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Mutsuga M. Patient management important for long-term support beyond 5 years in the BTT: republication of the article published in the Japanese Journal of Artificial Organs. J Artif Organs 2024; 27:182-187. [PMID: 38548928 DOI: 10.1007/s10047-024-01441-3] [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: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 08/27/2024]
Abstract
Heart transplantation is considered to be the best treatment for severe heart failure refractory to medical therapy, improving patients' survival and quality of life (QOL). However, the number of donors is smaller than the number of registered applicants for heart transplantation, which increases every year, and the waiting period for heart transplantation has been extended to more than 1700 days by 2022. Since 2011, reimbursement for the implantable left ventricular assist device (iLVAD) was established. The numbers of the iLVAD patients have been increasing year by year. Patients are managed at home with an iLVAD and can live with their families and even return to work, depending on the situation. On the other hand, self-management at home, including caregivers, is important for a safe life. Home management beyond 5 years is becoming more common due to long waiting time for transplant. This article outlines the important aspects of patient management for long-term support. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2023 (Vol. 52, No. 1, pp. 62-66), with some modifications.
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Affiliation(s)
- Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8560, Japan.
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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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Bandaru RR, Rawat A, Jalali I, Isaak AK, Alrahahleh AA, Bataineh SM, Wei CR, Hirani S. Comparing the Efficacy and Safety of Warfarin Monotherapy vs. Warfarin and Aspirin for Adult Patients With Left Ventricular Assist Devices: A Meta-Analysis. Cureus 2024; 16:e53101. [PMID: 38414699 PMCID: PMC10897739 DOI: 10.7759/cureus.53101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2024] [Indexed: 02/29/2024] Open
Abstract
The aim of this meta-analysis was to assess the safety and efficacy of warfarin plus aspirin versus warfarin monotherapy in patients with left ventricular assist devices (LVAD). The present meta-analysis was conducted using the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two authors systematically searched online databases, including PubMed, EMBASE, the Cochrane Library, and Web of Science from inception to December 31, 2023. Outcomes assessed in this meta-analysis included any thrombotic event, bleeding events, and all-cause mortality. A total of five articles were included in the meta-analysis, enrolling a pooled sample size of 876 patients, including 405 in the warfarin monotherapy group and 471 in the warfarin plus aspirin group. Pooled analysis showed that the risk of thrombotic events was not significantly different between the two groups (risk ratio (RR): 0.46, 95% confidence interval (CI): 0.15-1.37). The risk of bleeding events was significantly lower in patients receiving warfarin alone compared to patients receiving aspirin plus warfarin (RR: 0.67, 95% CI: 0.53-0.85). The risk of all-cause mortality was not significantly different between patients receiving warfarin alone and patients receiving aspirin plus warfarin (RR: 0.92, 95% CI: 0.65-1.30). Despite the potential benefits of discontinuing aspirin, the decision should be approached cautiously, considering the undefined risks of discontinuing anticoagulation in LVAD patients.
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Affiliation(s)
| | - Anurag Rawat
- Interventional Cardiology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Illahay Jalali
- Medicine, Tehran University of Medical Sciences, Tehran, IRN
| | - Abraham K Isaak
- Telemetry, Sharp Memorial Hospital, San Diego, USA
- Internal Medicine, Orotta School of Medicine and Dentistry, Asmara, ERI
| | | | | | - Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
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Gangwani MK, Aziz M, Nawras A, Priyanka F, Ahmed Z, Khan RS, Qamar MA, Haroon F, Aziz A, Smith WL, Kirshan Ravi SJ, Parikh V, Alyousif Z, Mahmood A, Tariq R, Rai D, Aronow WS. Predictors of gastrointestinal bleeding in patients following left ventricular assist device implantation: a systematic review and meta-analysis. Future Cardiol 2022; 18:957-967. [PMID: 36334072 DOI: 10.2217/fca-2022-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Aim: Our study aims to provide a more holistic understanding of the available data and predictive risk factors for gastrointestinal bleed (GIB). Materials & methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Web of Science Core Collection and calculated relative risk and meta-regression was utilized to evaluate for risk factors in order to assess the effect of covariates. Results: Our meta-analysis reported a pooled prevalence rate of GIB of 24.4%. Meta-regression analysis did not yield a statistically significant association between GIB and risk factors, including age, gender, hypertension, chronic kidney disease and diabetes. Conclusion: Studies investigating larger sample sizes are required for conclusive findings.
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Affiliation(s)
| | - Muhammad Aziz
- Department of Gastroenetrology, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Ali Nawras
- Department of Gastroenetrology, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Fnu Priyanka
- Department of Medicine, Chandka Medical College, Larkana, Pakistan
| | - Zohaib Ahmed
- Department of Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Raja Samir Khan
- Department of Gastroenetrology, Baylor College of Medicine, Houston, TX 77030, USA
| | | | - Fawad Haroon
- Department of Internal Medicine, Mercy Hospital St. Louis, MO 63141, USA
| | - Abeer Aziz
- Department of Medicine, Aga Khan University, USA
| | - Wade Lee Smith
- Department of Toledo Libraries, University of Toledo, Toledo, OH 43614, USA
| | | | - Vishal Parikh
- Department of Cardiology, Sands Constellation Heart Institute, Rochester Regional Health, Rochester, NY 14621, USA
| | - Zakaria Alyousif
- Department of Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Asif Mahmood
- Department of Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Raseen Tariq
- Department of Gastroenterology, Mayo Clinic, Rochester, MN 55902, USA
| | - Devesh Rai
- Department of Cardiology, Sands Constellation Heart Institute, Rochester Regional Health, Rochester, NY 14621, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA
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Dhawan R. Left ventricular assist devices: review of historical context, clinical indications, and device-related adverse events. Int Anesthesiol Clin 2022; 60:24-30. [PMID: 35993666 DOI: 10.1097/aia.0000000000000375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Richa Dhawan
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Illinois
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Pourtau L, Beneyto M, Porterie J, Roncalli J, Massot M, Biendel C, Fournier P, Itier R, Galinier M, Lairez O, Delmas C. Prevalence, management, and outcomes of haemorrhagic events in left ventricular assist device recipients. ESC Heart Fail 2022; 9:1931-1941. [PMID: 35338605 PMCID: PMC9065835 DOI: 10.1002/ehf2.13899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/07/2022] [Accepted: 03/02/2022] [Indexed: 01/12/2023] Open
Abstract
AIMS Left ventricular assist devices (LVADs) have reduced the mortality of patients with advanced heart failure both as bridge-to-transplant and as destination therapy. However, LVADs are associated with various complications, including bleedings, which affect the prognosis. The aim of the study was to explore the prevalence, management, and outcomes of haemorrhagic adverse events in LVAD recipients. METHODS AND RESULTS We conducted a retrospective, single-centre, cohort study including all patients who received an LVAD from January 2008 to December 2019 in our tertiary centre (Rangueil University Hospital, Toulouse, France). Bleeding events, death, and heart transplantation were collected from electronic medical files. Eighty-eight patients were included, and 43 (49%) presented at least one bleeding event. Gastrointestinal (GI) bleeding was the most frequent (n = 21, 24%), followed by epistaxis (n = 12, 14%) and intracranial haemorrhage (n = 9, 10%). Bleeding events were associated with increased mortality [hazard ratio (HR) 3.8, 95% confidence interval (CI) 1.5-9.3, P < 0.01], particularly in case of intracranial haemorrhage (HR 14.6, 95% CI 4.2-51.1, P < 0.0001). GI bleedings were associated with a trend towards increased mortality (HR 3.0, 95% CI 0.9-9.3, P = 0.05). Each bleeding episode multiplied the risk of death by 1.8 (95% CI 1.2-2.7, P < 0.01). Finally, only early bleedings (<9 months post-implantation) had an impact on mortality (HR 4.2, 95% CI 1.6-11.1, P < 0.01). Therapeutic management was mainly based on temporary interruption of anticoagulation and permanent interruption of antiplatelet therapy. Invasive management was rarely performed. CONCLUSIONS Haemorrhagic events in LVAD recipients are frequent and associated with increased mortality. GI bleedings are the most frequent, and intracranial haemorrhages the most associated with mortality. Management remains empirical requiring more research.
