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Bews H, Jia S, Liu Y, Sklar J, Ducas J, Kirkpatrick I, Tam JW, Shah AH. High output cardiac state: evaluating the incidence, plausible etiologies and outcomes. Curr Probl Cardiol 2024; 49:102561. [PMID: 38599560 DOI: 10.1016/j.cpcardiol.2024.102561] [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: 03/27/2024] [Accepted: 04/07/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION The high output cardiac state (HOCS) [cardiac index (CI) >4 L/min/m2 ], primarily driven by abnormally low systemic vascular resistance (SVR), is a relatively under-recognized condition. Although, majority of these patients meet criteria for heart failure (HF), their treatment should be aimed at the primary pathology, as the majority of guideline directed HF therapies can reduce SVR further. OBJECTIVES To characterize patients with HOCS and provide valuable insight into the condition. METHODS Patients investigated by right heart catheterization (RHC) at the St. Boniface Hospital, Winnipeg, Canada between January 2009 and November 2021 were reviewed. Two groups of patients were included: 1) HOCS [CI >4 L/min/m2], and 2) pre-HOCS [CI between 3.8-4.0 L/min/m2]. Their medical records were reviewed to identify plausible etiologies, relevant investigations, and outcomes. RESULTS 177/2950 (6 %) patients met criteria for inclusion: 144/177 (81 %) with HOCS [mean age 51 years (range 19 - 82); 67/144 (47 %) female] and 33/177 (19 %) with pre-HOCS [mean age 55 years (range 30 - 83); 6/33 (18 %) female]. The most common plausible etiologies for the HOCS included anemia (36 %), obesity (34 %), cirrhosis (17 %), and lung disease (32 %). Trans-thoracic echocardiography and magnetic resonance imaging findings were non-specific and predominantly described preserved left ventricular ejection fraction, and pulmonary hypertension. The population experienced high rates of hospitalization, and significantly high mortality [36/144 (25 %) of HOCS at a median follow-up of 31.5 months, and 13/33 (39 %) of pre-HOCS at a median follow-up of 17 months]. CONCLUSIONS HOCS is not an uncommon condition and is associated with high mortality. Current HF guideline should incorporate such evaluation into the diagnostic criteria.
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Affiliation(s)
- Hilary Bews
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sangyang Jia
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Yixiu Liu
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jaime Sklar
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Ducas
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Iain Kirkpatrick
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James W Tam
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ashish H Shah
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
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Mohamed WT, Jahagirdar V, Jaber F, Ahmed MK, Ghoz HM, Sperry BW, Clarkston WK. Pre- and Post-Implant Endoscopy in Left Ventricular Assist Device Recipients: A Single-Center Experience. Gastroenterology Res 2024; 17:1-9. [PMID: 38463148 PMCID: PMC10923248 DOI: 10.14740/gr1661] [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: 07/26/2023] [Accepted: 01/04/2024] [Indexed: 03/12/2024] Open
Abstract
Background Gastrointestinal bleeding (GIB) is common in left ventricular assist devices (LVADs) patients, but the optimal screening approach before LVAD implantation is still unclear. The aim of the study was to describe our experience with pre- and post-LVAD implantation endoscopic screening and subsequent GI bleeding in this cohort. Methods A retrospective review was conducted among all patients who underwent LVAD implantation at Saint Luke's Hospital, between 2010 and 2020. The data were reviewed to determine the yield and safety of endoscopic procedures performed within 1 month before LVAD placement and the incidence of GIB within 1 year after implantation. Results A total of 167 LVAD patients met the inclusion criteria, and 23 underwent pre-implantation endoscopic evaluation. Angiodysplasia had a significantly higher odds ratio (OR) of 9.41 (95% confidence interval (CI): 2.01 - 44.09) in post-LVAD endoscopy, while there was no significant difference in bleeding from other sources such as peptic ulcer disease or diverticular bleeding. There was no difference in the incidence of GIB in patients who underwent endoscopic evaluation pre-LVAD compared to post-LVAD GIB (32.6% vs. 39.1%, P = 0.64). Endoscopy was well-tolerated in this cohort, and argon plasma coagulation was the most commonly used intervention to achieve hemostasis. Conclusions According to our results, we recommend against routine pre-LVAD endoscopic screening. Instead, we suggest an individualized approach, where decisions are made on a case-by-case basis.
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Affiliation(s)
- Wael T. Mohamed
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Vinay Jahagirdar
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Mohamed K. Ahmed
- Division of Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Hassan M. Ghoz
- Division of Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Brett W. Sperry
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Wendell K. Clarkston
- Division of Gastroenterology, University of Missouri-Kansas City, Kansas City, MO, USA
- Division of Gastroenterology, Saint Luke’s Hospital, Kansas City, MO, USA
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Kominami K, Akino M. Partial Pressure of End-Tidal Oxygen and Blood Lactate During Cardiopulmonary Exercise Testing in Healthy Older Participants and Patients at Risk of Cardiac Disease. Cardiol Res 2024; 15:29-36. [PMID: 38464709 PMCID: PMC10923256 DOI: 10.14740/cr1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/03/2024] [Indexed: 03/12/2024] Open
Abstract
Background The partial pressure of end-tidal oxygen (PETO2) and end-tidal oxygen concentration (ETO2) are among the indices that can be measured by exhaled gas analysis. Several observational studies have shown that skeletal muscle function is impaired in patients with cardiac disease; thus, the assessment of skeletal muscle function is important. Additionally, although it has recently been suggested that the difference in PETO2 from rest to the ventilatory anaerobic threshold (VAT) reflects oxygen availability in peripheral factors, primarily skeletal muscle, the evidence for this is not well established. Therefore, we hypothesized and investigated whether increased blood lactate (BLa) levels, resulting from decreased skeletal muscle and mitochondrial oxygen availability, and PETO2 dynamics during cardiopulmonary exercise testing (CPET) would be related. Methods All participants performed the symptomatic limited CPET, and their BLa levels were measured. The difference in PETO2 and ETO2 from rest to VAT determined by the V-slope method (ΔPETO2 and ΔETO2) was calculated and compared with the increase in BLa due to exercise testing. Results We recruited 22 healthy older participants (nine males; 69.4 ± 6.8 years) and 11 patients with cardiovascular risk (eight males; 73.0 ± 8.8 years). ΔPETO2 and ΔETO2 did not differ between the two groups (P = 0.355 and P = 0.369, respectively), showing no correlation between increase in BLa from rest to VAT, but were significantly correlated with an increase in BLa from rest to the end of exercise (ΔPETO2, P = 0.030; ΔETO2, P = 0.029). The correlation was particularly pronounced among those at cardiovascular risk (ΔPETO2, P = 0.012; ΔETO2, P = 0.011). Conclusions ΔPETO2 and ΔETO2 from rest to VAT during CPET may be useful as indices reflecting skeletal muscle oxygen utilization capacity.
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Affiliation(s)
- Kazuyuki Kominami
- Department of Rehabilitation, Sanseikai Kitano Hospital, 6-30, 1- chome, Kitano 1-jyo, Kiyota-ku, Sapporo, Hokkaido 004-0861, Japan
| | - Masatoshi Akino
- Department of Internal Medicine, Sapporo Kiyota Hospital, 1-1, 1-chome, Shin-ei 1-jyo, Kiyota-ku, Sapporo, Hokkaido 004-0831, Japan
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(Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology). COR ET VASA 2022. [DOI: 10.33678/cor.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Ono M, Yamaguchi O, Ohtani T, Kinugawa K, Saiki Y, Sawa Y, Shiose A, Tsutsui H, Fukushima N, Matsumiya G, Yanase M, Yamazaki K, Yamamoto K, Akiyama M, Imamura T, Iwasaki K, Endo M, Ohnishi Y, Okumura T, Kashiwa K, Kinoshita O, Kubota K, Seguchi O, Toda K, Nishioka H, Nishinaka T, Nishimura T, Hashimoto T, Hatano M, Higashi H, Higo T, Fujino T, Hori Y, Miyoshi T, Yamanaka M, Ohno T, Kimura T, Kyo S, Sakata Y, Nakatani T. JCS/JSCVS/JATS/JSVS 2021 Guideline on Implantable Left Ventricular Assist Device for Patients With Advanced Heart Failure. Circ J 2022; 86:1024-1058. [PMID: 35387921 DOI: 10.1253/circj.cj-21-0880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, Faculty of Medicine, University of Toyama
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Akira Shiose
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Kenji Yamazaki
- Advanced Medical Research Institute, Hokkaido Cardiovascular Hospital
| | - Kazuhiro Yamamoto
- Department of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | - Masatoshi Akiyama
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Teruhiko Imamura
- Second Department of Internal Medicine, Faculty of Medicine, University of Toyama
| | - Kiyotaka Iwasaki
- Cooperative Major in Advanced Biomedical Sciences, Graduate School of Advanced Science and Engineering, Waseda University
| | - Miyoko Endo
- Department of Nursing, The University of Tokyo Hospital
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Koichi Kashiwa
- Department of Medical Engineering, The University of Tokyo Hospital
| | - Osamu Kinoshita
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | - Kaori Kubota
- Department of Transplantation Medicine, Osaka University Graduate School of Medicine
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Hiroshi Nishioka
- Department of Clinical Engineering, National Cerebral and Cardiovascular Center
| | - Tomohiro Nishinaka
- Department of Artificial Organs, National Cerebral and Cardiovascular Center
| | - Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Ehime University Hospital
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Masaru Hatano
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | - Taiki Higo
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Takeo Fujino
- Department of Cardiovascular Medicine, Kyushu University Hospital
| | - Yumiko Hori
- Department of Nursing and Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | | | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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Ahmed MM, Meece LE, Handberg EM, Pepine CJ. Intravenous administration of umbilical cord lining stem cells in left ventricular assist device recipient: Rationale and design of the uSTOP LVAD BLEED pilot study. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 16:100142. [PMID: 38559284 PMCID: PMC10976302 DOI: 10.1016/j.ahjo.2022.100142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 04/04/2024]
Abstract
Background Left ventricular assist device (LVAD) implantation provides a robust survival advantage, however despite improvements in mortality, the adverse event burden of durable mechanical circulatory support remains high. Bleeding complications are one such significant complication. The uSTOP LVAD BLEED (Utilization of umbilical cord lining Stem cells TO Prevent LVAD associated angiodysplastic BLEEDing) pilot study is designed to evaluate the safety and tolerability of escalating doses of umbilical cord lining stem cells (ULSCs) in LVAD recipients to ameliorate the dysregulation of angiogenic factors seen in this population. Design This Phase Ia single-ascending dose pilot study will evaluate the IV administration of ULSCs in stable out-patients supported with an LVAD. In a 3 + 3 design, a maximum of 18 patients will receive an IV infusion of ULSCs. Main outcome measures The primary endpoints are safety and tolerability, secondary exploratory endpoints will include biomarker evaluation of angiogenic dysregulation. Summary This represents a novel cell type and route of administration in this population, while collecting initial data regarding the magnitude and duration of effects of cell therapy, and assessing the possibility of decreasing bleeding by a strategy of vascular stabilization. Clinical trial registration ClinicalTrials.gov Identifier: NCT04811261. https://clinicaltrials.gov/ct2/show/NCT04811261.
