1
|
Inglis SS, Asleh R, Iyer VN, Schettle SD, Spencer PJ, Villavicencio MA, Rodeheffer RJ, Kushwaha SS, Behfar A, Rosenbaum AN. Inhibition of angiogenesis in the management of refractory gastrointestinal bleeding in patients with LVAD support. Artif Organs 2024; 48:646-654. [PMID: 38131635 DOI: 10.1111/aor.14694] [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: 09/16/2023] [Revised: 11/09/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) in patients with continuous flow left ventricular assist devices (CF-LVADs) is often related to GI angiodysplasia (GIAD). We previously reported data on VEGF inhibition with IV bevacizumab in the treatment of LVAD-associated GIAD bleeding, and now present follow-up data on patients treated with IV bevacizumab and/or low-dose oral pazopanib. METHODS All consecutive adult patients with LVAD-associated GIB from GIAD treated with bevacizumab or pazopanib, from July 20, 2017 to June 22, 2022, were included in the analysis. Data on hospitalizations, GI endoscopic procedures, and blood transfusions were obtained from first admission for GIB up to a median of 35.7 months following treatment initiation (range 1.3-59.8 months). RESULTS Eleven patients (91% male, mean 69.5 ± 8.9 years) were included. Eight patients (73%) received IV bevacizumab, two patients (18%) received oral pazopanib, and one patient (9%) received bevacizumab followed by pazopanib therapy. We observed a significantly decreased number of annualized hospitalizations for GIB (median difference - 2.87, p = 0.002), blood transfusions (median difference - 20.9, p = 0.01), and endoscopies (median difference - 6.95, p = 0.007) in patients pre- and post-anti-angiogenic therapy (bevacizumab and/or pazopanib). Similarly, a significant improvement in these clinical outcomes was noted in the bevacizumab group with decreased annualized hospitalizations (median difference - 2.75, p = 0.014), blood transfusions (median difference - 24.5, p = 0.047), and number of endoscopies (median differences -6.88, p = 0.006). CONCLUSION Anti-angiogenic therapy with IV bevacizumab and/or low-dose oral pazopanib appears to provide benefits in patients with LVAD-associated GIB with reduced hospitalizations, blood transfusions, and need for GI endoscopic procedures.
Collapse
Affiliation(s)
- Sara S Inglis
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Rabea Asleh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vivek N Iyer
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Atta Behfar
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew N Rosenbaum
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
2
|
Nishimura T, Toda K, Ako J, Hirayama A, Kinugawa K, Kobayashi Y, Ono M, Sato N, Shindo T, Shiose A, Takayama M, Yasukochi S, Sawa Y. Prevalence of bleeding events in real-world Japanese registry for Percutaneous Ventricular Assist Device. J Artif Organs 2024:10.1007/s10047-023-01429-5. [PMID: 38396197 DOI: 10.1007/s10047-023-01429-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/14/2023] [Indexed: 02/25/2024]
Abstract
PURPOSE Bleeding complication is a critical risk factor for outcomes of acute heart failure patients requiring mechanical circulatory support (MCS), including percutaneous catheter-type heart pumps (Impella). The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) is an ongoing, large-scale, real-world registry to characterize Japanese patients requiring Impella. Here we analyzed bleeding complication profiles in patients who received Impella. METHODS All consecutive Japanese patients who received Impella from October 2017 to January 2020 were enrolled. The 30-day survival and bleeding complications were analyzed. RESULTS A total of 1344 patients were included: 653 patients received Impella alone, 685 patients received a combination of veno-arterial extracorporeal membrane oxygenation and Impella (ECPELLA), and 6 patients had failed Impella delivery. Overall 30-day survival was 67.0%, with Impella alone at 81.9% and ECPELLA at 52.7%. Overall bleeding/hematoma adverse events with a relation or not-excluded relation to Impella was 6.92%. Among them, the rates of hematoma and bleeding from medical device access sites were 1.41% and 4.09%, respectively. There was no difference between etiologies for these events. CONCLUSION This study represents the first 3-year survival and the safety profile focused on bleeding adverse events from the J-PVAD registry. The results show that the real-world frequency of bleeding adverse events for patients who received Impella was an expected range from previous reports, and future real-world studies should aim to expand this data set to improve outcomes and adverse events.