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Affiliation(s)
- Laetitia Pourtau
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Maxime Beneyto
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Jean Porterie
- Department of Cardiovascular SurgeryRangueil University HospitalToulouseFrance
| | - Jerome Roncalli
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
- Medical School of ToulousePaul Sabatier UniversityToulouseFrance
| | - Montse Massot
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Caroline Biendel
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Pauline Fournier
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Romain Itier
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
| | - Michel Galinier
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
- Medical School of ToulousePaul Sabatier UniversityToulouseFrance
| | - Olivier Lairez
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
- Medical School of ToulousePaul Sabatier UniversityToulouseFrance
- Department of Nuclear MedicineRangueil University HospitalToulouseFrance
| | - Clement Delmas
- Department of CardiologyRangueil University Hospital1 avenue Jean Poulhès, TSA 50032Toulouse31059France
- Medical School of ToulousePaul Sabatier UniversityToulouseFrance
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8
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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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Robinson AC, January SE, Botkin KW, Vader JM, Hartupee JC, Tellor Pennington BR. Association of bleeding with serotonergic antidepressants in patients receiving left ventricular assist device support. Pharmacotherapy 2021; 42:4-13. [PMID: 34655495 DOI: 10.1002/phar.2632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/21/2021] [Accepted: 09/25/2021] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE This study sought to determine whether SA use is associated with bleeding in patients receiving CF-LVAD support. DESIGN A retrospective cohort analysis was conducted of all adult patients who received CF-LVAD implantation at our institution. SETTING Barnes-Jewish Hospital between July 1, 2009, and October 1, 2018. PATIENTS Patients at least 18 years of age who received a HVAD™ (HeartWare Corp.), HeartMate II™ (St. Jude Medical), or HeartMate 3™ (St. Jude Medical) CF-LVAD and survived for at least 30 days postoperatively were included. INTERVENTION Patients who received SAs (n = 203) were compared to those who did not (n = 391) from 30 days to 18 months following implantation. The primary outcome was the incidence of first bleeding events including gastrointestinal bleed (GIB), epistaxis, or intracerebral hemorrhage (ICH). MEASUREMENTS AND MAIN RESULTS During follow-up, 219 patients had bleeding events: 93 of 203 (45.8%) in the SA group versus 126 of 391 (32.2%) in the control group (p = 0.001). After adjustment for age, angiotensin-converting enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) use, history of bleeding events, history of smoking, and CF-LVAD type, SA use remained associated with bleeding (adjusted odds ratio: 1.75, 95% confidence interval: 1.22-2.51, p = 0.002). HeartMate 3™ patients experienced less bleeding than HeartMate II™ patients (adjusted odds ratio 0.46, 95% confidence interval: 0.23-0.90, p = 0.024). CONCLUSIONS In this single-center, retrospective cohort of patients supported with CF-LVADs, SA use was associated with the incidence of first bleeding events, primarily driven by GIB. Further studies are needed to assess any differential risk of bleeding among SA agents and to assess the utility of altering antithrombotic strategies.
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Affiliation(s)
- Adam C Robinson
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Kent W Botkin
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Justin M Vader
- Division of Cardiovascular Diseases, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Justin C Hartupee
- Division of Cardiovascular Diseases, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
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10
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Wilson TJ, Baran DA, Herre JM, Cameron CM, Yehya A, Ingemi AI. Gastrointestinal Bleeding Rates in Left Ventricular Assist Device Population Reduced with Octreotide Utilization. ASAIO J 2021; 67:989-994. [PMID: 33369929 PMCID: PMC8404958 DOI: 10.1097/mat.0000000000001342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Patients with continuous-flow left ventricular assist devices have a high risk of gastrointestinal bleeding (GIB) and recurrent bleeding. Studies have shown octreotide can reduce the risk of GIB. This retrospective, case-crossover study, evaluated the efficacy of octreotide for the prevention of recurrent GIB in patients with left ventricular assist devices between August 2008 and October 2018. A total of 32 patients received octreotide and were included in the study. Hospital admission for GIB was evaluated before and after the initiation of octreotide. Each case served as his/her own control. Most patients were on a reduced aspirin dose (56.2%) and had a reduced international normalized ratio goal (59.4%) before starting monthly octreotide. The most common dose of long-acting octreotide was 30 mg every 28 days. Overall, octreotide decreased the frequency of GIB (4.3 vs. 0.9 events/year, p < 0.001). Nineteen (59.4%) patients did not have a subsequent gastrointestinal bleed. Of the 13 patients who rebled after initiation of octreotide, the frequency of events decreased by 2.6 bleeds per patient per year (4.8 vs. 2.2; p = 0.043). In high-risk patients who have failed conventional therapy, octreotide can be useful for the prevention of recurrent GIB.
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Affiliation(s)
- Tyler J. Wilson
- From the Pharmacy Department, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - David A. Baran
- Advanced Heart Failure Center, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - John M. Herre
- Advanced Heart Failure Center, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - Chad M. Cameron
- From the Pharmacy Department, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - Amin Yehya
- Advanced Heart Failure Center, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - Amanda I. Ingemi
- From the Pharmacy Department, Sentara Norfolk General Hospital, Norfolk, Virginia
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11
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Preoperative Right Heart Dysfunction and Gastrointestinal Bleeding in Patients with Left Ventricular Assist Devices. ASAIO J 2021; 67:324-331. [PMID: 33627608 DOI: 10.1097/mat.0000000000001224] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Gastrointestinal bleeding (GIB) is a common cause of morbidity among patients supported by left ventricular assist devices (LVADs). The aim of this study was to identify if pre-LVAD right ventricular (RV) dysfunction is associated with risk of GIB after LVAD implantation. Of 398 patients implanted with LVADs between July 2008 and July 2016, 130 (33%) developed GIB at a median of 2.6 months following LVAD implantation. Arteriovenous malformations (AVMs) were found in 42 (34%) GIB patients. Patients with GIB were older and more likely to have hypertension, diabetes, and ischemic cardiomyopathy. On pre-LVAD echocardiography, GIB patients had increased RV diastolic dimension (4.7 ± 0.8 vs. 4.4 ± 0.9 cm, p = 0.02), a higher rate of greater than mild tricuspid valve (TV) regurgitation (73 [60%] vs. 120 [47%], p = 0.006), and underwent TV repair more often (38 [30%] vs. 43 [16%], p = 0.0006) during LVAD implantation. After multivariable adjustment, preoperative greater than mild RV enlargement (hazard ratio [HR] 2.32, 95% CI 1.12-5.03; p = 0.03), TV regurgitation (HR 1.83, CI 1.02-3.44; p = 0.01), and TV repair (HR 3.76, confidence interval [CI] 1.02-4.44; p = 0.01) remained associated with risk of GIB. This finding was driven by the AVM-GIB subgroup. Preoperative RV enlargement and TV regurgitation are associated with post-LVAD AVM-related GIB.