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Affiliation(s)
- Mustafa M. Ahmed
- University of Florida, Division of Cardiovascular Medicine, Gainesville, FL, United States of America
| | - Lauren E. Meece
- University of Florida, Division of Cardiovascular Medicine, Gainesville, FL, United States of America
| | - Eileen M. Handberg
- University of Florida, Division of Cardiovascular Medicine, Gainesville, FL, United States of America
| | - Carl J. Pepine
- University of Florida, Division of Cardiovascular Medicine, Gainesville, FL, United States of America
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Nascimbene A, Dong JF. Hydrodynamic Impact on Blood: From Left Ventricular Assist Devices to Artificial Hearts. Arterioscler Thromb Vasc Biol 2022; 42:481-483. [PMID: 35236108 PMCID: PMC8957568 DOI: 10.1161/atvbaha.122.317517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Angelo Nascimbene
- Center for Advanced Heart Failure, Health Science Center at Houston, University of Texas, Houston (A.N.)
| | - Jing-Fei Dong
- BloodWorks Northwest Research Institute, Seattle, WA (J.-f.D.)
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle (J.-f.D.)
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Yang M, Houck KL, Dong X, Hernandez M, Wang Y, Nathan SS, Wu X, Afshar-Kharghan V, Fu X, Cruz MA, Zhang J, Nascimbene A, Dong JF. Hyperadhesive von Willebrand Factor Promotes Extracellular Vesicle-Induced Angiogenesis: Implication for LVAD-Induced Bleeding. JACC Basic Transl Sci 2022; 7:247-261. [PMID: 35411318 PMCID: PMC8993768 DOI: 10.1016/j.jacbts.2021.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 11/22/2022]
Abstract
VWF in patients on LVAD supports was hyperadhesive, activated platelets, and generated platelet-derived extracellular vesicles. Extracellular vesicles from LVAD patients and those from shear-activated platelets promoted aberrant angiogenesis in a VWF-dependent manner. The activated VWF exposed the A1 domain through the synergistic actions of oxidative stress and HSS generated in LVAD-driven circulation.
Bleeding associated with left ventricular assist device (LVAD) implantation has been attributed to the loss of large von Willebrand factor (VWF) multimers to excessive cleavage by ADAMTS-13, but this mechanism is not fully supported by the current evidence. We analyzed VWF reactivity in longitudinal samples from LVAD patients and studied normal VWF and platelets exposed to high shear stress to show that VWF became hyperadhesive in LVAD patients to induce platelet microvesiculation. Platelet microvesicles activated endothelial cells, induced vascular permeability, and promoted angiogenesis in a VWF-dependent manner. Our findings suggest that LVAD-driven high shear stress primarily activates VWF, rather than inducing cleavage in the majority of patients.
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Key Words
- ADAMTS-13:Ag, ADAMTS-13 antigen
- AVS, aortic vascular segment
- EC, endothelial cell
- EV, extracellular vesicle
- EVFP, extracellular vesicle–free plasma
- GI, gastrointestinal
- GOF, gain of function
- GP, glycoprotein
- GPM, growth factor-poor medium
- GRM, growth factor-rich medium
- HSS, high shear stress
- LVAD, left ventricular assist device
- PS, phosphatidylserine
- SIPA, shear-induced platelet aggregation
- ULVWF, ultra-large von Willebrand factor
- VEGF, vascular endothelial growth factor
- VWF, von Willebrand factor
- VWF:Ag, von Willebrand factor antigen
- VWF:CB, von Willebrand factor binding to collagen
- VWF:pp, von Willebrand factor propeptide
- aVWS, acquired von Willebrand syndrome
- angiogenesis
- extracellular vesicles
- left ventricular assist devices
- pEV, extracellular vesicle from von Willebrand factor-activated platelets
- platelets
- shear stress
- von Willebrand factor
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Affiliation(s)
- Mengchen Yang
- Bloodworks Research Institute, Seattle, Washington, USA.,Department of Urology, Tianjin Medical University General Hospital, Tianjin, China
| | - Katie L Houck
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Xinlong Dong
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Maria Hernandez
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
| | - Yi Wang
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Sriram S Nathan
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
| | - Xiaoping Wu
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vahid Afshar-Kharghan
- Division of Internal Medicine, Department of Pulmonary Medicine, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Xiaoyun Fu
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Miguel A Cruz
- Cardiovascular Research Section, Department of Medicine, Baylor College of Medicine.,Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Angelo Nascimbene
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, Washington, USA.,Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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Efficacy of Pulsatile Flow Perfusion in Adult Cardiac Surgery: Hemodynamic Energy and Vascular Reactivity. J Clin Med 2021; 10:jcm10245934. [PMID: 34945230 PMCID: PMC8703987 DOI: 10.3390/jcm10245934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The role of pulsatile (PP) versus non-pulsatile (NP) flow during a cardiopulmonary bypass (CPB) is still debated. This study’s aim was to analyze hemodynamic effects, endothelial reactivity and erythrocytes response during a CPB with PP or NP. Methods: Fifty-two patients undergoing an aortic valve replacement were prospectively randomized for surgery with either PP or NP flow. Pulsatility was evaluated in terms of energy equivalent pressure (EEP) and surplus hemodynamic energy (SHE). Systemic (SVRi) and pulmonary (PVRi) vascular resistances, endothelial markers levels and erythrocyte nitric-oxide synthase (eNOS) activity were collected at different perioperative time-points. Results: In the PP group, the resultant EEP was 7.3% higher than the mean arterial pressure (MAP), which corresponded to 5150 ± 2291 ergs/cm3 of SHE. In the NP group, the EEP and MAP were equal; no SHE was produced. The PP group showed lower SVRi during clamp-time (p = 0.06) and lower PVRi after protamine administration and during first postoperative hours (p = 0.02). Lower SVRi required a higher dosage of norepinephrine in the PP group (p = 0.02). Erythrocyte eNOS activity results were higher in the PP patients (p = 0.04). Renal function was better preserved in the PP group (p = 0.001), whereas other perioperative variables were comparable between the groups. Conclusions: A PP flow during a CPB results in significantly lower SVRi, PVRi and increased eNOS production. The clinical impact of increased perioperative vasopressor requirements in the PP group deserves further evaluation.
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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.
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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)
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12
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Dlouha D, Ivak P, Netuka I, Benesova S, Tucanova Z, Hubacek JA. An Integrative Study of Aortic mRNA/miRNA Longitudinal Changes in Long-Term LVAD Support. Int J Mol Sci 2021; 22:ijms22147414. [PMID: 34299034 PMCID: PMC8303892 DOI: 10.3390/ijms22147414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/27/2021] [Accepted: 07/07/2021] [Indexed: 12/16/2022] Open
Abstract
Studying the long-term impact of continuous-flow left ventricular assist device (CF-LVAD) offers an opportunity for a complex understanding of the pathophysiology of vascular changes in aortic tissue in response to a nonphysiological blood flow pattern. Our study aimed to analyze aortic mRNA/miRNA expression changes in response to long-term LVAD support. Paired aortic samples obtained at the time of LVAD implantation and at the time of heart transplantation were examined for mRNA/miRNA profiling. The number of differentially expressed genes (Pcorr < 0.05) shared between samples before and after LVAD support was 277. The whole miRNome profile revealed 69 differentially expressed miRNAs (Pcorr < 0.05). Gene ontology (GO) analysis identified that LVAD predominantly influenced genes involved in the extracellular matrix and collagen fibril organization. Integrated mRNA/miRNA analysis revealed that potential targets of miRNAs dysregulated in explanted samples are mainly involved in GO biological process terms related to dendritic spine organization, neuron projection organization, and cell junction assembly and organization. We found differentially expressed genes participating in vascular tissue engineering as a consequence of LVAD duration. Changes in aortic miRNA levels demonstrated an effect on molecular processes involved in angiogenesis.
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Affiliation(s)
- Dana Dlouha
- Experimental Medicine Centre, Institute for Clinical and Experimental Medicine, 140 21 Prague, Czech Republic;
- Correspondence: ; Tel.: +420-261-362-229
| | - Peter Ivak
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, 140 21 Prague, Czech Republic; (P.I.); (I.N.); (Z.T.)
- Department of Physiology, 3rd Faculty of Medicine, Charles University, 100 00 Prague, Czech Republic
- Second Department of Surgery, Department of Cardiovascular Surgery, 1st Faculty of Medicine, Charles University, 121 08 Prague, Czech Republic
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, 140 21 Prague, Czech Republic; (P.I.); (I.N.); (Z.T.)
