748/wjg.v23.i22.3945] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/10/2017] [Accepted: 05/09/2017] [Indexed: 02/06/2023] Open
Abstract
Continuous-flow left ventricular assist devices (CF-LVADs) have significantly improved outcomes for patients with end-stage heart failure when used as a bridge to cardiac transplantation or, more recently, as destination therapy. However, its implantations carries a risk of complications including infection, device malfunction, arrhythmias, right ventricular failure, thromboembolic disease, postoperative and nonsurgical bleeding. A significant number of left ventricular assist devices (LVAD) recipients may experience recurrent gastrointestinal hemorrhage, mainly due to combination of antiplatelet and vitamin K antagonist therapy, activation of fibrinolytic pathway, acquired von Willebrand factor deficiency, and tendency to develop small intestinal angiodysplasias due to increased rotary speed of the pump. Gastrointestinal bleeding in LVAD patients remains a source of increased morbidity including the need for blood transfusions, extended hospital stays, multiple readmissions, and overall mortality. Management of gastrointestinal bleeding in LVAD patients involves multidisciplinary approach in stabilizing the patients, addressing risk factors and performing structured endoluminal evaluation with focus on upper gastrointestinal tract including jejunum to find and eradicate culprit lesion. Medical and procedural intervention is largely successful and universal bleeding cessation occurs in transplanted patients.
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37
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Tumor necrosis factor-α levels and non-surgical bleeding in continuous-flow left ventricular assist devices. J Heart Lung Transplant 2017; 37:107-115. [PMID: 28651907 DOI: 10.1016/j.healun.2017.06.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 06/02/2017] [Accepted: 06/03/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Non-surgical bleeding (NSB) due to angiodysplasia is common in left ventricular assist device (LVAD) patients. Thrombin-induced angiopoietin-2 (Ang-2) expression in LVAD patients leads to altered angiogenesis and is associated with lower angiopoietin-1 (Ang-1) and increased NSB. However, the mechanism for decreased Ang-1, made by pericytes, is unknown and the origin of thrombin in LVAD patients is unclear. We hypothesized that high tumor necrosis factor-α (TNF-α) levels in LVAD patients induce pericyte apoptosis, tissue factor (TF) expression and vascular instability. METHODS We incubated cultured pericytes with serum from patients with heart failure (HF), LVAD or orthotopic heart transplantation (OHT), with or without TNF-α blockade. We performed several measurements: Ang-1 expression was assessed by reverse transcript-polymerase chain reaction (RT-PCR) and pericyte death fluorescently; TF expression was assessed by RT-PCR in cultured endothelial cells incubated with patient plasma with or without TNF-α blockade; and TF expression was assessed in endothelial biopsy samples from these patients by immunofluorescence. We incubated cultured endothelial cells on Matrigel with patient serum with or without TNF-α blockade and determined tube formation by microscopy. RESULTS Serum from LVAD patients had higher levels of TNF-α, suppressed Ang-1 expression in pericytes, and induced pericyte death, and there was accelerated endothelial tube formation compared with serum from patients without LVADs. TF was higher in both plasma and endothelial cells from LVAD patients, and plasma from LVAD patients induced more endothelial TF expression. All of these effects were reversed or reduced with TNF-α blockade. High levels of TNF-α were associated with increased risk of NSB. CONCLUSIONS Elevated TNF-α in LVAD patients is a central regulator of altered angiogenesis, pericyte apoptosis and expression of TF and Ang-1.
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38
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See SB, Clerkin KJ, Kennel PJ, Zhang F, Weber MP, Rogers KJ, Chatterjee D, Vasilescu ER, Vlad G, Naka Y, Restaino SW, Farr MA, Topkara VK, Colombo PC, Mancini DM, Schulze PC, Levin B, Zorn E. Ventricular assist device elicits serum natural IgG that correlates with the development of primary graft dysfunction following heart transplantation. J Heart Lung Transplant 2017; 36:862-870. [PMID: 28431981 DOI: 10.1016/j.healun.2017.03.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/28/2017] [Accepted: 03/22/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pre-transplant sensitization is a limiting factor in solid-organ transplantation. In heart transplants, ventricular assist device (VAD) implantation has been associated with sensitization to human leukocyte antigens (HLA). The effect of VAD on non-HLA antibodies is unclear. We have previously shown that polyreactive natural antibodies (Nabs) contribute to pre-sensitization in kidney allograft recipients. Here we assessed generation of Nabs after VAD implantation in pre-transplant sera and examined their contribution to cardiac allograft outcome. METHODS IgM and IgG Nabs were tested in pre-transplant serum samples collected from 206 orthotopic heart transplant recipients, including 128 patients with VAD (VAD patients) and 78 patients without VAD (no-VAD patients). Nabs were assessed by testing serum reactivity to apoptotic cells by flow cytometry and to the generic oxidized epitope, malondialdehyde, by enzyme-linked immunosorbent assay. RESULTS No difference was observed in serum levels of IgM Nabs between VAD and no-VAD patients. However, serum IgG Nabs levels were significantly increased in VAD compared with no-VAD patients. This increase was likely due to the presence of the VAD, as revealed by lower serum IgG Nabs levels before implantation. Elevated pre-transplant IgG Nabs level was associated with development of primary graft dysfunction (PGD). CONCLUSIONS Our study demonstrates that VAD support elicits IgG Nabs reactive to apoptotic cells and oxidized epitopes. These findings further support broad and non-specific B-cell activation by VAD, resulting in IgG sensitization. Moreover, the association of serum IgG Nabs levels with development of PGD suggests a possible role for these antibodies in the inflammatory reaction accompanying this complication.