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Patel M, Ahuja T, Arnouk S, Gidea C, Reyentovich A, Smith DE, Moazami N, Papadopoulos J, Lewis TC. Comparison of Outcomes of Enoxaparin Bridge Therapy in HeartMate II versus HeartWare HVAD Recipients. J Cardiovasc Pharmacol Ther 2021; 26:473-479. [PMID: 33844604 DOI: 10.1177/10742484211006998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a lack of robust data evaluating outcomes of enoxaparin "bridge" therapy in left ventricular assist device (LVAD) patients. METHODS We performed a retrospective study of HeartMate II (HM II) and HeartWare HVAD recipients that received therapeutic enoxaparin as "bridge" therapy to describe bleeding and thrombotic events and compare outcomes between devices. The primary endpoint was the incidence of bleeding within 30 days of "bridge" episode. Major bleeding was defined by INTERMACS criteria. RESULTS We evaluated 257 "bridge" episodes in 54 patients, 35 with a HM II device and 19 with an HVAD device that underwent 176 and 81 bridging episodes, respectively. The median INR prior to "bridge" was lower in the HM II group compared to the HVAD group (1.5 vs 1.7, P < .01), however, there was no difference in the median duration of "bridge" therapy (7 vs 7 days, P = .42). There were a total of 30 (12%) bleeding episodes, with the majority in the HM II group vs HVAD (26 [15%] vs 4 [5%], P = .02). We observed 3 (1%) thromboembolic events in 2 (4%) patients with an HVAD device. On multivariate analysis, the presence of a HM II device was associated with a 4-fold increased risk of bleeding. CONCLUSION We found the use of enoxaparin "bridge" therapy to be associated with a higher incidence of bleeding in patients with a HM II device compared with an HVAD device. Assessment of device- and patient-specific factors should be evaluated to minimize bleeding events.
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Affiliation(s)
- Mitulkumar Patel
- Department of Pharmacy, 12297NYU Langone Health, New York, NY, USA
| | - Tania Ahuja
- Department of Pharmacy, 12297NYU Langone Health, New York, NY, USA
| | - Serena Arnouk
- Department of Pharmacy, 12297NYU Langone Health, New York, NY, USA
| | - Claudia Gidea
- Department of Cardiology, 12297NYU Langone Health, New York, NY, USA
| | - Alex Reyentovich
- Department of Cardiology, 12297NYU Langone Health, New York, NY, USA
| | - Deane E Smith
- Department of Cardiothoracic Surgery, 12297NYU Langone Health, New York, NY, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, 12297NYU Langone Health, New York, NY, USA
| | | | - Tyler C Lewis
- Department of Pharmacy, 12297NYU Langone Health, New York, NY, USA
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13
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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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14
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Prothrombin Complex Concentrate for Warfarin Reversal in Patients with Continuous-Flow Left Ventricular Assist Devices: A Narrative Review. ASAIO J 2020; 66:482-488. [PMID: 31192853 DOI: 10.1097/mat.0000000000001021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Durable left ventricular assist device (LVAD) recipients require long-term anticoagulation to prevent thromboembolic complications. Their management is complicated by the risk of bleeding, which may require rapid anticoagulation reversal. We conducted a narrative review of data published from January 2007 to September 2018, analyzing anticoagulation reversal strategies in patients with durable, continuous-flow LVADs. The aim of this review is to provide guidance for reversal strategies in patients with LVADs experiencing bleeding complications or needing urgent surgical procedures, incorporating four-factor prothrombin complex concentrate (4F-PCC). Most data were from small, retrospective studies. Data for 4F-PCC use were more robust for heart transplant than for other surgical procedures or bleeding management. In patients undergoing heart transplant, 4F-PCC reversed warfarin more rapidly and reduced total blood product use versus other reversal strategies. Most surgical procedures were conducted without excess bleeding when utilizing 4F-PCCs. Time to warfarin reversal was shorter when managing intracranial hemorrhage with 4F-PCC. No differences in thromboembolic rates between 4F-PCC and control groups were observed. Overall, the use of 4F-PCC resulted in more rapid and predictable warfarin reversal in LVAD patients with no apparent risk of thromboembolism. Well-designed, larger prospective trials are required to better define 4F-PCC use in patients with LVADs.
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15
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Williams NX, Carroll B, Noyce SG, Hobbie HA, Joh DY, Rogers JG, Franklin AD. Fully printed prothrombin time sensor for point-of-care testing. Biosens Bioelectron 2020; 172:112770. [PMID: 33157410 DOI: 10.1016/j.bios.2020.112770] [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: 10/01/2020] [Accepted: 10/25/2020] [Indexed: 01/14/2023]
Abstract
With an increasing number of patients relying on blood thinners to treat medical conditions, there is a rising need for rapid, low-cost, portable testing of blood coagulation time or prothrombin time (PT). Current methods for measuring PT require regular visits to outpatient clinics, which is cumbersome and time-consuming, decreasing patient quality of life. In this work, we developed a handheld point-of-care test (POCT) to measure PT using electrical transduction. Low-cost PT sensors were fully printed using an aerosol jet printer and conductive inks of Ag nanoparticles, Ag nanowires, and carbon nanotubes. Using benchtop control electronics to test this impedance-based biosensor, it was found that the capacitive nature of blood obscures the clotting response at frequencies below 10 kHz, leading to an optimized operating frequency of 15 kHz. When printed on polyimide, the PT sensor exhibited no variation in the measured clotting time, even when flexed to a 35 mm bend radius. In addition, consistent PT measurements for both chicken and human blood illustrate the versatility of these printed biosensors under disparate operating conditions, where chicken blood clots within 30 min and anticoagulated human blood clots within 20-100 s. Finally, a low-cost, handheld POCT was developed to measure PT for human blood, yielding 70% lower noise compared to measurement with a commercial potentiostat. This POCT with printed PT sensors has the potential to dramatically improve the quality of life for patients on blood thinners and, in the long term, could be incorporated into a fully flexible and wearable sensing platform.
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Affiliation(s)
- Nicholas X Williams
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Brittani Carroll
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Steven G Noyce
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Hansel Alex Hobbie
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Daniel Y Joh
- Department of Biomedical Engineering, Duke University, Durham, NC, 27708, USA
| | - Joseph G Rogers
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, NC, 27708, USA
| | - Aaron D Franklin
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA; Department of Chemistry, Duke University, Durham, NC, 27708, USA.