Collapse
Affiliation(s)
- Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Ehime University, Ehime, Japan.
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, School of Medicine, Kitasato University, Kanagawa, Japan
| | | | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Naoki Sato
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Takahiro Shindo
- Division of Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medicine, Fukuoka, Japan
| | - Morimasa Takayama
- Department of Cardiovascular Internal Medicine, Sakakibara Heart Institute, Tokyo, Japan
| | - Satoshi Yasukochi
- Department of Pediatric Cardiology, Nagano Children's Hospital, Nagano, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
3
|
Falland R, Allen S. Perioperative management of patients with a ventricular assist device undergoing non-cardiac surgery. BJA Educ 2023; 23:406-413. [PMID: 37720560 PMCID: PMC10501881 DOI: 10.1016/j.bjae.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 09/19/2023] Open
Affiliation(s)
- R. Falland
- Royal Adelaide Hospital, Adelaide, Australia
| | - S.J. Allen
- Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
4
|
Del Rio-Pertuz G, Nair N. Gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices: A comprehensive review. Artif Organs 2023; 47:12-23. [PMID: 36334280 DOI: 10.1111/aor.14432] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/05/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Gastrointestinal bleeding is a major cause of morbidity that plagues the quality of life of patients supported on contemporary continuous-flow left ventricular assist devices (CF-LVADs). Despite benefits in survival and the nearly 50% reduction in complications provided by CF-LVADs, bleeding remains one of the most frequent adverse events with CF-LVAD implants. The CF-LVADs cause an increased risk of bleeding mainly due to the activation of the coagulation cascade. METHODS A literature search was done using PubMed and Google Scholar from Inception to February 2022. Qualitative analyses of the articles retrieved were used to construct this review. This review attempts to provide a comprehensive summary of the epidemiology, pathophysiology, risk stratification, and management of gastrointestinal bleeding as a complication of CF-LVAD as well as propose an algorithm for diagnosis and treatment. RESULTS Bleeding can occur at different sites in the gastrointestinal tract, the most common underlying pathology being arteriovenous malformations located in the upper gastrointestinal tract The increased prevalence of gastrointestinal (GI) bleeding in CF-LVAD patients has been attributed to the physiology of the LVAD itself, the use of anticoagulants, as well as patient comorbidities. Management involves pharmacologic and nonpharmacologic strategies. CONCLUSIONS CF-LVAD-supported patients have a significant risk of GI bleeding that is mainly caused by arteriovenous malformations located in the upper GI tract. The increased prevalence of GI bleeding in CF-LVAD patients is attributed to several etiologies that include factors attributed to the device itself and extrinsic factors such as the use of anticoagulation.
Collapse
Affiliation(s)
- Gaspar Del Rio-Pertuz
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Nandini Nair
- Division of Cardiology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| |
Collapse
|
5
|
Abbasi MA, Stoller DA, Lyden E, Lowes BD, Zolty R, Lundgren SW. Impact of digoxin utilization on clinical outcomes following left ventricular assist device implantation. Int J Artif Organs 2022; 45:919-926. [PMID: 35945816 DOI: 10.1177/03913988221112684] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We aimed to assess the impact of digoxin use following left ventricular assist device (LVAD) implantation on clinical outcomes. METHODS Patients implanted with continuous flow LVADs at a single academic medical center and survived to initial hospital discharge were included in the analysis (n = 346). Clinical events were captured at a maximum of 2 years of follow up. Digoxin use was defined as 30-day continuous use post-LVAD. Negative binomial regression and Kaplan-Meier method were used to assess the association between digoxin use and clinical outcomes. RESULTS Mean age of the cohort was 56 years (±13) and 23% (79/346) were female sex. Digoxin was used in 144 patients (41.6%) for a median of 268 days (IQR 154, 616). Digoxin use was associated with a significant reduction in cumulative incidence of gastrointestinal bleeding (GIB) (15% vs 26%, p = 0.004). After adjusting for age, hypertension, post-operative hemoglobin, RDW, potassium, and GFR, and use of angiotensin receptor/neprilysin inhibitor, there remained a significant 47% reduction in GIB incidence in patients treated with digoxin. There was no significant difference in cumulative incidence in right ventricular failure (RVF) between the two groups. There was no difference in overall 2-year survival between groups. CONCLUSIONS Digoxin use was associated with reduction in GIB events, but not in RVF or mortality. Further studies are needed to confirm these findings and to investigate optimal timing and patient population.