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Affiliation(s)
- Sarah B See
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Peter J Kennel
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - Feifan Zhang
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Matthew P Weber
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Kortney J Rogers
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - Debanjana Chatterjee
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - Elena R Vasilescu
- Department of Pathology and Cell Biology, Department of Surgery, Columbia University Medical Center, New York, New York
| | - George Vlad
- Department of Pathology and Cell Biology, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Susan W Restaino
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Donna M Mancini
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - P Christian Schulze
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Bruce Levin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Emmanuel Zorn
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York.
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Bain J, Flannery AH, Flynn J, Dager W. Heparin induced thrombocytopenia with mechanical circulatory support devices: review of the literature and management considerations. J Thromb Thrombolysis 2017; 44:76-87. [DOI: 10.1007/s11239-017-1494-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
PURPOSE OF REVIEW Left ventricular assist devices (LVADs) have markedly improved the survival for patients with advanced heart failure but are plagued with significant morbidity, including pump thrombosis and bleeding. Better understanding of the platelet, and its role in the balance of bleeding and thrombosis, stands to impact the frequency and treatment of these significant complications. RECENT FINDINGS In patients with LVADs, there is little consistency linking traditional biomarkers of platelet activation and clinical events. A number of innovative methods of assessing platelet functionality, including shedding of platelet receptors and formation of microparticle complexes as well as measuring mitochondrial membrane potentials, exist and appear to be clinically relevant. Acquired von Willebrand syndrome, while not explaining all bleeding events, is a central feature of mechanical support and offers a target for innovative therapies. SUMMARY Although the platelet is only one component of impacting thrombosis and bleeding in patients supported with LVADs, it plays a central role in mediating these two opposing forces. Innovations in understanding platelet physiology as well as manipulating genomic and receptor interactions for an individual patient will be critical if we are to decrease these serious adverse events in the future.
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Patel SR, Vukelic S, Jorde UP. Bleeding in continuous flow left ventricular assist device recipients: an acquired vasculopathy? J Thorac Dis 2016; 8:E1321-E1327. [PMID: 27867617 DOI: 10.21037/jtd.2016.10.81] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Snehal R Patel
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York 10467, USA
| | - Sasa Vukelic
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York 10467, USA
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York 10467, USA
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Jeske WP, Walenga JM, Menapace B, Schwartz J, Bakhos M. Blood cell microparticles as biomarkers of hemostatic abnormalities in patients with implanted cardiac assist devices. Biomark Med 2016; 10:1095-1104. [DOI: 10.2217/bmm-2016-0150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
For heart failure patients unable to undergo cardiac transplantation, mechanical circulatory support with left ventricular assist devices can be utilized. These devices improve quality of life and prolong life expectancy, but they are associated with bleeding and thrombotic complications impacting patient survival. Little is known of the relevant mechanisms of these hemostatic issues, hindering identification of a clinically useful biomarker. However, there is suggestive evidence that blood cell-derived microparticles may fulfill this unmet clinical need. Recent publications have shown an association of up regulated microparticle production with implanted left ventricular assist devices and the potential to use this as a biomarker to predict thrombosis (and perhaps other adverse events) with an onset time earlier than currently used clinical indicators.