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16
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McNally AP, Bandy NL, Yahn C, Luo J, Collins J. Gastrointestinal Bleeding in Mechanical Cardiac Support. Am Surg 2020; 87:142-146. [PMID: 32866039 DOI: 10.1177/0003134820945265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mechanical cardiac support (MCS) is a lifesaving therapy option in patients with heart failure and other medical disorders. However, there is an associated risk of gastrointestinal bleeding (GIB). The goal of this study was to determine GIB incidence and associated risk factors. METHODS All patients at one institution from 2009 to 2018 under durable and nondurable support were retrospectively reviewed for GIB during their MCS period. Clinical records were evaluated for patient demographics, GIB characteristics, and interventions. Univariate and multivariate analyses were performed to compare patient groups. RESULTS A total of 427 patients were reviewed, with 111 (25.9%) patients representing 218 episodes of GIB during our study period. The incidence rate from support initiation to GIB was 44.9% by 6 months and 60.6% in 12 months, occurring at a mean of 216.7 days. Higher rates of bleeding were found in patients with hypertension (82% vs 71.5%; P = .03) and diabetes mellitus (62.2% vs 38.3%; P < .0001), as well as pulmonary (48.7% vs 35.4%; P = .014), hepatic (21.6% vs 10.4%; P = .003), and renal disease (48.7% vs 37.3%; P = .037). Endoscopy revealed an upper GI source in 56% (n = 123) of bleeds. The most common etiology of bleeding included angiodysplasia/vascular malformation (35.7%). Therapeutic intervention was performed in 109 (50%) cases, with only 1 surgical intervention. DISCUSSION Overall, GIB can be a significant adverse event in patients under mechanical cardiac support, so proper management of anticoagulation and early endoscopy evaluation remains of great importance.
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Affiliation(s)
- Alexander P McNally
- 6040Department of Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Nicholas L Bandy
- 6040Department of Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Colten Yahn
- 6040Department of Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jiangtao Luo
- EVMS-Sentara Healthcare Analytics and Delivery Science Institute (HADSI), Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jay Collins
- 6040Department of Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
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17
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Carlson LA, Maynes EJ, Choi JH, Hallett AM, Horan DP, Weber MP, Deb AK, Patel S, Samuels LE, Morris RJ, Entwistle JW, Massey H, Tchantchaleishvili V. Characteristics and outcomes of gastrointestinal bleeding in patients with continuous‐flow left ventricular assist devices: A systematic review. Artif Organs 2020; 44:1150-1161. [DOI: 10.1111/aor.13725] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/24/2020] [Accepted: 05/01/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Laura A. Carlson
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | | | - Jae Hwan Choi
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Andrew M. Hallett
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Dylan P. Horan
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Matthew P. Weber
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Avijit K. Deb
- Philadelphia College of Osteopathic Medicine Philadelphia PA USA
| | - Sinal Patel
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Louis E. Samuels
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Rohinton J. Morris
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - John W. Entwistle
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - H. Massey
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
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18
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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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Namdaran P, Zikos TA, Pan JY, Banerjee D. Thalidomide Use Reduces Risk of Refractory Gastrointestinal Bleeding in Patients with Continuous Flow Left Ventricular Assist Devices. ASAIO J 2020; 66:645-651. [PMID: 31425265 DOI: 10.1097/mat.0000000000001054] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Gastrointestinal (GI) bleeding is a common complication seen in patients with implanted continuous flow left ventricular assist devices (CF-LVAD), often attributed to arteriovenous malformations (AVMs). Whether thalidomide reduces recurrent GI bleeding risk in CF-LVAD patients has been incompletely evaluated. We conducted a retrospective review of all CF-LVAD patients at our institution with GI bleeding from AVMs who had a trial both off and on thalidomide. The primary endpoint was time to rebleed, while secondary endpoints included overall GI bleeding events, packed red blood cell (PRBC) transfusion requirements, and adverse events related to thalidomide. We report on 24 patients with recurrent AVM-associated GI bleeding who met criteria for and received thalidomide therapy, of which 17 had sufficient follow-up to be ultimately included for final analysis. We found the risk of rebleeding was significantly reduced in those on thalidomide therapy versus off (hazard ratio = 0.23, p = 0.022). The median number of GI bleeds per year was reduced from 4.6 to 0.4 (p = 0.0008) and the PRBC requirement was lower (36.1 vs. 0.9 units per year, p = 0.004) in those on thalidomide therapy. The adverse event rate with thalidomide was 59%, with symptoms resolution in most following dose reduction without increased bleeding. Thalidomide reduced the risk of AVM-associated GI rebleeding, number of bleeding events, and PRBC requirements in CF-LVAD patients. When initiating therapy, potential side effects and overall clinical context should be considered.
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Affiliation(s)
- Parhum Namdaran
- From the Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Y Pan
- Division of Gastroenterology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Dipanjan Banerjee
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
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Mondal S, Sankova S, Lee K, Sorensen E, Kaczorowski D, Mazzeffi M. Intraoperative and Early Postoperative Management of Patients Undergoing Minimally Invasive Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2020; 35:616-630. [PMID: 32505605 DOI: 10.1053/j.jvca.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Susan Sankova
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Khang Lee
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Erik Sorensen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - David Kaczorowski
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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AXELRAD JORDANE, FAYE ADAMS, PINSINO ALBERTO, THANATAVEERAT ANUSORN, CAGLIOSTRO BARBARA, PINEDA MARIEFINELLET, ROSS KATHERINE, TE-FREY ROSIET, EFFNER LISA, GARAN ARTHURR, TOPKARA VELIK, TAKAYAMA HIROO, TAKEDA KOJI, NAKA YOSHIFUMI, RAMIREZ IVONNE, GARCIA-CARRASQUILLO REUBEN, COLOMBO PAOLOC, GONDA TAMAS, YUZEFPOLSKAYA MELANA. Endoscopic Algorithm for Management of Gastrointestinal Bleeding in Patients With Continuous Flow LVADs: A Prospective Validation Study. J Card Fail 2020; 26:324-332. [PMID: 31794863 PMCID: PMC9936864 DOI: 10.1016/j.cardfail.2019.11.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/07/2019] [Accepted: 11/27/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a common complication of left ventricular assist device (LVAD) therapy accounting for frequent hospitalizations and high resource utilization. METHODS We previously developed an endoscopic algorithm emphasizing upfront evaluation of the small bowel and minimizing low-yield procedures in LVAD recipients with GIB. We compared the diagnostic and therapeutic yield of endoscopy, health-care costs, and re-bleeding rates between conventional GIB management and our algorithm using chi-square, Fisher's exact test, Wilcoxon-Mann-Whitney, and Kaplan-Meier analysis. RESULTS We identified 33 LVAD patients with GIB. Presentation was consistent with upper GIB in 20 (61%), lower GIB in 5 (15%), and occult GIB in 8 (24%) patients. Forty-one endoscopies localized a source in 23 (56%), resulting in 14 (34%) interventions. Algorithm implementation compared with our conventional cohort was associated with a 68% increase in endoscopic diagnostic yield (P< .01), a 113% increase in therapeutic yield (P= .01), a 27% reduction in the number of procedures per patient (P < .01), a 33% decrease in length of stay (P < .01), and an 18% reduction in estimated costs (P < .01). The same median number of red blood cell transfusions were used in the 2 cohorts, with no increase in re-bleeding events in the algorithm cohort (33.3%) compared with our conventional cohort (43.7%). CONCLUSIONS Our endoscopic management algorithm for GIB in LVAD patients proved effective in reducing low-yield procedures, improving the diagnostic and therapeutic yield of endoscopy, and decreasing health-care resource utilization and costs, while not increasing the risk of a re-bleeding event.