- Second Department of Surgery, Department of Cardiovascular Surgery, 1st Faculty of Medicine, Charles University, 121 08 Prague, Czech Republic
| | - Sarka Benesova
- Laboratory of Informatics and Chemistry, Faculty of Chemical Technology, University of Chemistry and Technology, 166 28 Prague, Czech Republic;
- Laboratory of Gene Expression, Institute of Biotechnology CAS, BIOCEV, 252 50 Vestec, Czech Republic
| | - Zuzana Tucanova
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, 140 21 Prague, Czech Republic; (P.I.); (I.N.); (Z.T.)
| | - Jaroslav A. Hubacek
- Experimental Medicine Centre, Institute for Clinical and Experimental Medicine, 140 21 Prague, Czech Republic;
- 3rd Department of Internal Medicine, 1st Faculty of Medicine, Charles University, 121 08 Prague, Czech Republic
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13
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Schaeffer T, Pfister O, Mork C, Mohacsi P, Rueter F, Scheifele S, Morgen A, Zenklusen U, Doebele T, Maurer M, Erb J, Fassl J, Cueni N, Siegemund M, Pargger H, Gahl B, Osswald S, Eckstein F, Grapow M. 5-year results of a newly implemented mechanical circulatory support program for terminal heart failure patients in a Swiss non-cardiac transplant university hospital. J Cardiothorac Surg 2021; 16:64. [PMID: 33789723 PMCID: PMC8011141 DOI: 10.1186/s13019-021-01447-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/19/2021] [Indexed: 11/18/2022] Open
Abstract
Background In Switzerland, long-term circulatory support programs have been limited to heart transplant centers. In 2014, to improve the management of patients with end-stage heart failure not eligible for transplantation, we implemented a left ventricular assist device (LVAD) program for destination therapy at the University Hospital of Basel. Methods We described the program set-up with practical aspects. Patients aged 65 and above with therapy refractory end-stage heart failure without major contraindication for LVAD implantation were included. Younger patients with bridge-to-candidacy profile were also considered. Using the Kaplan-Meier estimate, we retrospectively analyzed the overall survival and freedom from major adverse events after LVAD implantation. We compared our results to internationally reported data. Results Between October 2014 and September 2019, 16 patients received an LVAD in our center. The mean age at implantation was 67.1 years. The mean EuroSCORE II was 24.4% and the median INTERMACS level was 4. Thirteen patients received an LVAD as destination therapy and three patients as bridge-to-candidacy. The overall survival was 87.5 and 70% at 1 and 2 years, respectively. Freedom from stroke was 81.3% at 1 and 2 years. Freedom from device infection was 67.7 and 58.7% at 1 and 2 years, respectively. Freedom from gastrointestinal bleeding was 75 and 56.3% at 1 and 2 years, respectively. Freedom from readmission was 50 and 31.3% and at 6 months and 1 year, respectively. Conclusions The Basel experience demonstrated the possible implementation of an LVAD program for destination therapy or bridge-to-candidacy in a non-transplant comprehensive heart-failure center with midterm survival results and freedom from major adverse events comparable to international registries. Patient selection remains crucial. Trial registration This study was registered on the ClinicalTrials.gov database (NCT04263012).
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Affiliation(s)
- Thibault Schaeffer
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Otmar Pfister
- Department of cardiology, University Hospital of Basel, Basel, Switzerland
| | - Constantin Mork
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Paul Mohacsi
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Florian Rueter
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Simon Scheifele
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Anne Morgen
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Urs Zenklusen
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Thomas Doebele
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Markus Maurer
- Department of Anesthesiology, University Hospital of Basel, Basel, Switzerland
| | - Joachim Erb
- Department of Anesthesiology, University Hospital of Basel, Basel, Switzerland
| | - Jens Fassl
- Institute of Cardiac Anesthesiology, Heart Center of the Technical University of Dresden, Dresden, Germany
| | - Nadine Cueni
- Department of Intensive Care, University Hospital of Basel, Basel, Switzerland
| | - Martin Siegemund
- Department of Intensive Care, University Hospital of Basel, Basel, Switzerland
| | - Hans Pargger
- Department of Intensive Care, University Hospital of Basel, Basel, Switzerland
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of cardiology, University Hospital of Basel, Basel, Switzerland
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Martin Grapow
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland. .,HerzZentrum Hirslanden Zürich, Witellikerstrasse 36, Zürich, Switzerland.
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14
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McNamara N, Narroway H, Williams M, Brookes J, Farag J, Cistulli D, Bannon P, Marasco S, Potapov E, Loforte A. Contemporary outcomes of continuous-flow left ventricular assist devices-a systematic review. Ann Cardiothorac Surg 2021; 10:186-208. [PMID: 33842214 DOI: 10.21037/acs-2021-cfmcs-35] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background End stage heart failure is a major cause of morbidity and mortality, and its prevalence is expected to rise with the ageing population. For suitable patients, orthotopic heart transplantation remains the gold standard therapy, however, a paucity of donor organs has led to the development of left ventricular assist devices (LVAD). These devices can be utilized as either a bridge-to-transplant (BTT) or as an alternative to heart transplantation. While these devices can prolong life and improve quality of life, they are associated with a significant number of adverse events. We aim to systematically review the literature to quantify survival and the incidence of adverse events following implantation of continuous-flow LVADs (cf-LVAD). Methods A systematic review was performed to determine outcomes following implantation of a cf-LVAD. Primary outcomes were survival and frequency of adverse events (such as bleeding, infection, thrombosis, stroke and right ventricular failure). Secondary outcomes included quality of life and assessment of functional status. Results Sixty-three studies reported clinical outcomes of 9,280 patients. Survival after cf-LVAD varied between studies. Industry-funded trials generally reported better overall survival than the single- and multi-center case series, which showed significant variation. The largest registry report documented twelve, twenty-four and forty-eight-month survival rates of 82%, 72% and 57% respectively. The most commonly reported adverse events were gastrointestinal bleeding (GIB), device-related infection, neurological events and right heart failure (RHF). Bleeding, RHF and infection were the most frequent complications experienced by those supported with cf-LVAD, occurring in up to 35%, 40% and 55% of patients, respectively. Quality of life as measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and functional status as measured with the 6-minute walk test (6MWT) improved after cf-LVAD implantation with no decline evident two years after implantation. Conclusions The paucity of donor hearts has led to the development of left-ventricular assist devices as a BTT or as a destination therapy (DT). Outcomes after cf-LVAD implantation are excellent, with short-term survival comparable to heart transplantation, but long-term survival remains limited due to the incidence of post-implantation adverse events. Despite these complications, quality of life and functional status improve significantly post-implantation and remain improved over the long-term. This study demonstrates the potential benefits of cf-LVAD therapy whilst also identifying adverse events as an area of increased morbidity and mortality.
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Affiliation(s)
- Nicholas McNamara
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Health and Medicine, University of Sydney, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - Harry Narroway
- Department of Vascular Surgery, Gosford Hospital, Gosford, Australia
| | - Michael Williams
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Health and Medicine, University of Sydney, Sydney, Australia
| | - John Brookes
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - James Farag
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - David Cistulli
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul Bannon
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - Silvana Marasco
- Cardiothoracic Surgical Department, The Alfred, Melbourne, Australia.,Department of Medicine and Surgery, Monash University, Melbourne, Australia
| | - Evgenij Potapov
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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15
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Logan C, Yumul I, Cepeda J, Pretorius V, Adler E, Aslam S, Martin NK. Cost-effectiveness of using hepatitis C viremic hearts for transplantation into HCV-negative recipients. Am J Transplant 2021; 21:657-668. [PMID: 32777173 PMCID: PMC8216294 DOI: 10.1111/ajt.16245] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/08/2020] [Accepted: 07/25/2020] [Indexed: 01/25/2023]
Abstract
Outcomes following hepatitis C virus (HCV)-viremic heart transplantation into HCV-negative recipients with HCV treatment are good. We assessed cost-effectiveness between cohorts of transplant recipients willing and unwilling to receive HCV-viremic hearts. Markov model simulated long-term outcomes among HCV-negative patients on the transplant waitlist. We compared costs (2018 USD) and health outcomes (quality-adjusted life-years, QALYs) between cohorts willing to accept any heart and those willing to accept only HCV-negative hearts. We assumed 4.9% HCV-viremic donor prevalence. Patients receiving HCV-viremic hearts were treated, assuming $39 600/treatment with 95% cure. Incremental cost-effectiveness ratios (ICERs) were compared to a $100 000/QALY gained willingness-to-pay threshold. Sensitivity analyses included stratification by blood type or region and potential negative consequences of receipt of HCV-viremic hearts. Compared to accepting only HCV-negative hearts, accepting any heart gained 0.14 life-years and 0.11 QALYs, while increasing costs by $9418/patient. Accepting any heart was cost effective (ICER $85 602/QALY gained). Results were robust to all transplant regions and blood types, except type AB. Accepting any heart remained cost effective provided posttransplant mortality and costs among those receiving HCV-viremic hearts were not >7% higher compared to HCV-negative hearts. Willingness to accept HCV-viremic hearts for transplantation into HCV-negative recipients is cost effective and improves clinical outcomes.
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Affiliation(s)
- Cathy Logan
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Ily Yumul
- Division of Cardiology, Department of Medicine, University of Iowa
| | - Javier Cepeda
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Victor Pretorius
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Diego
| | - Eric Adler
- Division of Cardiology, Department of Medicine, University of California San Diego
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
- Population Health Sciences, University of Bristol, UK
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16
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Imamura T, Narang N, Nitta D, Fujino T, Nguyen A, Chung B, Holzhauser L, Kim G, Raikhelkar J, Kalantari S, Smith B, Juricek C, Rodgers D, Ota T, Song T, Jeevanandam V, Sayer G, Uriel N. HeartWare Ventricular Assist Device Cannula Position and Hemocompatibility-Related Adverse Events. Ann Thorac Surg 2020; 110:911-917. [PMID: 32035046 PMCID: PMC7416438 DOI: 10.1016/j.athoracsur.2019.12.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/25/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND HeartWare ventricular assist device (HVAD) cannula position is associated with hemodynamics and heart failure readmissions. However, its impact on hemocompatibility-related adverse events (HRAEs) remains uncertain. METHODS HVAD patients were followed for 1 year after index hospitalization, when cannula coronal angle was quantified from chest x-ray film. Invasive right heart catheterization and transthoracic echocardiography were performed. One-year occurrences of each HRAE were compared between those with and without a cannula coronal angle of greater than 65 degrees. RESULTS Among 63 HVAD patients (median age 60 years, 63% male), 10 (16%) had a cannula coronal angle greater than 65 degrees. The wide-angle group had elevated intracardiac pressures and lower pulmonary artery pulsatility index (P < .05). They also had reduced right ventricular function by echocardiography. Freedom from HRAEs tended to be lower in the wide-angle group (24% vs 62%; P = .11). The rate of gastrointestinal bleeding was significantly higher in the greater than 65 degrees group (0.90 events/year vs 0.40 events/year; P = .013). The rates of stroke and pump thrombosis were statistically comparable irrespective of cannula angle (P > .05). CONCLUSIONS HVAD cannula coronal angle was associated with reduced right ventricular function and HRAEs. Prospective studies evaluating surgical techniques to ensure optimal device positioning and its effects on HRAEs are warranted.
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Affiliation(s)
- Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois; Second Department of Medicine, University of Toyama, Toyama, Japan.