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Affiliation(s)
- Walter P Jeske
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Jeanine M Walenga
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Bryan Menapace
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Jeffrey Schwartz
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Mamdouh Bakhos
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
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Monitoring hemostasis parameters in left ventricular assist device recipients - a preliminary report. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 13:224-228. [PMID: 27785136 PMCID: PMC5071589 DOI: 10.5114/kitp.2016.62609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 09/05/2016] [Indexed: 11/17/2022]
Abstract
Introduction Mechanical circulatory support (MCS) therapy is associated with the improvement of long-term prognosis in patients with end-stage heart failure. For years it has been used as a bridge to transplant. However, more recently it is even being used as a destination therapy. Recently, clinicians have identified common MCS therapy-associated complications: pump thrombosis, bleeding, and hemolysis. These complications are very challenging with regard to both diagnosis and management. Aim To determine time-dependant changes of selected hemostasis/coagulation parameters in patients with end-stage heart failure treated with MCS and antithrombotic therapy. Material and methods Sixteen patients with end-stage heart failure on left ventricular assist device (LVAD) were followed for 6 weeks (six blood samples for each patient). Every week an extended hemostasis panel was assessed, including activated partial thromboplastin time, prothrombin time, international normalized ratio, von Willebrand factor (vWF) activity, factor VIII activity, fibrinogen level, D-dimer, platelet response to arachidonic acid (ASPI test) and adenosine diphosphate (ADP test), thrombin receptor activating peptide-6 (TRAP test) and collagen (COL test). Results The study population comprised 16 men. The median time from LVAD implantation was 120 days (100–150 days). During the study period the D-dimer and fibrinogen concentrations were elevated but remained similar throughout all six measurements. Meanwhile factor VIII and vWF activities were elevated in the first two measurements and then subsequently declined. Inhibition of platelet aggregation was greater early after LVAD implantation. During subsequent weeks the inhibition of platelet aggregation was less pronounced. No patient developed any bleeding or thrombo-embolic event during the study period. Conclusions Patients on MCS therapy demonstrate significant time-dependant changes in hemostasis parameters (both in the coagulation system and platelet aggregation).
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Tabit CE, Chen P, Kim GH, Fedson SE, Sayer G, Coplan MJ, Jeevanandam V, Uriel N, Liao JK. Elevated Angiopoietin-2 Level in Patients With Continuous-Flow Left Ventricular Assist Devices Leads to Altered Angiogenesis and Is Associated With Higher Nonsurgical Bleeding. Circulation 2016; 134:141-52. [PMID: 27354285 DOI: 10.1161/circulationaha.115.019692] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 05/18/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Nonsurgical bleeding is the most common adverse event in patients with continuous-flow left ventricular assist devices (LVADs) and is caused by arteriovenous malformations. We hypothesized that deregulation of an angiogenic factor, angiopoietin-2 (Ang-2), in patients with LVADs leads to increased angiogenesis and higher nonsurgical bleeding. METHODS Ang-2 and thrombin levels were measured by ELISA and Western blotting, respectively, in blood samples from 101 patients with heart failure, LVAD, or orthotopic heart transplantation. Ang-2 expression in endothelial biopsy was quantified by immunofluorescence. Angiogenesis was determined by in vitro tube formation from serum from each patient with or without Ang-2-blocking antibody. Ang-2 gene expression was measured by reverse transcription-polymerase chain reaction in endothelial cells incubated with plasma from each patient with or without the thrombin receptor blocker vorapaxar. RESULTS Compared with patients with heart failure or those with orthotopic heart transplantation, serum levels and endothelial expression of Ang-2 were higher in LVAD patients (P=0.001 and P<0.001, respectively). This corresponded to an increased angiogenic potential of serum from patients with LVADs (P<0.001), which was normalized with Ang-2 blockade. Furthermore, plasma from LVAD patients contained higher amounts of thrombin (P=0.003), which was associated with activation of the contact coagulation system. Plasma from LVAD patients induced more Ang-2 gene expression in endothelial cells (P<0.001), which was reduced with thrombin receptor blockade (P=0.013). LVAD patients with Ang-2 levels above the mean (12.32 ng/mL) had more nonsurgical bleeding events compared with patients with Ang-2 levels below the mean (P=0.003). CONCLUSIONS Our findings indicate that thrombin-induced Ang-2 expression in LVAD patients leads to increased angiogenesis in vitro and may be associated with higher nonsurgical bleeding events. Ang-2 therefore may contribute to arteriovenous malformation formation and subsequent bleeding in LVAD patients.