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Affiliation(s)
- JORDAN E. AXELRAD
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York,Division of Gastroenterology, Department of Medicine, NYU School of Medicine, New York, New York
| | - ADAM S. FAYE
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York
| | - ALBERTO PINSINO
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | | | - BARBARA CAGLIOSTRO
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - MARIE FINELLE T. PINEDA
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - KATHERINE ROSS
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - ROSIE T. TE-FREY
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - LISA EFFNER
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - ARTHUR R. GARAN
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - VELI K. TOPKARA
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - HIROO TAKAYAMA
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - KOJI TAKEDA
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - YOSHIFUMI NAKA
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - IVONNE RAMIREZ
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York
| | - REUBEN GARCIA-CARRASQUILLO
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York
| | - PAOLO C. COLOMBO
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - TAMAS GONDA
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York
| | - MELANA YUZEFPOLSKAYA
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
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Gastrointestinal Bleeding After HeartMate II or HVAD Implantation: Incidence, Location, Etiology, and Effect on Survival. ASAIO J 2020; 66:283-290. [DOI: 10.1097/mat.0000000000000998] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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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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The incidence, risk factors, and outcomes of gastrointestinal bleeding in patients with a left ventricular assist device: a Japanese single-center cohort study. J Artif Organs 2019; 23:27-35. [PMID: 31705323 DOI: 10.1007/s10047-019-01138-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 10/05/2019] [Indexed: 01/12/2023]
Abstract
Continuous flow-left ventricular assist devices (CF-LVADs) have become a therapeutic option in the management of advanced heart failure. Several studies show that patients with CF-LVAD are at an increased risk of gastrointestinal bleeding (GIB). However, few reports have presented the characteristics of GIB in Japanese populations. We investigated the incidence, etiology, and outcome of GIB in patients with CF-LVAD. Records of adult patients who received CF-LVADs between October 2008 and January 2017 were reviewed. GIB was defined as detection of bleeding sites by any type of diagnostic imaging. 54 patients received CF-LVAD, of which eight (14%) presented with overt GIB (12 events). GIB patients are significantly older (p = 0.04) and their pre-operative inferior vena cava diameter was larger (p = 0.02). Multivariate analysis revealed that the use of Jarvik 2000 (p = 0.003) was a risk factor for GIB. In total, 85.8% of patients were free from GIB at 1 year. The most common site was the small intestine (67%). The most common cause was angiodysplasia (50%). Six patients required blood transfusion (nine events) and four underwent endoscopic clippings (five events); however, no patients needed surgeries. The incidence of GIB in our cohort was similar to the global registry data. Double balloon endoscopy is useful for diagnosis and treatment of small intestinal lesions. Future efforts to further understand the incidence of GIB in Japanese populations by multicenter data are needed.
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Yin MY, Ruckel S, Kfoury AG, McKellar SH, Taleb I, Gilbert EM, Nativi-Nicolau J, Stehlik J, Reid BB, Koliopoulou A, Stoddard GJ, Fang JC, Drakos SG, Selzman CH, Wever-Pinzon O. Novel Model to Predict Gastrointestinal Bleeding During Left Ventricular Assist Device Support. Circ Heart Fail 2019; 11:e005267. [PMID: 30571195 DOI: 10.1161/circheartfailure.118.005267] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a leading cause of morbidity during continuous-flow left ventricular assist device (CF-LVAD) support. GIB risk assessment could have important implications for candidate selection, informed consent, and postimplant therapeutic strategies. The aim of the study is to derive and validate a predictive model of GIB in CF-LVAD patients. METHODS AND RESULTS CF-LVAD recipients at the Utah Transplantation Affiliated Hospitals program between 2004 and 2017 were included. GIB associated with a decrease in hemoglobin ≥2 g/dL was the primary end point. A weighted score comprising preimplant variables independently associated with GIB was derived and internally validated. A total of 351 patients (median age, 59 years; 82% male) were included. After a median of 196 days, GIB occurred in 120 (34%) patients. Independent predictors of GIB included age >54 years, history of previous bleeding, coronary artery disease, chronic kidney disease, severe right ventricular dysfunction, mean pulmonary artery pressure <18 mm Hg, and fasting glucose >107 mg/dL. A weighted score termed Utah bleeding risk score, effectively stratified patients based on their probability of GIB: low (0-1 points) 4.8%, intermediate (2-4) 39.8%, and high risk (5-9) 83.8%. Discrimination was good in the development sample (c-index: 0.83) and after internal bootstrap validation (c-index: 0.74). CONCLUSIONS The novel Utah bleeding risk score is a simple tool that can provide personalized GIB risk estimates in CF-LVAD patients. This scoring system may assist clinicians and investigators in designing tailored risk-based strategies aimed at reducing the burden posed by GIB in the individual CF-LVAD patient and healthcare systems.
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Affiliation(s)
- Michael Yaoyao Yin
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
| | - Shane Ruckel
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
| | - Abdallah G Kfoury
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Salt Lake City, UT (A.G.K., B.B.R.)
| | - Stephen H McKellar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City (S.H.M., A.K., G.J.S., C.H.S.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Iosif Taleb
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
| | - Edward M Gilbert
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Jose Nativi-Nicolau
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Josef Stehlik
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Bruce B Reid
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Salt Lake City, UT (A.G.K., B.B.R.)
| | - Antigone Koliopoulou
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City (S.H.M., A.K., G.J.S., C.H.S.)
| | - Gregory J Stoddard
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City (S.H.M., A.K., G.J.S., C.H.S.)
| | - James C Fang
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
| | - Stavros G Drakos
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City (S.H.M., A.K., G.J.S., C.H.S.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
| | - Omar Wever-Pinzon
- Division of Cardiology, Department of Medicine (M.Y.Y., S.R., I.T., E.M.G., J.N.-N., J.S., G.J.S., J.C.F., S.G.D., O.W.-P.)
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT (S.H.M., E.M.G., J.N.-N., J.S., J.C.F., S.G.D., C.H.S., O.W.-P.)