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Daisuke Nitta
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeo Fujino
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Luise Holzhauser
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | | | - Gabriel Sayer
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
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17
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Kapuria D, Khumri T, Shamim S, Surana P, Khan S, Al-Khalisi N, Aggarwal S, Koh C, Chhabra R. Characterization and timing of gastrointestinal bleeding in continuous flow left ventricular assist device recipients. Heliyon 2020; 6:e04695. [PMID: 32939410 PMCID: PMC7479277 DOI: 10.1016/j.heliyon.2020.e04695] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/11/2018] [Accepted: 08/07/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIMS Heart failure is one of the leading causes of morbidity and mortality in the United States. The advent of left ventricular assist devices (LVAD) has improved the survival and quality of life in patients with end stage heart failure. Gastrointestinal bleeding (GIb) remains one of the limitations of LVADs. METHODS A single center, retrospective review of records was performed for patients who underwent LVAD implantation between 2010 and 2015. All patients who survived more than 30 days were followed till March 2016 and are described below. RESULTS A total of 79 patients were included in the study. The rate of GIb was 34.1% (27 patients) with a mean time to bleed of 267 days. Older patients were more likely to bleed. Upper GI bleeding was the source of bleeding in 54% patients. Arteriovenous malformations (AVM) were the source of bleeding in 74% bleeders and 80% of these patients had de novo AVM formation. 14/27 (51%) patients had a re-bleeding event. Thrombotic events were 4.5 times more likely to occur in patients who also had a GI bleed. CONCLUSIONS GI bleeding in LVAD patients is common with the source of bleeding more commonly being in the upper GI tract. GI bleeding may occur as early as 10 days post procedure, despite previous negative screening endoscopies. There is an increased risk of thrombotic events in patients who have experienced a GI bleed.
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Affiliation(s)
- Devika Kapuria
- Department of Internal Medicine, University of Missouri, Kansas City-School of Medicine, USA
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA
| | - Taiyeb Khumri
- Department of Cardiology, University of Missouri, Kansas City- School of Medicine, USA
| | - Shariq Shamim
- Department of Cardiology, University of Missouri, Kansas City- School of Medicine, USA
| | - Pallavi Surana
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA
| | - Salman Khan
- Department of Internal Medicine, University of Missouri, Kansas City-School of Medicine, USA
| | - Nabil Al-Khalisi
- Department of Radiology, University of Missouri, Kansas City-School of Medicine, USA
| | | | - Christopher Koh
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA
| | - Rajiv Chhabra
- Department of Gastroenterology, University of Missouri, Kansas-School of Medicine, USA
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18
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Hanff TC, Birati EY. Left Ventricular Assist Device as Destination Therapy: a State of the Science and Art of Long-Term Mechanical Circulatory Support. Curr Heart Fail Rep 2020; 16:168-179. [PMID: 31631240 DOI: 10.1007/s11897-019-00438-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize and summarize recent developments in the care of patients with end-stage heart failure being managed with a left ventricular assist device (LVAD) as destination therapy. RECENT FINDINGS Although the survival of patients treated with LVAD continues to improve, the rates of LVAD-associated complication, such as right ventricular failure, bleeding complications, and major infection, remain high, and management of these patients remains challenging. The durability and hemocompatibility of LVAD support have greatly increased in recent years as a result of new technologies and novel management strategies. Challenges remain in the comprehensive care of patients with destination therapy LVADs, including management of comorbidities and optimizing patient function and quality of life.
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Affiliation(s)
- Thomas C Hanff
- Department of Medicine Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edo Y Birati
- Department of Medicine Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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19
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Implication of Hemodynamic Assessment during Durable Left Ventricular Assist Device Support. MEDICINA-LITHUANIA 2020; 56:medicina56080413. [PMID: 32824131 PMCID: PMC7466331 DOI: 10.3390/medicina56080413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 11/16/2022]
Abstract
Durable left ventricular assist device therapy has improved survival in patients with advanced heart failure refractory to conventional medical therapy, although the readmission rates due to device-related comorbidities remain high. Left ventricular assist devices are designed to support a failing left ventricle through relief of congestion and improvement of cardiac output. However, many patients still have abnormal hemodynamics even though they may appear to be clinically stable. Furthermore, such abnormal hemodynamics are associated with an increased risk of future adverse events including recurrent heart failure, gastrointestinal bleeding, stroke, and pump thrombosis. Correction of residual hemodynamic derangements post-implantation may be a target in improving longitudinal clinical outcomes during left ventricular assist device support. Automatic and timely device speed adjustments considering a patients' hemodynamic status (i.e., with a smart pump) are potential improvements in forthcoming devices.
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20
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Hasan BM, McMahon C, Khalid RA, Colak Y, Mayorga DC, Elkafrawy A, Tandon K, Shafiq M, Hussain I, Erim T, Castro F, Charles R, Chhabra R. Utility and safety of balloon-assisted enteroscopy in patients with left ventricular assist devices: a retrospective multicenter study. Endosc Int Open 2020; 8:E1002-E1008. [PMID: 32743049 PMCID: PMC7373663 DOI: 10.1055/a-1181-8340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/16/2020] [Indexed: 02/06/2023] Open
Abstract
Objective and study aims Patients with left-ventricular assist devices (LVADs) have an increased risk of gastrointestinal bleeding, especially from the small bowel, often necessitating evaluation with balloon-assisted enteroscopy (BAE). Our study aimed to assess the periprocedural safety and utility of BAE for gastrointestinal bleeding in patients with LVADs. Patients and methods This was a multicenter retrospective cohort study of adults with LVADs who underwent BAE between January 2007 to December 2018. Results Thirty-four patients underwent a total of 46 BAEs (9 were single-balloon enteroscopies [SBEs] and 37 were double-balloon enteroscopies [DBEs]). Mean age of patients was 66.4 ± 8.3 years. Patients tolerated anesthesia well, without complications. There were no complications from the BAE itself. One patient required repeat BAE due to a progressive drop in hemoglobin and another patient developed paroxysmal supraventricular tachycardia. One patient died within 72 hours of the procedure due to worsening of LVAD thrombosis. Diagnostic yields were 69.6 % for all procedures, 73.0 % for DBE and 55.6 % for SBE ( P = 0.309). Therapeutic yields were 67.4 % overall: 73.0 % for DBE and 44.4 % for SBE ( P = 0.102). In those that presented with overt gastrointestinal bleeding, DBE had a higher diagnostic yield compared to SBE (84.2 % vs. 42.9 %; P = 0.057) and a significantly higher therapeutic yield (84.2 % vs. 28.6 %; p = 0.014). Conclusions This is the largest multicenter study of patients with LVADs who underwent DBE. BAE appears to be a safe and useful modality for the evaluation of gastrointestinal bleeding in these patients.
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Affiliation(s)
- Badar M. Hasan
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Charles McMahon
- Department of Internal Medicine, Division of Gastroenterology, Loyola University Medical Center, Chicago, Illinois, United States
| | - Rumman A. Khalid
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Yasar Colak
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Daniel C. Mayorga
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Ahmed Elkafrawy
- Department of Gastroenterology and Hepatology, Saint Lukeʼs Hospital of Kansas City/University of Missouri Kansas City (UMKC), Missouri, United States
| | - Kanwarpreet Tandon
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Muhammad Shafiq
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Ishtiaq Hussain
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Tolga Erim
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Fernando Castro
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Roger Charles
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Rajiv Chhabra
- Department of Gastroenterology and Hepatology, Saint Lukeʼs Hospital of Kansas City/University of Missouri Kansas City (UMKC), Missouri, United States
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21
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Michelis KC, Zhong L, Peltz M, Pandey A, Tang WHW, Rohatgi A, Young JB, Drazner MH, Grodin JL. Dynamic Forecasts of Survival for Patients Living With Destination Left Ventricular Assist Devices: Insights From INTERMACS. J Am Heart Assoc 2020; 9:e016203. [PMID: 32648531 PMCID: PMC7660737 DOI: 10.1161/jaha.119.016203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Left ventricular assist devices (LVADs) improve outcomes in patients with end-stage heart failure and are increasingly implanted for destination therapy. We describe dynamic estimates of event-free survival with conditional survival probabilities in a destination therapy LVAD population. Methods and Results We studied 8245 adult patients in INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) implanted with a continuous-flow destination therapy LVAD. The composite primary end point was death, device exchange or removal, or heart transplantation. Conditional survival probabilities were calculated and stratified by implantation characteristics and nonfatal adverse events experienced within the first year after implant. Probabilities of surviving an additional 1 to 3 years were numerically higher after longer prior event-free survival. INTERMACS profile 1, extracorporeal membrane oxygenation support, prior or concomitant surgery, and dialysis within 48 hours of implantation were associated with significantly lower event-free survival in the first year but did not impact event-free survival beyond then. For patients who experienced a nonfatal adverse event within the first year, subsequent 1-year conditional survival was lower than in the absence of that event for stroke (65% [95% CI, 57%-73%] versus 75% [95% CI, 73%-77%]; P<0.001), device-related infection (64% [95% CI 57%-71%] versus 76% [95% CI, 74%-78%]; P<0.001), and pump thrombosis or malfunction (64% [95% CI, 57%-70%] versus 76% [95% CI, 74%-78%]; P<0.001). Conclusions Conditional survival in patients with destination therapy LVADs improves over time, even for patients with unfavorable implantation characteristics. However, LVAD-related complications including stroke, device-related infection, and pump thrombosis or malfunction have an enduring negative influence on dynamic estimates of long-term prognosis.
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Affiliation(s)
- Katherine C Michelis
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Lin Zhong
- Division of Bioinformatics Department of Clinical Sciences University of Texas Southwestern Medical Center Dallas TX
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery University of Texas Southwestern Medical Center Dallas TX
| | - Ambarish Pandey
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - W H Wilson Tang
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland OH
| | - Anand Rohatgi
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - James B Young
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland OH
| | - Mark H Drazner
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Justin L Grodin
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
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Combs PS, Imamura T, Siddiqi U, Mirzai S, Spiller R, Stonebraker C, LaBuhn C, Bullard H, Simone P, Jeevanandam V. Opioid Use and Morbidities during Left Ventricular Assist Device Support. Int Heart J 2020; 61:547-552. [DOI: 10.1536/ihj.19-660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Pamela S. Combs
- Department of Medicine, University of Chicago Medical Center
| | - Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center
- Second Department of Medicine, University of Toyama
| | - Umar Siddiqi
- Department of Surgery, University of Chicago Medical Center
| | - Saeid Mirzai
- Department of Surgery, University of Chicago Medical Center
| | - Robert Spiller
- Department of Surgery, University of Chicago Medical Center
| | | | - Colleen LaBuhn
- Department of Medicine, University of Chicago Medical Center
| | - Heather Bullard
- Department of Pharmacy, University of Chicago Medical Center
| | - Pamela Simone
- Department of Pharmacy, University of Chicago Medical Center
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23
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Taylor C, Bittner K, Bartell N, Aranez J, Alexis JD, Carlson B, Chen L, McNitt S, Kothari T, Kaul V, Kothari S. Outcomes of gastrointestinal bleeding in patients with left ventricular assist devices: a tertiary care experience. Endosc Int Open 2020; 8:E301-E309. [PMID: 32140555 PMCID: PMC7055617 DOI: 10.1055/a-1090-7200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/28/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Left ventricular assist device (LVAD) placement is a therapeutic modality for patients with end-stage heart failure. Gastrointestinal bleeding is a common complication following LVAD implantation. The aim of this study was to report our experience in management and outcomes of gastrointestinal bleeding in a large cohort of patients with LVADs. Patients and methods We performed a retrospective review of all patients who underwent LVAD implantation at the University of Rochester Medical Center from January 2008 to June 2017. Data were collected on patient characteristics, clinical aspects of gastrointestinal bleeding events, and procedural interventions. A Cox proportional hazard model was utilized to identify potential risk factors for a gastrointestinal bleeding event. Results During the study period, 345 patients underwent LVAD implantation. Of these, 125 patients (36.2 %) experienced 297 gastrointestinal bleeding events resulting in 533 endoscopic procedures. The diagnostic yield of endoscopy in determining a bleeding source was 49.5 %. If required, therapeutic interventions were successful in achieving homeostasis in 96.2 % of procedures. Our 30-day overall post-procedure adverse event (AE) rate was 6.6 %. Procedure-related (bleeding, infection, and perforation) AEs were very minimal (2.8 %). A Cox proportional hazard model indicated that older age at implant, female sex, African-American race, diabetes mellitus, and pulmonary hypertension were statistically significant predictors of a gastrointestinal bleeding event following LVAD implantation. Conclusions LVAD patients have a high risk of gastrointestinal bleeding. Endoscopy was able to safely locate a bleeding lesion in approximately half of our patients and was successful in treating bleeding lesions in a majority of the cases.