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Affiliation(s)
- Corey E Tabit
- From the Department of Medicine, Section of Cardiology (C.E.T., P.C., G.H.K., G.S., M.J.C., N.U., J.K.L.) and Department of Surgery, Section of Cardiac and Thoracic Surgery (V.T.), University of Chicago, IL; and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.E.F.)
| | - Phetcharat Chen
- From the Department of Medicine, Section of Cardiology (C.E.T., P.C., G.H.K., G.S., M.J.C., N.U., J.K.L.) and Department of Surgery, Section of Cardiac and Thoracic Surgery (V.T.), University of Chicago, IL; and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.E.F.)
| | - Gene H Kim
- From the Department of Medicine, Section of Cardiology (C.E.T., P.C., G.H.K., G.S., M.J.C., N.U., J.K.L.) and Department of Surgery, Section of Cardiac and Thoracic Surgery (V.T.), University of Chicago, IL; and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.E.F.)
| | - Savitri E Fedson
- From the Department of Medicine, Section of Cardiology (C.E.T., P.C., G.H.K., G.S., M.J.C., N.U., J.K.L.) and Department of Surgery, Section of Cardiac and Thoracic Surgery (V.T.), University of Chicago, IL; and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.E.F.)
| | - Gabriel Sayer
- From the Department of Medicine, Section of Cardiology (C.E.T., P.C., G.H.K., G.S., M.J.C., N.U., J.K.L.) and Department of Surgery, Section of Cardiac and Thoracic Surgery (V.T.), University of Chicago, IL; and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.E.F.)
| | - Mitchell J Coplan
- From the Department of Medicine, Section of Cardiology (C.E.T., P.C., G.H.K., G.S., M.J.C., N.U., J.K.L.) and Department of Surgery, Section of Cardiac and Thoracic Surgery (V.T.), University of Chicago, IL; and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.E.F.)
| | - Valluvan Jeevanandam
- From the Department of Medicine, Section of Cardiology (C.E.T., P.C., G.H.K., G.S., M.J.C., N.U., J.K.L.) and Department of Surgery, Section of Cardiac and Thoracic Surgery (V.T.), University of Chicago, IL; and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.E.F.)
| | - Nir Uriel
- From the Department of Medicine, Section of Cardiology (C.E.T., P.C., G.H.K., G.S., M.J.C., N.U., J.K.L.) and Department of Surgery, Section of Cardiac and Thoracic Surgery (V.T.), University of Chicago, IL; and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.E.F.)
| | - James K Liao
- From the Department of Medicine, Section of Cardiology (C.E.T., P.C., G.H.K., G.S., M.J.C., N.U., J.K.L.) and Department of Surgery, Section of Cardiac and Thoracic Surgery (V.T.), University of Chicago, IL; and Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.E.F.).
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Grosman-Rimon L, Billia F, Fuks A, Jacobs I, A McDonald M, Cherney DZ, Rao V. New therapy, new challenges: The effects of long-term continuous flow left ventricular assist device on inflammation. Int J Cardiol 2016; 215:424-30. [PMID: 27131263 DOI: 10.1016/j.ijcard.2016.04.133] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/16/2016] [Indexed: 10/21/2022]
Abstract
Surgically implanted continuous flow left ventricular assist devices (CF-LVADs) are currently used in patients with end-stage heart failure (HF). However, CF-LVAD therapy introduces a new set of complications and adverse events in these patients. Major adverse events with the CF-LVAD include right heart failure, vascular dysfunction, stroke, hepatic failure, and multi-organ failure, complications that may have inflammation as a common etiology. Our aim was to review the current evidence showing a relationship between these adverse events and elevated levels of inflammatory biomarkers in CF-LVAD recipients.
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Affiliation(s)
- Liza Grosman-Rimon
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada.
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - Avi Fuks
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - Ira Jacobs
- Faculty of Kinesiology and Physical Education, University of Toronto, Canada
| | - Michael A McDonald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - David Z Cherney
- Division of Nephrology, University Health Network, University of Toronto, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada.
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Nair N, Schmitt AA, Rau EM, Anders S, Sandler D, Icenogle TB. Thrombolytics in VAD management - A single-center experience. IJC HEART & VASCULATURE 2016; 11:49-54. [PMID: 28616525 PMCID: PMC5462631 DOI: 10.1016/j.ijcha.2016.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/04/2016] [Indexed: 11/24/2022]
Abstract
Background With continued increase in the use of mechanical circulatory support, the incidence of device thrombus remains a challenge. This study is a retrospective analysis of data at a single center to assess the safety and efficacy of thrombolytic use in durable mechanical assist devices. Methods Data was analyzed retrospectively from 154 patients who underwent left ventricular assist device (LVAD) implantation from 1/1/2005 to 6/30/2014. The HMII device was implanted in 131 patients while 23 received the HVAD. LVAD thrombus was diagnosed when lactate dehydrogenase levels exceeded 1000 units/l accompanied by clinical signs of hemolysis and heart failure, echocardiographic data and surges in pump power. TPA (tissue plasminogen activator) protocol consisted of a 5 mg intravenous bolus followed by 3 mg/h infusion in normal saline for 10 h. If symptoms persisted another cycle of TPA at 1 mg/h was continued up to 48 h. Results The TPA group had a 70% success rate. Success was defined as complete resolution of hemolysis and clinical symptoms with no requirement for LVAD exchange at 30 days. 95% survival was noted at 30 days and 90% were free of a hemorrhagic stroke in the TPA group. The rates of hemorrhagic strokes in the TPA group and the control group were not different (OR = 0.92). Conclusion The TPA protocol described here was successful consistently. Though this study is limited by its size and retrospective nature it leads the way for larger studies to generate more robust comparisons between different types of mechanical assist devices as well as the tailored use of thrombolytics in this patient population.