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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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Usman MS, Ahmed S, Yamani N, Akhtar T, Asmi N, Siddiqi TJ, Khan SU, Doukky R, Khan MS. Meta-Analysis of the Effect of Preoperative Atrial Fibrillation on Outcomes After Left Ventricular Assist Device Implantation. Am J Cardiol 2019; 124:158-162. [PMID: 31047654 DOI: 10.1016/j.amjcard.2019.03.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 11/28/2022]
Abstract
The effect of preoperative atrial fibrillation (AF) on clinical outcomes after left ventricular assist device (LVAD) implantation remains uncertain. We sought to conduct a meta-analysis to assess the safety and efficacy of LVAD implantation in AF patients. Medline and Scopus were searched for studies that assessed the effect of preoperative AF on clinical outcomes in patients who underwent LVAD implantation. Outcomes of interest included all-cause mortality, thromboembolic events, and bleeding. Estimates were combined using random effects model to calculate risk ratios (RRs) with 95% confidence intervals. In this meta-analysis of 7 studies including 5,658 patients, preoperative AF was not associated with increased risk of all-cause mortality at 30 days (RR = 0.84 [0.51, 1.37]; p = 0.49; I2 = 0%), 6 months (RR = 1.17 [0.96, 1.14]; p = 0.11; I2 = 21%), 1 year (RR = 1.16 [0.84, 1.60]; p = 0.37; I2 = 53%) and 2 years (RR = 1.14 [0.96, 1.36]; p = 0.12; I2 = 23%). Preoperative AF did not increase the risk of thromboembolism (RR = 0.86 [0.38, 1.92]; p = 0.71; I2 = 26%), pump thrombosis (RR = 1.22 [0.88, 1.68]; p = 0.23; I2 = 49%), stroke (RR = 1.02 [0.87, 1.19]; p = 0.79; I2 = 11%), or major bleeding (RR = 0.86 [0.38, 1.92]; p = 0.71; I2 = 26%) after LVAD implantation. However, AF was associated with significantly increased risk of gastro-intestinal bleeding in patients receiving LVADs (RR = 1.27 [1.05, 1.55]; p = 0.014; I2 = 0%). In conclusion, this meta-analysis reports a significantly increased risk of gastrointestinal (GI) bleeding in LVADs recipients having concomitant AF. However, AF had no significant effect on all-cause mortality, stroke, or thromboembolic events in these patients. Further well-conducted studies are needed to validate these results.
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Affiliation(s)
| | - Saba Ahmed
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Naser Yamani
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Tauseef Akhtar
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Nisar Asmi
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, Illinois
| | | | - Safi U Khan
- Department of Internal Medicine, West Virginia University, Morgantown, West Virginia
| | - Rami Doukky
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, Illinois; Division of Cardiology, Rush University Medical Center, Chicago, Illinois
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Stoppe C, Nesterova E, Elke G. Nutritional support in patients with extracorporeal life support and ventricular assist devices. Curr Opin Crit Care 2019; 24:269-276. [PMID: 29847341 DOI: 10.1097/mcc.0000000000000512] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Extracorporeal life support (ECLS) including venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD) provide mechanical pulmonary and circulatory support, respectively, in patients with acute pulmonary or cardiovascular failure. This review discusses recently published data regarding specific topics of nutritional support in patients with ECLS and VAD. RECENT FINDINGS ECLS may aggravate loss of endogenous and exogenous micronutrients and macronutrients. Observational studies have shown that enteral nutrition is feasible and most commonly used in patients with ECLS. Indirect calorimetry may be feasible for measuring energy expenditure during ECLS. Specific tools are available to assess malnutrition or nutrition risk in patients with VAD but require further validation in the perioperative setting. If parenteral nutrition is indicated, the use of intravenous lipid emulsions may be associated with membrane oxygenator dysfunction of the ECLS device or increased infectious risk in patients with VAD. SUMMARY Despite the exponential use of ECLS and VAD over the last decade, the role of nutrition on clinical outcome in this patient population remains an important but yet underinvestigated field.
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Affiliation(s)
- Christian Stoppe
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Ekaterina Nesterova
- Department of Anesthesiology and Intensive Care Medicine, National Pirogov Surgical Medical Center, Moscow, Russia
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Stoppe C, Whitlock R, Arora RC, Heyland DK. Nutrition support in cardiac surgery patients: Be calm and feed on! J Thorac Cardiovasc Surg 2019; 158:1103-1108. [PMID: 31202453 DOI: 10.1016/j.jtcvs.2019.02.132] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Christian Stoppe
- Department of Intensive Care Medicine and 3CARE, University Hospital of the RWTH Aachen, Aachen, Germany.
| | - Richard Whitlock
- Department of Surgery, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Rakesh C Arora
- Department of Surgery, Max Rady College, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University and the Clinical Evaluation Research Unit, Angada 4, Kingston General Hospital, Kingston, Ontario, Canada
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Thohan V, Shi Y, Rappelt M, Yousefzai R, Sulemanjee NZ, Hastings TE, Cheema OM, Downey F, Crouch JD. The association between novel clinical factors and gastrointestinal bleeding among patients supported with continuous-flow left ventricular assist device therapy. J Card Surg 2019; 34:453-462. [PMID: 31058372 DOI: 10.1111/jocs.14062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/15/2019] [Accepted: 04/11/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study explores novel preimplantation risk factors associated with gastrointestinal bleeding (GIB) after continuous-flow left ventricular assist device (CF-LVAD) implantation. CF-LVAD therapy implantation for patients with advanced heart failure is associated with a 20% to 40% incidence of GIB. METHODS This study includes patients receiving CF-LVAD at a quaternary medical center from 2006 to 2014 (n = 254). The primary endpoint was GIB within 12 months after implantation; the secondary outcome was 3-year all-cause mortality. The Student t test or the χ2 test compared continuous or categorical variables. Competing risks analysis calculated the cumulative incidence of GIB postimplantation. Cox proportional hazards model was used for univariate/multivariate models predicting GIB. RESULTS Sixty-four patients had GIB, with incidence rates at 1, 3, and 12 months of 11.8%, 19.3%, and 25.2%, respectively. Endoscopy revealed no identified source of bleeding in 41%; 33% of lesions were localized in the upper gastrointestinal tract, with the bulk (39%) categorized as vascular. Patients with prior gastrointestinal abnormalities (n = 98) had a greater risk of GIB post-CF-LVAD (HR 1.85 [1.11-3.09]; P = 0.02) than those with normal gastrointestinal evaluation results (n = 45) and those without preimplantation gastrointestinal evaluation (n = 111). Baseline blood urea nitrogen, chronic obstructive pulmonary disease, and prior percutaneous coronary intervention were statistically associated with post-CF-LVAD GIB. The presence of GIB within 12 months of CF-LVAD implantation was associated with an increased risk of 3-year all-cause mortality (HR 2.57 [1.57-4.15]; P < 0.01). CONCLUSIONS First-year GIB is associated with increased mortality post-CF-LVAD. We advocate a closer examination of several GIB risk factors when evaluating CF-LVAD candidates.