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Affiliation(s)
- Caren Taylor
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Krystle Bittner
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Nicholas Bartell
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Jose Aranez
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Jeffrey D Alexis
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Beth Carlson
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Leway Chen
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Scott McNitt
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Truptesh Kothari
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Vivek Kaul
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Shivangi Kothari
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
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24
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Veenis JF, Brugts JJ. Remote monitoring for better management of LVAD patients: the potential benefits of CardioMEMS. Gen Thorac Cardiovasc Surg 2020; 68:209-218. [PMID: 31981137 DOI: 10.1007/s11748-020-01286-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/31/2019] [Indexed: 12/17/2022]
Abstract
Left ventricular assist devices (LVAD) are frequently used in the treatment of end-stage heart failure (HF), and due to the shortage of heart donors and destination programs, it is likely to keep on growing. Still, LVAD therapy is not without complications and morbidity and rehospitalization rates are high. New ways to improve LVAD care both from the side of the patient and the physician are warranted. Remote monitoring could be a tool to tailor treatment in these patients, as no feedback exists at all about patient functioning on top of the static pump parameters. We aim to provide an overview and evaluation of the novel remote monitoring strategies to optimize LVAD management and elaborate on the opportunities of remote hemodynamic monitoring with CardioMEMS, at home in these patients as the next step to improve care.
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Affiliation(s)
- Jesse F Veenis
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015GD, Rotterdam, The Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015GD, Rotterdam, The Netherlands.
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25
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Imamura T, Nguyen A, Rodgers D, Kim G, Raikhelkar J, Kalantari S, Narang N, Juricek C, Ota T, Jeevanandam V, Sayer G, Uriel N. Omega-3 and hemocompatibility-related adverse events. J Card Surg 2019; 35:405-412. [PMID: 31850548 DOI: 10.1111/jocs.14384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hemocompatibility-related clinical adverse events (HRAEs) are major causes of readmission in patients with left ventricular assist devices (LVADs). Omega-3 is an unsaturated fatty acid that possesses anti-inflammatory and antiangiogenic properties. We aimed to investigate the impact of omega-3 therapy on HRAEs during LVAD support. METHODS Consecutive LVAD patients who were followed for 6 months were enrolled, and stratified by the use of omega-3. Freedom from any HRAEs and net burden of HRAEs, which was calculated by using a hemocompatibility score (using 4 escalating tiers of hierarchal severity to derive a total score for events), were compared between those with and without omega-3 therapy. RESULTS Among 169 LVAD patients (57 years old and 124 males), 31 patients received 4 g/d of omega-3 therapy and 138 patients were in the control group. During the 6-month observational period, freedom from any HRAEs was 90% in the omega-3 group compared with 70% in the control group with a hazard ratio of 0.35 (95% confidence interval 0.11-0.87 and P = .042). The average hemocompatibility score in the omega-3 group was significantly lower compared with the control group (0.23 vs 0.91; P = .042), due to reduced Tier I scores (mild HRAE; P = .003) and Tier IIIB scores (severe HRAE; P < .001). The similar trends remained at propensity-matched populations. CONCLUSIONS Omega-3 therapy was associated with reduced HRAEs including both bleeding and thromboembolic events in LVAD patients.
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Affiliation(s)
- Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.,Second Department of Medicine, University of Toyama, Toyama, Japan
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | | | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
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26
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Ahsan I, Faraz A, Mehmood A, Ullah W, Ghani AR. Clinical Approach to Manage Gastrointestinal Bleeding with a Left Ventricular Assist Device (LVAD). Cureus 2019; 11:e6341. [PMID: 31938629 PMCID: PMC6952049 DOI: 10.7759/cureus.6341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Left ventricular assist devices (LVADs) are an exceedingly important form of mechanical support for patients with end-stage heart failure. LVADs can be utilized both as a bridge to cardiac transplant and also as a definitive treatment. However, a few complications are associated with LVAD placement, the most common and cumbersome of which is gastrointestinal (GI) bleeding with an incidence of about 30%. These bleeding events often require transfusion therapy, but they are rarely fatal. The etiologies of GI bleeding following LVAD are multifactorial and include unstable hemodynamics, an acquired von Willebrand factor (vWf) deficiency, impaired platelet aggregation, and activation of fibrinolytic systems. The treatment of choice in LVAD implantation-associated GI bleeding is endoscopy, which plays a vital role in both its diagnosis and management. Even so, its effectiveness in controlling post-LVAD implantation GI bleeding is still poorly ascertained. In this article, we will review the use of medication and alterations in the LVAD setting to prevent the occurrence of GI bleeding, as well as the findings of previously reported literature on LVAD implantation-associated GI bleeding.
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Affiliation(s)
- Irfan Ahsan
- Internal Medicine, Geisinger Health System, Danville, USA
| | - Aniqa Faraz
- Internal Medicine, University of Buffalo, Buffalo, USA
| | - Asif Mehmood
- Internal Medicine, Geisinger Medical Center, Danville, USA
| | - Waqas Ullah
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, USA
| | - Ali R Ghani
- Cardiovascular Medicine, Saint Louis University, Saint Louis, USA
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27
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Rapid Development of Bleeding Esophageal Varices after Placement of Continuous Flow Left Ventricular Assist Device. Case Reports Hepatol 2019; 2019:8410420. [PMID: 31781429 PMCID: PMC6875215 DOI: 10.1155/2019/8410420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
We describe a patient with compensated cirrhosis and portal hypertension who underwent continuous flow LVAD implantation. Shortly after LVAD implantation, the patient developed new onset bleeding esophageal varices and ultimately had a fatal outcome. Our experience suggests that even well-compensated cirrhotic patients with significant portal hypertension are at risk of variceal bleeding after LVAD placement.
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28
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Hilal T, Mudd J, DeLoughery TG. Hemostatic complications associated with ventricular assist devices. Res Pract Thromb Haemost 2019; 3:589-598. [PMID: 31624778 PMCID: PMC6781923 DOI: 10.1002/rth2.12226] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/08/2019] [Indexed: 01/03/2023] Open
Abstract
Hemostatic complications are common in patients with ventricular assist devices. The pathophysiologic mechanisms that lead to dysregulated hemostasis involve complex interactions between device surface, sheer stress, and blood flow. These factors lead to various manifestations that require a thorough understanding of the interplay among platelets, coagulation factors, and red cells. In this article, we review the pathophysiology of hematologic complications (bleeding, acquired von Willebrand disease, heparin-induced thrombocytopenia, hemolysis, stroke and pump thrombosis), the clinical manifestations, and the management of each. We summarize the evidence available for management of these entities and provide a pragmatic clinical review.
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Affiliation(s)
- Talal Hilal
- Division of Hematology/OncologyMayo Clinic Cancer CenterMayo ClinicPhoenixArizona
| | - James Mudd
- Center for Advanced Heart Disease and TransplantationProvidence Sacred Heart Medical CenterSpokaneWashington
| | - Thomas G. DeLoughery
- Division of Hematology/Medical OncologyKnight Cancer CenterOregon Health & Science UniversityPortlandOregon
- Division of Laboratory MedicineDepartment of PathologyOregon Health & Science UniversityPortlandOregon
- Division of Hematology/OncologyDepartment of PediatricsOregon Health & Science UniversityPortlandOregon
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29
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Li S, Oshea B, Sun S. Special considerations in the management of lower GI bleed by interventional radiology. J Interv Med 2019; 2:101-105. [PMID: 34805880 PMCID: PMC8562260 DOI: 10.1016/j.jimed.2019.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Despite the rapid development of diagnostic and therapeutic modalities and techniques to manage LGIB patients from interventional radiology's standpoint, a successful localization of the bleeding site that leads to an effective embolotherapy remains a significant technical challenge. The interventional radiologist's decisions when managing patients with LGIB may significantly impact the clinical outcomes; therefore, management should be made based on careful and thorough considerations of factors such as etiology, locations, patient's comorbidities, and potential post-procedure complications, among others. The purpose of this paper is to review the management of LGIB by interventional radiology, focusing on a few challenging and common clinical situations that require special consideration by interventional radiologists.
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Affiliation(s)
- Shihong Li
- University of Iowa Health Care, Department of Radiology, Division of Interventional Radiology. Iowa City, Iowa, 52242, USA
| | - Brendan Oshea
- University of Iowa Health Care, Department of Radiology, Division of Interventional Radiology. Iowa City, Iowa, 52242, USA
| | - Shiliang Sun
- University of Iowa Health Care, Department of Radiology, Division of Interventional Radiology. Iowa City, Iowa, 52242, USA
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30
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Boruah P, Saqib N, Barooah J, Baruah D, Sharma P. Left Ventricular Assist Device: What the Internist Needs to Know. A Review of the Literature. Cureus 2019; 11:e4399. [PMID: 31245189 PMCID: PMC6559676 DOI: 10.7759/cureus.4399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/05/2019] [Indexed: 01/22/2023] Open
Abstract
Left ventricular assist devices (LVADs) have revolutionized therapy for patients with Stage D heart failure (HF) with reduced systolic function providing not only improved survival benefits but also meaningful changes in quality of life and functional capacity. With technological advances and improved durability of devices, length of survival has significantly improved. With continued organ donor shortage, LVADs are frequently serving as a substitute for cardiac transplant as destination therapy, particularly among the elderly. Internists not only face the important challenge of identifying the patients in need referral for these advanced therapies, they are also faced with the challenges of taking care of these patients. This review will help the internists to better understand the present status, indications and advances in LVADs and also understand the complications and adverse effects associated with these devices.