Collapse
Affiliation(s)
- Muhannad Aboud Abbasi
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Douglas A Stoller
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth Lyden
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Brian D Lowes
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ronald Zolty
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Scott W Lundgren
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
6
|
Abdelilah-Seyfried S, Iruela-Arispe ML, Penninger JM, Tournier-Lasserve E, Vikkula M, Cleaver O. Recalibrating vascular malformations and mechanotransduction by pharmacological intervention. J Clin Invest 2022; 132:160227. [PMID: 35426368 PMCID: PMC9012280 DOI: 10.1172/jci160227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
| | - M. Luisa Iruela-Arispe
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Josef M. Penninger
- Department of Medical Genetics, Life Sciences Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elisabeth Tournier-Lasserve
- INSERM UMR 1141 Neurodiderot, University of Paris, Paris, France
- AP-HP, Department of Genetics of Neurovascular Diseases, Hôpital Saint-Louis, Paris, France
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, Brussels, Belgium
| | - Ondine Cleaver
- Department of Molecular Biology, UT Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
7
|
McMullen L, Barker K, Fried J, Wagener G. Clinical considerations for the evaluation of patients with left ventricular assist devices. JAAPA 2022; 35:37-42. [PMID: 34939589 DOI: 10.1097/01.jaa.0000803636.43190.eb] [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: 11/25/2022]
Abstract
ABSTRACT A left ventricular assist device (LVAD) provides mechanical circulatory support for patients with end-stage heart failure. As these devices become more prevalent, clinicians must be familiar with the device's function, common complications, and management strategies when evaluating this patient population.
Collapse
Affiliation(s)
- Leah McMullen
- At Columbia University Medical Center in New York, N.Y., Leah McMullen and Kelly Barker practice in the cardiothoracic ICU. Justin Fried is an assistant professor of medicine in the division of cardiology at Columbia University Medical Center. Gebhard Wagener is a professor of anesthesiology at Columbia University Medical Center and chief of the division of vascular anesthesiology. The authors have disclosed no potential conflicts of interest, financial or otherwise
| | | | | | | |
Collapse
|
8
|
Goltstein LCMJ, Grooteman KV, Rocco A, Holleran G, Frago S, Salgueiro PS, Aparicio T, Scaglione G, Chetcuti Zammit S, Prados-Manzano R, Benamouzig R, Nardone G, McNamara D, Benallaoua M, Michopoulos S, Sidhu R, Kievit W, Drenth JPH, van Geenen EJM. Effectiveness and predictors of response to somatostatin analogues in patients with gastrointestinal angiodysplasias: a systematic review and individual patient data meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:922-932. [PMID: 34508668 DOI: 10.1016/s2468-1253(21)00262-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrointestinal angiodysplasias are vascular malformations that often cause red blood cell transfusion-dependent anaemia. Several studies suggest that somatostatin analogues might decrease rebleeding rates, but the true effect size is unknown. We therefore aimed to investigate the efficacy of somatostatin analogues on red blood cell transfusion requirements of patients with gastrointestinal angiodysplasias and to identify subgroups that might benefit the most from somatostatin analogue therapy. METHODS We did a systematic review and individual patient data meta-analysis. We searched MEDLINE, Embase, and Cochrane on Jan 15, 2016, with an updated search on April 25, 2021. All published randomised controlled trials and cohort studies that reported on somatostatin analogue therapy in patients with gastrointestinal angiodysplasias were eligible for screening. We excluded studies without original patient data, single case reports, small case series (ie, <10 participants), studies in which patients had a specific aetiology of gastrointestinal angiodysplasias, and studies in which somatostatin analogue therapy was initiated simultaneously with other treatment modalities. Authors of eligible studies were invited to share individual patient data. Aggregated data was used if individual patient data were not provided. The primary outcome was the mean reduction in the number of red blood cell transfusions during somatostatin analogue therapy, compared with baseline, expressed as the incidence rate ratio (IRR) and absolute mean decrease. We defined patients as either good responders (≥50% reduction in the number of red blood cell transfusions) or poor responders (<50% reduction). A mixed-effects negative binomial regression was used to account for clustering of patients and skewness in data. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42020213985. FINDINGS We identified 11 eligible studies (one randomised controlled trial and ten cohort studies) of moderate-to-high quality and obtained individual patient data from the authors of nine (82%) studies. The remaining two (18%) studies provided sufficient information in the published manuscript to extract individual patient data. In total, we analysed data from 212 patients. Somatostatin analogues reduced the number of red blood cell transfusions with an IRR of 0·18 (95% CI 0·14-0·24; p<0·0001) during a median treatment duration of 12 months (IQR 6·0-12·0) and follow-up period of 12 months (12·0-12·0), correlating with a mean absolute decrease in the number of red blood cell transfusions from 12·8 (95% CI 10·4-15·8) during baseline to 2·3 (1·9-2·9) during follow-up-ie, a reduction of 10·5 red blood cell transfusions (p<0·0001). 177 (83%) of 212 patients had a good response to somatostatin analogue therapy (defined as at least a 50% reduction in the number of red blood cell transfusions). Heterogeneity across studies was moderate (I2=53%; p=0·02). Location of gastrointestinal angiodysplasias in the stomach compared with angiodysplasias in the small bowel and colon (IRR interaction 1·92 [95% CI 1·13-3·26]; p=0·02) was associated with worse treatment response. Octreotide was associated with a better treatment response than lanreotide therapy (IRR interaction 2·13 [95% CI 1·12-4·04]; p=0·02). The certainty of evidence was high for the randomised controlled trial and low for the ten cohort studies. Adverse events occurred in 38 (18%) of 212 patients receiving somatostatin analogue therapy, with ten (5%) discontinuing this therapy because of adverse events. The most common adverse events were loose stools (seven [3%] of 212), cholelithiasis (five [2%]), flatulence (four [2%]), and administration site reactions (erythema, five [2%]). INTERPRETATION Somatostatin analogue therapy is safe and effective in most patients with red blood cell transfusion-dependent bleeding due to gastrointestinal angiodysplasias. Somatostatin analogue therapy is more effective in patients with angiodysplasias located in the small bowel and colon, and octreotide therapy seems to be more effective than lanreotide therapy. FUNDING The Netherlands Organisation for Health Research and Development and the Radboud University Medical Center.
Collapse
Affiliation(s)
- Lia C M J Goltstein
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Karina V Grooteman
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University Federico II, Naples, Italy
| | - Grainne Holleran
- Department of Clinical Medicine, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Santiago Frago
- Department of Digestive Diseases, Miguel Servet University Hospital, Zaragoza, Spain
| | - Paulo S Salgueiro
- Gastroenterology Department, Centro Hospitalar Universitário do Porto-Hospital de Santo António, Porto, Portugal
| | - Thomas Aparicio
- Department of Gastroenterology, Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | | | | | - Raul Prados-Manzano
- Department of Gastroenterology, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Robert Benamouzig
- Department of Gastroenterology, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Bobigny, France
| | - Gerardo Nardone
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University Federico II, Naples, Italy
| | - Deirdre McNamara
- Department of Clinical Medicine, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Mourad Benallaoua
- Department of Gastroenterology, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Bobigny, France
| | | | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Wietske Kievit
- Radboud Institute for Health Science, Department of Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
9
|
Stern B, Maheshwari P, Gorrepati VS, Bethards D, Chintanaboina J, Boehmer J, Clarke K. Initial endoscopic intervention is not associated with reduced risk of recurrent gastrointestinal bleeding in left ventricular assist device patients. Ann Gastroenterol 2021; 34:660-668. [PMID: 34475736 PMCID: PMC8375646 DOI: 10.20524/aog.2021.0656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/23/2020] [Indexed: 11/11/2022] Open
Abstract