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Affiliation(s)
- Vinay Thohan
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - Yang Shi
- Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin
| | - Matthew Rappelt
- Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin
| | - Rayan Yousefzai
- Department of Cardiology, Brown University, Providence, Rhode Island
| | - Nasir Z Sulemanjee
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - Thomas E Hastings
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - Omar M Cheema
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - Frank Downey
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
| | - John D Crouch
- Aurora Cardiovascular Services, Aurora Health Care, Milwaukee, Wisconsin
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Shah R, Qayed E. Outcomes and Predictors of Readmissions with GI Bleeding in Patients with Left Ventricular Assist Devices. South Med J 2019; 111:666-673. [PMID: 30392001 DOI: 10.14423/smj.0000000000000883] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Gastrointestinal (GI) bleeding is a major comorbidity in patients with left ventricular assist devices (LVADs). The study aim was to estimate the rate of hospital readmissions for GI bleeding in patients with LVADs using a nationally representative database. Additionally, we evaluated the etiologies, costs, endoscopy utilization, mortality, and predictors of GI bleeding readmissions in these patients. METHODS We analyzed data from the National Readmissions Database (NRD) from 2010 through 2014. We compared hospitalized adult patients with congestive heart failure (CHF) who underwent LVAD implantation (cases) with CHF patients without LVAD or heart transplant (controls). Three age- and sex-matched controls were randomly selected per single case. A multivariate Cox regression model was used to compare the hazards of 60-day all-cause and GI bleeding readmission between the groups, controlling for significant confounders. RESULTS A total of 3293 hospitalized patients with CHF who had LVAD placement (cases) and 9879 who did not have LVADs (controls) were included in the study. At 60 days, patients with LVAD had a significantly higher readmission rate with GI bleeding (8.7% vs 2.3%, adjusted hazard ratio [aHR] 4.45, 95% confidence interval 3.71-5.33, P < 0.0001). The all-cause readmission rate also was higher (43.3% vs 35.7%, aHR 1.23, 95% confidence interval 1.12-1.34, P < 0.0001). The most common etiologies of bleeding in patients with LVADs were gastroduodenal and small intestinal arteriovenous malformations (28.6%). During bleeding readmissions, patients with LVAD were more likely to undergo endoscopy (72.1% vs 33.5%, P < 0.0001) and receive packed red blood cell transfusions (62% vs 36.6%, P< 0.0001) compared with controls. GI bleeding readmissions were more costly ($40,936 vs $35,313, P< 0.0001), and longer (12 vs 10.9 days, P< 0.0001) in patients with LVADs compared with controls. Independent risk factors for 60-day GI bleeding readmission were increasing age (aHR 1.04, P< 0.0001) and GI bleeding during index admission (aHR 2.68, P< 0.0001). In those without bleeding during index admission, increasing age and chronic anemia were associated with 60-day GI bleeding readmission. Mortality during bleeding readmission was similarly low in patients with LVADs compared with CHF controls (0.2% vs 0.3%, P = 0.14). CONCLUSIONS After LVAD implantation, there is a fivefold increased risk of readmission with GI bleeding within 60 days. Gastroduodenal and small intestinal arteriovenous malformations are the most common culprit lesions. These findings suggest that small bowel enteroscopy should be considered as the initial test of choice in patients with suspected upper gastroduodenal bleeding. Readmissions with bleeding in patients with LVADs increase morbidity and cost of care but not mortality. Older patients and those with a history of bleeding during LVAD implantation are at higher risk of bleeding readmission and may benefit from close monitoring and cautious anticoagulation to prevent rebleeding.
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Affiliation(s)
- Rushikesh Shah
- From the Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Emad Qayed
- From the Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
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Gastrointestinal Bleeding With Left Ventricular Assist Devices (LVAD): Locating the Leak and Identifying Outcomes. J Clin Gastroenterol 2019; 53:e202-e207. [PMID: 29688916 DOI: 10.1097/mcg.0000000000001041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND GOALS Gastrointestinal bleeding (GIB) is a significant complication following left ventricular assist device (LVAD) implantation. We evaluated the incidence, predictors, endoscopic findings, and outcomes of GIB in LVAD recipients. STUDY Retrospective review of 205 adult patients undergoing HeartMate II LVAD implantation from January 2012 to June 2016. Patients were reviewed and separated into GIB (n=57; 28%) and non-GIB (n=148; 72%) groups. RESULTS Median time to GIB was 55 (range, 3 to 730) days. The GIB group patients were older (61±12 vs. 56±13, P=0.0042), more often underwent concomitant tricuspid valve (TV) repair (16% vs. 4%, P=0.007), and a higher percentage were assigned for destination therapy (75% vs. 55%, P=0.01). Angioectasia (33%) was the most common identified cause of GIB. Median time to endoscopic intervention was 1 day. The total number of hospital readmissions after LVAD was higher in the GIB group (median of 5 vs. 3, P=0.001), as was the total number of blood products transfused after LVAD (29 vs. 13, P≤0.0001). GIB was associated with an increased risk of death (hazard ratio, 1.94; 95% confidence interval, 1.16-3.25; P=0.01) and the mortality rate during hospitalization for GIB was 11% (P=0.0004). Receiving a heart transplant was associated with a decreased hazard of death (hazard ratio, 0.40; 95% confidence interval, 0.19-0.85; P=0.016). CONCLUSIONS Older age and destination therapy as implant strategy were found to be associated with an increased risk of GIB, consistent with previous studies. A unique finding in our study is the association of TV repair with a higher incidence of GIB. Further studies are needed to investigate possible mechanisms by which TV repair increases the incidence of GIB.
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Gastrointestinal Bleeding in Left Ventricular Assist Device: Octreotide and Other Treatment Modalities. ASAIO J 2019; 64:433-439. [PMID: 29406356 DOI: 10.1097/mat.0000000000000758] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Left ventricular assist devices (LVADs) offer a therapeutic strategy for patients with end-stage heart failure. Increased device utilization has also increased the incidence of device-related complications including gastrointestinal bleeding (GIB). Multiple mechanisms have been proposed in the pathophysiology of continuous-flow LVAD-associated GIB including physiologic changes associated with high shear and nonpulsatile flow such as gastrointestinal arteriovenous malformations and acquired von Willebrand syndrome. Strategies to minimize the morbidity and mortality of LVAD-associated GIB are needed. Octreotide, a somatostatin analogue, has been described as an adjunct to current therapies and interventions. Factors that contribute to LVAD-associated GIB may be targeted by the pharmacologic effects of octreotide, including improved platelet aggregation, increased vascular resistance, and decreased splanchnic circulation. Octreotide has demonstrated clinical benefit in several case series and clinical trials for the treatment of LVAD-associated GIB. The focus of this article will be to review the pathophysiology of LVAD-associated GIB, discuss pharmacologic and nonpharmacologic treatment modalities, and review available literature on the role of octreotide in the management of LVAD-associated GIB.