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Affiliation(s)
- Pranjal Boruah
- Cardiology, Geisinger Commonwealth School of Medicine, Wright Center for Graduate Medical Education, Scranton, USA
| | - Najam Saqib
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, USA
| | - Jumee Barooah
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, USA
| | - Dhiraj Baruah
- Radiology, Medical College of Wisconsin, Milwaukee, USA
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31
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Association of Oxidative Stress and Platelet Receptor Glycoprotein GPIbα and GPVI Shedding During Nonsurgical Bleeding in Heart Failure Patients With Continuous-Flow Left Ventricular Assist Device Support. ASAIO J 2019; 64:462-471. [PMID: 28953486 DOI: 10.1097/mat.0000000000000680] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Nonsurgical bleeding (NSB) in heart failure (HF) patients with continuous-flow left ventricular assist device (CF-LVAD) support is the most common clinical complication. The aim of this study was to investigate the association between oxidative stress and platelet glycoproteins GPIbα and GPVI shedding on the incidence of NSB in CF-LVAD patients. Fifty-one HF patients undergoing CF-LVAD implantation and 11 healthy volunteers were recruited. Fourteen patients developed NSB (bleeder group) during 1 month follow-up duration, while others were considered nonbleeder group (n = 37). Several biomarkers of oxidative stress were quantified at baseline and weekly intervals in all patients. Surface expression and plasma elements of platelet receptor glycoproteins GPIbα and GPVI were measured. Oxidative stress biomarkers and platelet GPIbα and GPVI receptor-shedding (decreased surface expression and higher plasma levels) were found to be preexisting conditions in baseline samples of both groups of HF patients when compared with healthy volunteers. Significantly elevated oxidative stress biomarkers and platelet glycoprotein receptor shedding were observed in postimplant bleeder group temporarily when compared with nonbleeder group. Strong significant associations between biomarkers of oxidative stress and platelet glycoprotein receptor shedding were observed, suggesting a possible role of oxidative stress in platelet integrin shedding leading to NSB in CF-LVAD patients. Receiver operating characteristic analyses of GPIbα and GPVI indicated that the likelihood of NSB had a predictive power of bleeding complication in CF-LVAD patients. In conclusion, elevated oxidative stress may play a role in GPIbα and GPVI shedding in the event of NSB. Thus, oxidative stress and GPIbα and GPVI shedding may be used as potential biomarkers for bleeding risk stratification in those patients.
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Horiuchi H, Doman T, Kokame K, Saiki Y, Matsumoto M. Acquired von Willebrand Syndrome Associated with Cardiovascular Diseases. J Atheroscler Thromb 2019; 26:303-314. [PMID: 30867356 PMCID: PMC6456452 DOI: 10.5551/jat.rv17031] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The blood glycoprotein von Willebrand factor (VWF) plays an important role in hemostasis and thrombosis. VWF is produced and secreted as large multimers by endothelial cells and megakaryocytes. It is then cleaved in a sheer-stress dependent manner by a specific protease, ADAMTS13, into multimers consisting of 2–80 subunits. Among VWF multimers, high molecular weight (HMW) multimers play important roles in platelet aggregation. Therefore, their loss induces a hemostatic disorder known as von Willebrand disease (VWD) type 2A. Various cardiovascular diseases, such as aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM), and several congenital structural diseases, as well as mechanical circulatory support systems, generate excessive high shear stress in the bloodstream. These cause excessive cleavage of VWF multimers resulting in a loss of HMW multimers, known as acquired von Willebrand syndrome (AVWS), a hemostatic disorder similar to VWD type 2A. Bleeding often occurs in the gastrointestinal tract since a fragile angiodysplasia develops associated with these diseases. Radical treatment for AVWS is to remove the pathological high shear causing AVWS.
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Affiliation(s)
- Hisanori Horiuchi
- Department of Molecular and Cellular Biology, Institute of Development, Aging and Cancer, Tohoku University
| | - Tsuyoshi Doman
- Department of Molecular and Cellular Biology, Institute of Development, Aging and Cancer, Tohoku University
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
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Li X, Kondray V, Tavri S, Ruhparwar A, Azeze S, Dey A, Partovi S, Rengier F. Role of imaging in diagnosis and management of left ventricular assist device complications. Int J Cardiovasc Imaging 2019; 35:1365-1377. [PMID: 30830527 DOI: 10.1007/s10554-019-01562-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/11/2019] [Indexed: 12/14/2022]
Abstract
Heart failure is a clinical condition that is associated with significant morbidity and mortality. With the advent of left ventricular assist device (LVAD), an increasing number of patients have received an artificial heart both as a bridge-to-therapy and as a destination therapy. Clinical trials have shown clear survival benefits of LVAD implantation. However, the increased survival benefits and improved quality of life come at the expense of an increased complication rate. Common complications include perioperative bleeding, infection, device thrombosis, gastrointestinal bleeding, right heart failure, and aortic hemodynamic changes. The LVAD-associated complications have unique pathophysiology. Multiple imaging modalities can be employed to investigate the complications, including computed tomography (CT), positron emission tomography-computed tomography (PET-CT), catheter angiography and echocardiography. Imaging studies not only help ascertain diagnosis and evaluate the severity of disease, but also help direct relevant clinical management and predict prognosis. In this article, we aim to review the common LVAD complications, present the associated imaging features and discuss the role of imaging in their management.
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Affiliation(s)
- Xin Li
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Victor Kondray
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sidhartha Tavri
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Samuel Azeze
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Aritra Dey
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sasan Partovi
- Department of Radiology, Section of Interventional Radiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Fabian Rengier
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
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Imamura T, Kinugawa K, Uriel N. Therapeutic Strategy for Gastrointestinal Bleeding in Patients With Left Ventricular Assist Device. Circ J 2018; 82:2931-2938. [DOI: 10.1253/circj.cj-18-0883] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center
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35
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Laparoscopic procedures in patients with cardiac ventricular assist devices. Surg Endosc 2018; 33:2181-2186. [PMID: 30367296 DOI: 10.1007/s00464-018-6497-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Cardiac left ventricular assist device (LVAD) placement is a common therapy for heart failure. Non-cardiac surgical care of these patients can be complex given the need for anticoagulation, perioperative monitoring, comorbidities, and anatomical considerations due to the device itself. There are no guidelines or significant patient series reported to date for laparoscopic procedures in this population. We herein report the techniques and outcomes for commonly performed laparoscopic procedures in patients with LVADs at a high volume center. METHODS From our database of patients with ventricular assist devices, we retrospectively identified patients who underwent laparoscopic abdominal surgery. Intraoperative and perioperative data were collected, including anticoagulation management, transfusions and complications. Techniques and preoperative considerations from the surgeons were also compiled and described. RESULTS Of 374 patients that had placement of LVADs, 17 had an elective laparoscopic procedure: enteral access placement (n = 7), cholecystectomy (n = 6), hernia repair (n = 2), small bowel resection (n = 1) and splenectomy (n = 1). Preoperative evaluation routinely included radiologic imaging to evaluate driveline location. The most common abdominal entry technique was a periumbilical open Hasson technique (11/17). No cases were converted to open. Overall, the average blood loss was 132 ± 64 mL and the average operative time was 1.8 ± 0.3 h. Five of the 17 patients required intraoperative blood transfusion. No patients suffered perioperative thrombotic events or LVAD complications secondary to holding anticoagulation. No patients required interventions or reoperation for bleeding complications. There were no mortalities related to these procedures. CONCLUSIONS Laparoscopic abdominal procedures are safe and feasible in patients with LVADs. Although special consideration for bleeding and thrombotic risks, placement of ports and perioperative management is required, the presence of a LVAD itself should not be considered a contraindication for laparoscopic surgery and may in fact be the preferred method for access in these patients.
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Tainter CR, Braun OÖ, Teran F, Nguyen AP, Robbins K, O'Brien EO, McMillan ZM, Schmidt U, Meier A, Goebel M, Pretorius V, Brambatti M, Adler ED, Seethala R. Emergency department visits among patients with left ventricular assist devices. Intern Emerg Med 2018; 13:907-913. [PMID: 29273909 DOI: 10.1007/s11739-017-1776-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 12/13/2017] [Indexed: 11/26/2022]
Abstract
Continuous-flow left ventricular assist devices (LVADs) are increasingly implanted to support patients with end-stage heart failure. These patients are at high risk for complications, many of which necessitate emergency care. While rehospitalization rates have been described, there is little data regarding emergency department (ED) visits. We hypothesize that ED visits are frequent and often require admission after LVAD implantation. We performed a retrospective review of patients in our health-care system followed by the advanced heart failure service for LVAD management after implantation between January 2011 and July 2015. We accounted for all ED visits in our system through February 2016, 7 months after the last implantation included. Clinically relevant demographic variables and ED visit details were recorded and analyzed to describe this population. We identified 81 patients with complete data, among whom there were 283 visits (3.49 visits/patient), occurring at a rate of approximately 7.3 ED visits per patient per year alive with LVAD. The most common reason for an ED visit is a complication related to bleeding (18% of visits), followed by chest pain (14%) and dizziness or syncope (13%). Thirty-six percent of patients were discharged from the ED without hospital admission. A growing populace with implanted LVADs represents an important population within emergency medicine. They are at risk for significant complications and frequently present to the ED. While many of these visits may be managed without hospital admission, this specialized patient group represents a potential area for improvement in provider education.