Background Left ventricular assist devices (LVADs) are increasingly used for mechanical support of end-stage heart failure. Gastrointestinal bleeding (GIB) confers a significant morbidity in LVAD patients, with rates of up to 30% at 5 years. We assessed predictors of index and recurrent GIB (rGIB) in LVAD patients to risk stratify patients and evaluate if endoscopic approach and intervention at index GIB impacted rGIB. Methods A retrospective chart review of all LVAD patients at our institution from 01/01/2006 to 31/10/2016 was completed. Predictors for index and recurrent GIB were analyzed. Multivariate logistic regression analysis was created using only statistically significant dependent variables and adjusted for demographic variables. Results A total of 77/214 (36%) patients developed GIB, and 38/214 (17.8%) developed rGIB. Destination therapy (P=0.01), longer duration of LVAD (P=0.03), and low albumin (<3.5 g/dL) (P<0.001) were associated with increased risk of index GIB. Charlson Comorbidity Index, heart failure etiology, and Medicare were predictors of index GIB on univariate analysis, but this was not seen on multivariate analysis. Performing an endoscopy with/without intervention, non- angioectasia lesions, and location of bleeding were not statistically significant predictors of rGIB. Longer duration of hospitalization appeared to be protective for rGIB on univariate analysis. Conclusions Index endoscopy and intervention is not associated with reduced risk of rGIB in LVAD patients. Several independent factors are associated with the risk of index GIB. Albumin is a potentially modifiable risk factor, and likely contributes to bleeding through poor nutrition. It is a surrogate marker for systemic illness, and may have pharmacologic implications.
Collapse
Affiliation(s)
- Benjamin Stern
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Benjamin Stern, Venkata S. Gorrepati, Deborah Bethards, Kofi Clarke)
| | - Parth Maheshwari
- Department of Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Parth Maheshwari)
| | - Venkata S Gorrepati
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Benjamin Stern, Venkata S. Gorrepati, Deborah Bethards, Kofi Clarke)
| | - Deborah Bethards
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Benjamin Stern, Venkata S. Gorrepati, Deborah Bethards, Kofi Clarke)
| | - Jayakrishna Chintanaboina
- Division of Gastroenterology, University of California San Francisco Fresno, Fresno, CA, USA (Jayakrishna Chintanaboina)
| | - John Boehmer
- Division of Cardiology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (John Boehmer)
| | - Kofi Clarke
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Benjamin Stern, Venkata S. Gorrepati, Deborah Bethards, Kofi Clarke)
| |
Collapse
|
10
|
El Rafei A, Trachtenberg BH, Schultz J, John R, Estep JD, Araujo-Gutierrez R, Suarez TEE, Goodwin K, Cogswell R. Association between digoxin use and gastrointestinal bleeding in contemporary continuous flow left ventricular assist device support. J Heart Lung Transplant 2021; 40:671-676. [PMID: 33875331 DOI: 10.1016/j.healun.2021.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/21/2021] [Accepted: 03/02/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Assess the association between digoxin use and gastrointestinal bleeding (GIB) in a multicenter continuous flow left ventricular assist device (LVAD) cohort. METHODS Patients implanted with continuous flow LVADs with data on GIB and digoxin use from two centers were included in the analysis (n = 649). GIB events were captured up to 2 years of follow-up. Digoxin use was defined as digoxin prescribed at discharge or within the first 3 months after LVAD implantation. A negative binomial regression model was performed to determine the association between digoxin use and number of GIB events over the follow-up period. RESULTS Mean age of the cohort was 57 years (±14) and 45% (293/649) were bridge to transplant (BTT). Digoxin was prescribed in 33% of patients. Digoxin use was associated with an unadjusted 32% reduction in the incidence of rate of all cause GIB (IRR 0.68, 95% CI 0.46-0.99, p = 0.049). After adjusting for age, sex, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, renal function, and implanting center there was still a 34% reduction in the incidence rate (IRR 0.67, 95% CI 0.45-0.99, p = 0.048). When limiting the analysis to those with likely arteriovenous malformation associated GIB, the association strengthened (unadjusted: IRR 0.48, 95 % CI 0.26-0.89, p = 0.02, adjusted: IRR 0.47, 95 % CI 0.25-0.9, p = 0.022). CONCLUSIONS In this multicenter study, inclusive of contemporary devices, digoxin use was associated with reduced GIB events. Prospective data will be required to confirm this association.