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Affiliation(s)
- N Nair
- Providence Spokane Heart Institute, Providence Sacred Heart Medical Center, Spokane, WA 99204, United States
| | - A A Schmitt
- Providence Spokane Heart Institute, Providence Sacred Heart Medical Center, Spokane, WA 99204, United States
| | - E M Rau
- Providence Spokane Heart Institute, Providence Sacred Heart Medical Center, Spokane, WA 99204, United States
| | - S Anders
- Providence Spokane Heart Institute, Providence Sacred Heart Medical Center, Spokane, WA 99204, United States
| | - D Sandler
- Providence Spokane Heart Institute, Providence Sacred Heart Medical Center, Spokane, WA 99204, United States
| | - T B Icenogle
- Providence Spokane Heart Institute, Providence Sacred Heart Medical Center, Spokane, WA 99204, United States
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Vega EA, Miko Enomoto T. Complications Following Left Ventricular Assist Device Implantation: Diagnosis and Management of Common Adverse Events. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Management of anticoagulation and antiplatelet therapy in patients with left ventricular assist devices. J Thromb Thrombolysis 2015; 39:337-44. [PMID: 25549823 DOI: 10.1007/s11239-014-1162-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Left ventricular assist devices (LVADs) have increased the survival of patients with advanced heart failure fourfold. Despite these advances, significant bleeding and thrombotic complications occur. Hemorrhage requiring surgery has been reported in up to 30% of adults and 50% of children after LVAD placement. LVAD thrombosis and embolic stroke lead to significant long-term morbidity. Adults are treated with antithrombotic therapy to prevent thrombotic complications, but the amount and intensity of treatment differs between institutions. The goal international normalized ratio for warfarin therapy varies from 1.5 to 3.0. Some physicians manage adult LVAD patients without antiplatelet medication, whereas other adults are treated with aspirin as a single agent or combined with dipyridamole. In contrast, physicians typically manage children with LVADs using the Edmonton Anticoagulation and Platelet Inhibition Protocol, a detailed algorithm for anticoagulation and antiplatelet treatment modified based on thromboelastography results. LVAD implantation causes consumption of coagulation proteins, activation of fibrinolysis, and loss of high molecular weight von Willebrand protein multimers. How these changes in the coagulation system influence the risk of hemorrhage and initiation of thrombosis is unknown. Prospective, controlled studies are needed to determine the antithrombotic regimen that most effectively balances bleeding and thrombosis in LVAD patients.
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Doligalski CT, Jennings DL. Device-Related Thrombosis in Continuous-Flow Left Ventricular Assist Device Support. J Pharm Pract 2015; 29:58-66. [PMID: 26602063 DOI: 10.1177/0897190015615894] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advanced heart failure therapy has been revolutionized with the advent of continuous-flow ventricular assist devices (CF-LVADs) which have improved both survival and quality of life. Despite this, support with CF-LVADs is frequently complicated, with 70% of recipients experiencing a major complication in the first year of durable support. The most concerning of these complications to emerge is device-related thrombosis, which is associated with increased morbidity and mortality. Pathophysiology and diagnosis are multifaceted and complex, with pump-specific and patient-specific factors to be considered. Incidence estimates are evolving with increases seen in the past 2 years compared with earlier implant data. Evidence for treatment is limited to case series and reports, which are subject to significant publication bias. Finally, appropriate primary and secondary prophylaxis is imprecise with multiple antiplatelet and antithrombotic strategies described. This review seeks to summarize the current literature surrounding the pathophysiology, diagnosis, and management of thrombosis in CF-LVAD recipients.
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Affiliation(s)
| | - Douglas L Jennings
- Department of Pharmacy, New York Presbyterian Hospital, New York, New York USA
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