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Affiliation(s)
- Christopher R Tainter
- Department of Emergency Medicine and Division of Critical Care, Department of Anesthesiology, UC San Diego, 200W. Arbor Dr. #8676, San Diego, CA, 92103, USA.
| | - Oscar Ö Braun
- Department of Medicine, Division of Cardiology, UC San Diego, San Diego, CA, USA
| | - Felipe Teran
- Department of Emergency Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Albert P Nguyen
- Department of Anesthesiology, Division of Critical Care, UC San Diego, San Diego, CA, USA
| | - Kimberly Robbins
- Department of Anesthesiology, Division of Critical Care, UC San Diego, San Diego, CA, USA
| | - Edward O O'Brien
- Department of Anesthesiology, Division of Critical Care, UC San Diego, San Diego, CA, USA
| | - Zeb M McMillan
- Department of Anesthesiology, Division of Critical Care, UC San Diego, San Diego, CA, USA
| | - Ulrich Schmidt
- Department of Anesthesiology, Division of Critical Care, UC San Diego, San Diego, CA, USA
| | - Angela Meier
- Department of Anesthesiology, Division of Critical Care, UC San Diego, San Diego, CA, USA
| | - Mat Goebel
- UC San Diego School of Medicine, San Diego, CA, USA
| | | | - Michela Brambatti
- Department of Medicine, Division of Cardiology, UC San Diego, San Diego, CA, USA
| | - Eric D Adler
- Department of Medicine, Division of Cardiology, UC San Diego, San Diego, CA, USA
| | - Raghu Seethala
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Quantification of Von Willebrand Factor Cleavage by adamts-13 in Patients Supported by Left Ventricular Assist Devices. ASAIO J 2018; 63:849-853. [PMID: 28682993 DOI: 10.1097/mat.0000000000000602] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Patients supported by left ventricular assist devices (LVADs) often present with the loss of large von Willebrand factor (VWF) multimers. This VWF deficiency is believed to contribute to the bleeding diathesis of patients on LVAD support and is caused by excessive VWF cleavage by the metalloprotease ADAMTS-13 under high shear stress. However, only a small percentage of patients who have suffered the loss of large VWF multimers bleed. The actual rates of VWF cleavage in these patients have not been reported, primarily because of the lack of reliable detection methods. We have developed and validated a selected reaction monitoring (SRM) mass spectrometry method to quantify VWF cleavage as the ratio of the ADAMTS-13-cleaved peptide MVTGNPASDEIK to the ILAGPAGDSNVVK peptide. The rate of VWF cleavage was found to be 1.26% ± 0.36% in normal plasma. It varied significantly in patient samples, ranging from 0.23% to 2.5% of total VWF antigen, even though all patients had the loss of large VWF multimers. Von Willebrand factor cleavage was greater in post-LVAD samples from patients in whom bleeding had developed, but was mostly reduced in patients in whom thrombosis had developed. This SRM method is reliable to quantify the rate of VWF cleavage in patients on LVAD support.
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Welden CV, Truss W, McGwin G, Weber F, Peter S. Clinical Predictors for Repeat Hospitalizations in Left Ventricular Assist Device (LVAD) Patients With Gastrointestinal Bleeding. Gastroenterology Res 2018; 11:100-105. [PMID: 29707076 PMCID: PMC5916633 DOI: 10.14740/gr972w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/01/2018] [Indexed: 02/07/2023] Open
Abstract
Background Patients implanted with left ventricular assist devices (LVAD) carry an increased risk of gastrointestinal bleeding (GIB), estimated at 25% in most studies. Significant efforts are employed in localizing and stopping the source of bleeding, but the rates of repeat hospitalization for GIB remain surprisingly high. Given the increasing incidence of LVAD-dependent end-stage heart failure and the excessive costs associated with repetitive endoscopic investigations, risk factors associated with re-bleeding need to be determined. The aim of our study was to investigate clinical predictors associated with repeat hospitalizations for GIB in patients implanted with a LVAD. Methods We conducted a retrospective cohort using the prospectively assembled ventricular assist device database at the University of Alabama at Birmingham. We identified all end-stage heart failure patients who were implanted with a continuous-flow (CF) LVAD between Jan 1, 2009 and Dec 31, 2013. We excluded pulsatile devices, biventricular assist devices (BiVADs), right ventricular assist devices (RVADs), and patients under 19 years of age. Results There were 102 patients implanted with a CF-LVAD within the specified time period. With an average follow-up of 127 weeks, 32 (31.4%) patients developed GIB requiring 79 separate hospitalizations. Average time from LVAD implantation to first bleed was 343 days. The re-bleeding rate requiring readmission was 56.3% in those admitted with GIB, with eight (25%) of the patients necessitating multiple readmissions. The average hospital stay for a primary diagnosis of GIB was 9.45 days. Totally, 68 (86%) patients required endoscopic evaluation during their hospitalization, with 35 (44%) necessitating multiple procedures during the same admission. The average time to first endoscopy was 2.5 days with a median of 2 days. Patients receiving early endoscopy (< 48 h from admission) were 57% less likely to require future readmission for GIB compared to patients undergoing late endoscopy (> 48 h) (OR: 0.43, CI: 0.19 - 0.9). Other factors associated with repeat admissions for GIB included indication for LVAD (bridge to transplant had OR: 0.07, CI: 0.02 - 0.27), male gender (OR: 10.4, CI: 1.8 - 59), length of initial hospital stay (OR: 0.83, CI: 0.71 - 0.97), and INR on admission (OR: 3.6, CI: 1.46 - 8.8). Although not statistically significant, patients undergoing subsequent endoscopies during a single admission were 84% less likely to develop re-bleeding in the future (OR: 0.158, CI: 0.025 - 1.02). Conclusions GIB in LVAD patients is a significant problem with high rates of readmission despite extensive endoscopic investigations and anticoagulant adjustments. Our experience revealed that early endoscopy, longer initial hospital stay, and better INR control were all associated with decreased rates of readmission for GIB in this population. These modifiable factors should be emphasized and addressed in the future to reduce the burdens associated with repeated hospitalizations.
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Affiliation(s)
| | - Wiley Truss
- Univeristy of Alabama at Birmingham, Birmingham, Al 35203, USA
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Al 35294, USA
| | - Frederick Weber
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Al 35233, USA
| | - Shajan Peter
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Al 35233, USA
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Gaffey AC, Chen CW, Chung JJ, Han J, Bermudez CA, Wald J, Atluri P. Is there a difference in bleeding after left ventricular assist device implant: centrifugal versus axial? J Cardiothorac Surg 2018; 13:22. [PMID: 29433532 PMCID: PMC5810067 DOI: 10.1186/s13019-018-0703-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 01/22/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (CF-LVAD) have become the standard of care for patients with end stage heart failure. Device reliability has increased, bringing the potential for VAD, compared to transplant, into debate. However, complications continue to limit VADs as first line therapy. Bleeding is a major morbidity. A debate exists as to the difference in bleeding profile between the major centrifugal and axial flow devices. We hypothesized that there would be similar adverse bleeding event profiles between the 2 major CF-LVADs. METHODS We retrospectively investigated isolated CF LVADs performed at our institution between July 2010 and July 2015: HeartMateII (HMII, n = 105) and HeartWare (HVAD, n = 34). We reviewed demographic, perioperative and short- and long-term outcomes. RESULTS There was no significant difference in demographics or comorbidities. There was a low incidence of gastrointestinal (GI) bleed 3.9% in HMII and 2.9% in HVAD (p = 0.78). Preoperatively, the cohorts did not differ in coagulation measures (p = 0.95). Within the post-operative period, there was no difference in product transfusion: red blood cells (p = 0.10), fresh frozen plasma (p = 0.19), and platelets (p = 0.89). Post-operatively, a higher but not significantly different number of HMII patients returned to the operating room for bleeding (n = 27) compared to HVAD (n = 6, p = 0.35). There was no difference in rates of stroke (p = 0.65), re-intubation (p = 0.60), driveline infection (p = 0.05), and GI bleeding (p = 0.31). The patients had equivalent ICU LOS (p = 0.86) and index hospitalization LOS (p = 0.59). CONCLUSION We found no difference in the rate of bleeding complications between the current commercially available axial and centrifugal flow devices.
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Affiliation(s)
- Ann C Gaffey
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA.
| | - Carol W Chen
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Jennifer J Chung
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Jason Han
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Joyce Wald
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
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Juricek C, Imamura T, Nguyen A, Chung B, Rodgers D, Sarswat N, Kim G, Raikhelkar J, Ota T, Song T, Burkhoff D, Sayer G, Jeevanandam V, Uriel N. Long-Acting Octreotide Reduces the Recurrence of Gastrointestinal Bleeding in Patients With a Continuous-Flow Left Ventricular Assist Device. J Card Fail 2018; 24:249-254. [PMID: 29427603 DOI: 10.1016/j.cardfail.2018.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/20/2017] [Accepted: 01/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recurrent gastrointestinal bleeding is one of the most significant adverse events in patients with left ventricular assist devices (LVADs). METHODS We enrolled LVAD patients who had received an intramuscular injection of 20 mg octreotide every 4 weeks as secondary prevention for recurrent gastrointestinal bleeding despite conventional medical therapies and repeated transfusions. The frequency of gastrointestinal bleeding and other associated clinical outcomes before and during octreotide therapy were compared. RESULTS Thirty LVAD patients (66.4 ± 8.8 years old, 16 men [53%]) received octreotide therapy for 498.8 ± 356.0 days without any octreotide-associated adverse events. The frequency of gastrointestinal bleeding was decreased significantly during octreotide therapy (from 3.4 ± 3.1 to 0.7 ± 1.3 events/year; P < .001), accompanied by significant reductions in red blood cell and flesh frozen plasma transfusions, days in hospital, and need for endoscopic procedures (P < .05 for all). CONCLUSIONS Octreotide therapy reduced the frequency of recurrent gastrointestinal bleeding and may be considered for secondary prevention.
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Affiliation(s)
- Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nitasha Sarswat
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, Columbia University Medical Center, New York, New York
| | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | | | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
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Abstract
PURPOSE OF REVIEW In this paper, we will review developments in the field of durable mechanical circulatory support over the past 3 years. RECENT FINDINGS The role of left ventricular assist device (LVAD) placement in non-inotrope-dependent ambulatory heart failure patients remains controversial in light of recent clinical trials. New devices are on the horizon for destination therapy in advanced heart failure patients. The concept of hemocompatibility and the calculation of hemocompatibility scores represent a novel approach to common adverse events. Recent research in mechanical circulatory support has impacted our approach to durable LVAD therapy and set the stage for further advancements in the field.
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Abstract
An increasing number of end-stage heart failure patients are now implanted with continuous-flow left ventricular assist devices (CF-LVADs). Although this therapeutic approach is associated with improved clinical outcomes, continuous flow physiology reduces arterial pulse pressure and pulsatility to an extent that is unique to this population. Recent data suggest that high blood pressure (BP) contributes to life-threatening complications such as pump thrombosis and stroke of CF-LVAD patients. However, limited understanding of the distinct hemodynamics of these pumps makes measurement and, consequently, medical management of BP quite challenging. Here, we review the evolution of LVAD design, the impact of CF-LVAD flow, and "artificial pulse" technology on hemodynamics and BP measurement, as well as suggest new approaches for the assessment and interpretation of the unique physiology of modern LVADs.