Collapse
Affiliation(s)
- Abdelghani El Rafei
- Department of Medicine, Division of Internal Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Barry H Trachtenberg
- Department of Heart Failure & Transplant Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Research Institute, Houston, Texas
| | - Jessica Schultz
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Ranjit John
- Department of Surgery, Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Jerry D Estep
- Department of Cardiovascular Medicine, Cleveland Clinic Sydell and Arnold Miller Family, Cleveland, Ohio
| | - Raquel Araujo-Gutierrez
- Department of Heart Failure & Transplant Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Research Institute, Houston, Texas
| | - T Eric E Suarez
- Department of Cardiovascular Surgery, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
| | - Kevin Goodwin
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - Rebecca Cogswell
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
11
|
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.
Collapse
|
12
|
Thalidomide Use Reduces Risk of Refractory Gastrointestinal Bleeding in Patients with Continuous Flow Left Ventricular Assist Devices. ASAIO J 2021; 66:645-651. [PMID: 31425265 DOI: 10.1097/mat.0000000000001054] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Gastrointestinal (GI) bleeding is a common complication seen in patients with implanted continuous flow left ventricular assist devices (CF-LVAD), often attributed to arteriovenous malformations (AVMs). Whether thalidomide reduces recurrent GI bleeding risk in CF-LVAD patients has been incompletely evaluated. We conducted a retrospective review of all CF-LVAD patients at our institution with GI bleeding from AVMs who had a trial both off and on thalidomide. The primary endpoint was time to rebleed, while secondary endpoints included overall GI bleeding events, packed red blood cell (PRBC) transfusion requirements, and adverse events related to thalidomide. We report on 24 patients with recurrent AVM-associated GI bleeding who met criteria for and received thalidomide therapy, of which 17 had sufficient follow-up to be ultimately included for final analysis. We found the risk of rebleeding was significantly reduced in those on thalidomide therapy versus off (hazard ratio = 0.23, p = 0.022). The median number of GI bleeds per year was reduced from 4.6 to 0.4 (p = 0.0008) and the PRBC requirement was lower (36.1 vs. 0.9 units per year, p = 0.004) in those on thalidomide therapy. The adverse event rate with thalidomide was 59%, with symptoms resolution in most following dose reduction without increased bleeding. Thalidomide reduced the risk of AVM-associated GI rebleeding, number of bleeding events, and PRBC requirements in CF-LVAD patients. When initiating therapy, potential side effects and overall clinical context should be considered.
Collapse
|
13
|
Kim YK, Balcetis N, Novitch R, Oh-park M. Risk factors of readmission to acute care hospital among individuals with heart failure and left ventricular assist device (LVAD) at inpatient rehabilitation setting (STROBE compliant article). Medicine (Baltimore) 2020; 99:e23618. [PMID: 33350737 PMCID: PMC7769323 DOI: 10.1097/md.0000000000023618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/10/2020] [Indexed: 11/25/2022] Open
Abstract
In post-acute care hospital setting, the heart failure (HF) individuals with left ventricular assist device (LVAD) have about 30% of transfer to acute care hospitals which requires readmission. There is relative increase in cost and mortality due to the readmission.The goal of this study is to identify possible risk factors at Inpatient Rehabilitation Unit (IRU) to decrease the rate of readmission to acute care hospitals.This study is retrospective study at the Inpatient Rehabilitation Unit (IRU)Twenty one individuals with HF and LVAD were admitted to IRU. We determined 2 subgroups. One is the readmission group (Readmission) and the other is the control group (Control). Readmission (n = 6) is the individuals who were transferred to acute care hospital, and Control (n = 15) is the individuals who were discharged.To compare Readmission group with Control group and evaluate demographic, laboratory, and functional outcome parameters. Main Outcome Measures are Body Mass Index (BMI), International Normalized Ratio (INR), and Functional independence measure (FIM).At admission, INR in Readmission group was 3.4 ± 1.2 and in Control group was 2.2 ± 0.5 with a statistically significant p value (P = .004) and FIM score in Readmission group was 81.2 ± 15.9 and in Control group was 96.3 ± 11.5 with a statistically significant p value (P = .023).The study showed the individuals with HF and LVAD at IRU had high INR and low FIM which may be the cause for readmission and need more attentive care. This data can help identify the factors causing readmission and help reduce the rate of readmission. Further evaluation is necessary to determine the cause for readmission.
Collapse
Affiliation(s)
- Yong Kyun Kim
- Department of Rehabilitation, Myongji Hospital, Hanyang University School of Medicine, Gyeonggi, Korea
| | | | | | | |
Collapse
|
14
|
Sidhu K, Lam PH, Mehra MR. Evolving trends in mechanical circulatory support: Clinical development of a fully magnetically levitated durable ventricular assist device. Trends Cardiovasc Med 2020; 30:223-229. [DOI: 10.1016/j.tcm.2019.05.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/29/2019] [Accepted: 05/29/2019] [Indexed: 12/17/2022]
|
15
|
Gustafsson F, Netuka I. Interplay of pump design elements and bleeding predilection-Mechanisms for a forward momentum. J Heart Lung Transplant 2019; 38:817-819. [PMID: 31352997 DOI: 10.1016/j.healun.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Finn Gustafsson
- Department of Cardiology and Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| |
Collapse
|
16
|
Left ventricular assist devices and their complications: A review for emergency clinicians. Am J Emerg Med 2019; 37:1562-1570. [PMID: 31072684 DOI: 10.1016/j.ajem.2019.04.050] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/25/2019] [Accepted: 04/28/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION End stage heart failure is associated with high mortality. However, recent developments such as the ventricular assist device (VAD) have improved patient outcomes, with left ventricular assist devices (LVAD) most commonly implanted. OBJECTIVE This narrative review evaluates LVAD epidemiology, indications, normal function and components, and the assessment and management of complications in the emergency department (ED). DISCUSSION The LVAD is a life-saving device in patients with severe heart failure. While first generation devices provided pulsatile flow, current LVAD devices produce continuous flow. Normal components include the pump, inflow and outflow cannulas, driveline, and external controller. Complications related to the LVAD can be divided into those that are LVAD-specific and LVAD-associated, and many of these complications can result in severe patient morbidity and mortality. LVAD-specific complications include device malfunction/failure, pump thrombosis, and suction event, while LVAD-associated complications include bleeding, cerebrovascular event, infection, right ventricular failure, dysrhythmia, and aortic regurgitation. Assessment of LVAD function, patient perfusion, and mean arterial pressure is needed upon presentation. Electrocardiogram and bedside ultrasound are key evaluations in the ED. LVAD evaluation and management require a team-based approach, and consultation with the LVAD specialist is recommended. CONCLUSION Emergency clinician knowledge of LVAD function, components, and complications is integral in optimizing care of these patients.
Collapse
|
17
|
Eisen HJ. Left Ventricular Assist Devices (LVADS): History, Clinical Application and Complications. Korean Circ J 2019; 49:568-585. [PMID: 31243930 PMCID: PMC6597447 DOI: 10.4070/kcj.2019.0161] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 12/17/2022] Open
Abstract
Congestive heart failure is a major cause of morbidity and mortality as well as a major health care cost in the developed world. Despite the introduction of highly effective heart failure medical therapies and simple devices such as cardiac resynchronization therapy that reduce mortality, improve cardiac function and quality of life, there remains a large number of patients who do not respond to these therapies or whose heart failure progresses despite optimal therapy. For these patients, cardiac transplantation is an option but is limited by donor availability as well as co-morbidities which may limit survival post-transplant. For these patients, left ventricular assist devices (LVADs) offer an alternative that can improve survival as well as exercise tolerance and quality of life. These devices have continued to improve as technology has improved with substantially improved durability of the devices and fewer post-implant complications. Pump thrombosis, stroke, gastrointestinal bleeding and arrhythmias post-implant have become less common with the newest devices, making destination therapy where ventricular assist device are implanted permanently in patients with advanced heart failure, a reality and an appropriate option for many patients. This may offer an opportunity for long term survival in many patients. As the first of the totally implantable devices are introduced and go to clinical trials, LVADs may be introduced that may truly be alternatives to cardiac transplantation in selected patients. Post-implant right ventricular failure remains a significant complication and better ways to identify patients at risk as well as to manage this complication must be developed.
Collapse
Affiliation(s)
- Howard J Eisen
- Heart and Vascular Institute, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA.
| |
Collapse
|