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43
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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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Affiliation(s)
- Juglans Alvarez
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
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Koul A, Pham DM, Nanda A, Woods KE, Keilin SD. Safety and efficacy of single-balloon enteroscopy in management of gastrointestinal bleeding in patients with a left ventricular assist device. Endosc Int Open 2017; 5:E179-E183. [PMID: 28299353 PMCID: PMC5348294 DOI: 10.1055/s-0043-102397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Background and study aims Left ventricular assist devices (LVADs) are currently the standard of care in treatment of patients with end-stage heart failure waiting for heart transplant as well as destination therapy for non-transplant candidates. However, patients with LVADs are at increased risk of gastrointestinal bleeding due to the device's unique effects on hemodynamics. A major source of gastrointestinal bleeding in these patients are gastrointestinal angioectasias located within the small bowel that can only be reached with deep enteroscopy. The goal of our study was to determine the safety and efficacy of single-balloon enteroscopy (SBE) in treating gastrointestinal bleeding in patients with LVADs. Patients and methods We present a retrospective case series performed on patients with LVADs who underwent SBE to treat episodes of gastrointestinal bleeding. All procedures were performed at Emory University Hospital by a single endoscopist. Patient demographics, diagnosis and treatment of gastrointestinal bleeding, episodes of re-bleeding, and procedure-related complications were examined. Results A total of 27 SBE procedures performed in 14 patients were reviewed. SBE was performed in an antegrade approach in 89 % (24/27) of cases. Deep intubation was achieved in all antegrade procedures, with the distal jejunum reached in 79 % (19/24) of cases. The diagnostic yield was 78 %. There were no reported complications associated with the procedures. Conclusions SBE is a safe and effective modality to manage gastrointestinal bleeding in patients with LVADs.
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Affiliation(s)
- Abhinav Koul
- Emory University School of Medicine, Department of Medicine, Division of Digestive Diseases, Atlanta, Georgia, United States
| | - Donald M. Pham
- Atlanta Gastroenterology Associates, Duluth, Georgia, United States
| | - Arjun Nanda
- University of Alabama at Birmingham, Department of Gastroenterology and Hepatology, Birmingham, Alabama, United States
| | - Kevin E. Woods
- Emory University School of Medicine, Department of Medicine, Division of Digestive Diseases, Atlanta, Georgia, United States
| | - Steven D. Keilin
- Emory University School of Medicine, Department of Medicine, Division of Digestive Diseases, Atlanta, Georgia, United States,Corresponding author Steven D. Keilin, M.D., Associate Professor of Medicine Director, Pancreaticobiliary ServiceAssociate Director, Advanced Endoscopy FellowshipDivision of GastroenterologyEmory University School of MedicineEmory Clinic, Building B1365 Clifton Road NEAtlanta, GA 30322
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Gastrointestinal Symptoms from Left-Ventricular Assist Device External Compression of the Gastric Lumen. ACG Case Rep J 2016; 3:e180. [PMID: 28008413 PMCID: PMC5171931 DOI: 10.14309/crj.2016.153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/16/2016] [Indexed: 11/17/2022] Open
Abstract
A 74-year-old man with a left-ventricular assist device (LVAD) as destination therapy for end-stage ischemic cardiomyopathy presented with acute upper gastrointestinal bleeding. Other symptoms included chronic early satiety, intermittent nausea, and non-specific abdominal discomfort since LVAD implantation 3 years ago. An actively bleeding duodenal arteriovenous malformation was successfully treated with endoscopic coagulation. There was also evidence of moderate external compression of the anterior gastric wall from the LVAD pump with luminal narrowing in the antrum. While bleeding may be the most commonly encountered gastrointestinal manifestation in LVAD patients, other potential complications, including luminal compression by the device, should be recognized.
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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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Esmaeilzadeh F, Wauters A, Wijns W, Argacha JF, van de Borne P. Effects of HeartWare ventricular assist device on the von Willebrand factor: results of an academic Belgian center. BMC Cardiovasc Disord 2016; 16:155. [PMID: 27485105 PMCID: PMC4969666 DOI: 10.1186/s12872-016-0334-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 07/23/2016] [Indexed: 12/21/2022] Open
Abstract
Background Left Ventricular Assist Device (LVAD) is a promising therapy for patients with advanced heart failure (HF), but bleeding complications remain an important issue. Previous series show that acquired von Willebrand syndrome was present in up to 100 % of first generation LVAD recipients. We report the effects of new generation LVADs on vW factor (vWF) metabolism and activity in our center. Methods Fifteen LVAD recipients (HeartWare®, Framingham, MA, USA) were compared to 12 HF patients, matched for age and body mass index. vWF antigen and activity, as well as D-dimers, were measured on hemostasis analyzers. A vWF LVAD-induced alteration was evocated when the [vWF activity]/[vWF antigen] ratio was <0.6. ADAMTS13 and high molecular weight multimers of vWF were also assessed. Results LVAD recipients had similar levels of endothelial vWF production than the HF subjects (137 ± 14.5 vs. 147 ± 11.7 %; respectively, p = 0.611) but a decreased vWF activity (90 ± 11 vs. 132.6 ± 13 %; respectively, p = 0.017). [vWF activity]/[vWF antigen] ratio was 0.65 ± 0.02 in the LVAD recipients and 0.92 ± 0.06 in the subjects with HF (p = 0.001). ADAMTS13 activity was 80.3 ± 4.7 % in LVAD recipients and 96.2 ± 3.5 % in the HF patients (p = 0.016). LVAD patients disclosed markedly elevated D-dimers (3217.7 ± 735 vs. 680.6 ± 223.2 ng/mL FEU in the HF patients, p = 0.006). The LVAD patients experienced one major hemorrhagic event and one systemic thrombotic event during the median follow-up of 345 days. Conclusions LVAD recipients achieved a new hemostatic equilibrium characterized by infrequent major hemorrhagic and thrombotic events, despite a mildly impaired vWF function and a markedly enhanced thrombin formation. Trial registration ISRCTN39517567 Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0334-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fatemeh Esmaeilzadeh
- Department of Cardiology, Université Libre de Bruxelles (ULB), 808 Lennik Street, 1070, Brussels, Belgium.
| | - Aurélien Wauters
- Department of Cardiology, Université Libre de Bruxelles (ULB), 808 Lennik Street, 1070, Brussels, Belgium
| | - Walter Wijns
- Laboratory of Haemostasis, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jean-François Argacha
- Department of Cardiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Philippe van de Borne
- Department of Cardiology, Université Libre de Bruxelles (ULB), 808 Lennik Street, 1070, Brussels, Belgium
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Acquired von Willebrand syndrome associated with left ventricular assist device. Blood 2016; 127:3133-41. [PMID: 27143258 DOI: 10.1182/blood-2015-10-636480] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 04/24/2016] [Indexed: 12/14/2022] Open
Abstract
Left ventricular assist devices (LVAD) provide cardiac support for patients with end-stage heart disease as either bridge or destination therapy, and have significantly improved the survival of these patients. Whereas earlier models were designed to mimic the human heart by producing a pulsatile flow in parallel with the patient's heart, newer devices, which are smaller and more durable, provide continuous blood flow along an axial path using an internal rotor in the blood. However, device-related hemostatic complications remain common and have negatively affected patients' recovery and quality of life. In most patients, the von Willebrand factor (VWF) rapidly loses large multimers and binds poorly to platelets and subendothelial collagen upon LVAD implantation, leading to the term acquired von Willebrand syndrome (AVWS). These changes in VWF structure and adhesive activity recover quickly upon LVAD explantation and are not observed in patients with heart transplant. The VWF defects are believed to be caused by excessive cleavage of large VWF multimers by the metalloprotease ADAMTS-13 in an LVAD-driven circulation. However, evidence that this mechanism could be the primary cause for the loss of large VWF multimers and LVAD-associated bleeding remains circumstantial. This review discusses changes in VWF reactivity found in patients on LVAD support. It specifically focuses on impacts of LVAD-related mechanical stress on VWF structural stability and adhesive reactivity in exploring multiple causes of AVWS and LVAD-associated hemostatic complications.
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50
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Cochrane J, Jackson C, Schlepp G, Strong R. Gastrointestinal angiodysplasia is associated with significant gastrointestinal bleeding in patients with continuous left ventricular assist devices. Endosc Int Open 2016; 4:E371-7. [PMID: 27004257 PMCID: PMC4798933 DOI: 10.1055/s-0042-101752] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Patients with a continuous-flow left ventricular assist device (LVAD) have a 65 % incidence of bleeding events within the first year. The majority of gastrointestinal bleeding (GIB) is from gastrointestinal angiodyplasia (GIAD). The primary aim of the study was to determine whether GIAD was associated with a higher rate of significant bleeding, an increased number of bleeding events per year, and a higher rate of transfusion compared to non-GIAD sources. PATIENTS AND METHODS This retrospective cohort study included 118 individuals who received a LVAD at a tertiary medical center from 2006 through 2014. Patients were subdivided into GIB and non-GIB for comparison of patient demographics, comorbid conditions, and laboratory data. GIB was further divided into sources of GIB, GIAD, obscure, or non-GIAD to establish severity of bleeding, rate of re-bleeding, and transfusion rate. RESULTS GIAD is associated with an increased number of bleeding events compared to non-GIAD sources of GIB (2.07 vs 1.23, P = 0.01) and a higher number of bleeding events per year (0.806 vs. 0.455 P = 0.001). GIAD compared to non-GIAD sources of GIB was associated with an increased incidence of major bleeding (100 % vs 60 %, P = 0.006) and increased rates of transfusion (8.8 vs 2.95 units, P = 0.0004). Cox Regression analysis between non-GIB and GIAD demonstrated increased risk with age (P = 0.001), history of chronic kidney disease (P = 0.005), and length of stay after LVAD implantation of more than 45 days (P = 0.04). History of hypertension (P = 0.045), diabetes mellitus (P = 0.016), and male gender was associated with decreased risk (P = 0.04). CONCLUSION Patients with a continuous-flow LVAD who develop a GIB secondary to GIAD have a higher rate of major bleeding, multiple bleeding events, and require more transfusions to achieve stabilization compared to patients who do not have GIAD.
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Affiliation(s)
- Justin Cochrane
- Assistant Clinical Associate Professor University of Washington Medical School, Providence Sacred Heart Medical Center Internal Medicine Residency Spokane, Washington, United States,Corresponding author Justin Cochrane, DO 4320 W Deska Dr Apt 109Spokane, WA 99224+1-513-418-1788
| | - Christian Jackson
- Loma Linda University Medical Center, Department of Medicine, Section of Gastroenterology, Loma Linda, California, United States
| | - Greg Schlepp
- Spokane Digestive Disease Center Spokane, Washington, United States
| | - Richard Strong
- Loma Linda University Medical Center, Department of Medicine, Section of Gastroenterology, Loma Linda, California, United States
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