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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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Patel B, Shiani A, Rodriguez AC, Lipka S, Davis-Yadley AH, Nelson KK, Rabbanifard R, Kumar A, Brady PG. Outcomes in Patients with Left Ventricular Assist Devices, Pacemakers, and Implantable Cardioverter Defibrillators Undergoing Single Balloon Enteroscopy. South Med J 2019; 112:130-134. [PMID: 30708381 DOI: 10.14423/smj.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Obscure overt gastrointestinal bleeding can be challenging to evaluate in patients with electronic cardiac devices such as continuous flow left ventricular assist devices (LVADs), pacemakers (PPMs), and implantable cardioverter defibrillators (ICDs). Limited data exist on the utility and safety of single balloon enteroscopy (SBE) in patients with cardiac devices. We aimed to evaluate the safety, efficacy, diagnostic, and therapeutic outcomes of the aforementioned devices in patients undergoing SBE. METHODS A retrospective study was performed using the medical records of 57 patients undergoing SBE at our institution from 2010 to 2014. Patients were divided into two groups: those with cardiac devices and those without. Data on comorbidities, complications, findings, diagnostic, and therapeutic yield were compared. t Test and logistic regression assessed the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and standard deviation. For dichotomous data, the results were summarized as odds ratio and 95% confidence intervals. RESULTS The overall age in patients with cardiac devices was 67.89 ± 6.96 versus 66.03 ± 11.95 years in the control. The cardiac device group was composed of 42.1% women; the control comprised 21.1% women. There were 19 patients with cardiac devices; 8 (LVAD + ICD), 1 (LVAD + PPM + ICD), 2 (PPM + ICD), 6 (PPM), 2 (ICD); 38 patients were in the control group. Patients with cardiac devices were hospitalized more often than patients without devices; this finding was not statistically significant (odds ratio 1.826, 95% confidence interval 0.544-6.128, P = 0.389). Procedure times were longer in the cardiac device group, 65.16 ± 49.92 minutes, when compared with the control, 57.40 ± 20.42, but it also did not reach statistical significance (mean difference 7.758, 95% confidence interval -11.360 to 26.876, P = 0.049). There was no statistically significant difference in major or minor events between patients with cardiac devices and the control group. Diagnostic and therapeutic yield and rebleeding rates were similar across both groups. CONCLUSIONS Patients in the cardiac device group did not appear to be at any more significant risk than those without cardiac devices. Furthermore, diagnostic and therapeutic yield and rebleeding rates appear to be similar across both groups. Clinicians may perform SBE in these patients safely and effectively, with good overall outcomes.
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Affiliation(s)
- Brijesh Patel
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Ashok Shiani
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Andrea C Rodriguez
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Seth Lipka
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Ashley H Davis-Yadley
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Kirbylee K Nelson
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Roshanak Rabbanifard
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Ambuj Kumar
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
| | - Patrick G Brady
- From the Departments of Digestive Diseases and Nutrition, Internal Medicine, and Evidence-Based Medicine and Research Outcomes, University of South Florida, Tampa
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Schultz J, John R, Alexy T, Thenappan T, Cogswell R. Association between angiotensin II antagonism and gastrointestinal bleeding on left ventricular assist device support. J Heart Lung Transplant 2018; 38:469-471. [PMID: 30665699 DOI: 10.1016/j.healun.2018.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/18/2018] [Accepted: 12/24/2018] [Indexed: 01/12/2023] Open
Affiliation(s)
- Jessica Schultz
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ranjit John
- Department of Surgery, Division of Cardiovascular Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Thenappan Thenappan
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rebecca Cogswell
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
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Carnicelli AP, Thakkar A, Deicicchi DJ, Storm AC, Rimsans J, Connors JM, Mehra MR, Groarke JD, Givertz MM. Resource utilization and hospital readmission associated with gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices. J Thromb Thrombolysis 2018; 47:375-383. [PMID: 30523584 DOI: 10.1007/s11239-018-1781-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Gastrointestinal bleeding (GIB) occurs in up to 40% of patients with continuous-flow (CF) left ventricular assist devices (LVADs). We sought to identify targets to improve hospital resource utilization and decrease readmissions after GIB. We performed a single-center, retrospective analysis of LVAD-associated GIB resulting in hospital admission between July 2011 and April 2014. Follow-up data were collected through March 2015. We analyzed 57 admissions for GIB in 23 patients. One or more diagnostic imaging study was performed in 47% of admissions, with a definite or probable source of GIB identified in 23%. A total of 76 endoscopies were performed (≥ 1 endoscopy in 79% of admissions, ≥ 2 in 42%). Definite or probable bleeding sources were identified in 25% and 12% of endoscopies, respectively. Patients who underwent multiple endoscopies were no more likely to have a bleeding source identified (OR 1.48; 95% CI 0.50-4.32; p = 0.59) and had longer hospital stays (11.1 vs. 7.8 days, p < 0.02). Readmission rates for GIB at 30 and 90 days were 33% and 53%, respectively. A decrease in antiplatelet regimen at discharge was associated with lower rate of readmission for GIB (OR 0.16; 95% CI 0.03-0.82; p = 0.03) or any cause (OR 0.21; 95% CI 0.05-0.85; p = 0.04) at 30 and 90 days. GIB in patients with CF-LVADs is associated with significant in-hospital resource utilization and high rates of readmission. Imaging and endoscopy are common, but have low diagnostic yield and infrequently result in successful intervention. Strategies to reduce resource utilization and prevent readmission are warranted.
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Affiliation(s)
- Anthony P Carnicelli
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Department of Medicine, Duke University Hospital, Durham, NC, USA
| | - Anjali Thakkar
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - David J Deicicchi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew C Storm
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology and Hepatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica Rimsans
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jean M Connors
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mandeep R Mehra
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Groarke
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael M Givertz
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Hickman AW, Lonardo NW, Mone MC, Presson AP, Zhang C, Barton RG, Selzman CH, Drakos SG, Koliopoulou A, McKellar SH. Acid Suppression to Prevent Gastrointestinal Bleeding in Patients With Ventricular Assist Devices. J Surg Res 2018; 234:96-102. [PMID: 30527506 DOI: 10.1016/j.jss.2018.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/16/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RA) for preventing GIB in patients with VAD. MATERIALS AND METHODS The surgical ICU and VAD databases within a large regional academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. An observational cohort study was conducted to identify which acid suppressing drug regimen was associated with the fewest number of GIB events within 30 d after VAD implantation: PPI, H2RA, or neither. Secondary outcomes included timing, etiology, and location of GIB. Multivariable logistic regression was used to compare treatment cohorts to GIB. Odds ratios, 95% confidence intervals, and P-values were reported from the model. RESULTS One hundred thirty-eight patients were included for final analysis, 19 of which had a GIB within 30 days of VAD implantation. Both H2RA and PPI use were associated with reduced GIB compared with the cohort with no acid suppressive therapy. In the multivariate analysis, the PPI cohort showed a statistically significant reduction in GIB (Odds ratio 0.18 [95% confidence interval 0.04-0.79] P = 0.026). CONCLUSIONS Using PPI postoperatively in patients with new VAD was associated with a reduced incidence of GIB. Given that GIB is a known complication after VAD placement, clinicians should consider the use of acid suppressive therapy for primary prevention.
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Affiliation(s)
- Abby W Hickman
- Pharmacy Department University of Utah Hospital, Salt Lake City, Utah.
| | - Nick W Lonardo
- Pharmacy Department University of Utah Hospital, Salt Lake City, Utah
| | - Mary C Mone
- General Surgery Division, Department of Surgery, Salt Lake City, Utah
| | - Angela P Presson
- Department of Epidemiology & Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Chong Zhang
- Department of Epidemiology & Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Richard G Barton
- General Surgery Division, Department of Surgery, Salt Lake City, Utah
| | - Craig H Selzman
- Cardiothoracic Division, Department of Surgery, Salt Lake City, Utah
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Al-Bawardy B, Schettle SD, Gorospe E, Kee Song LMW, Pereira NL, Alexander JA, Bruining DH, Coelho-Prabhu N, Fidler JL, Mauermann WJ, Barbara DW, Dierkhising R, Rajan E. Small bowel bleeding in patients with left ventricular assist device: outcomes of conservative therapy versus balloon-assisted enteroscopy. Ann Gastroenterol 2018; 31:692-697. [PMID: 30386119 PMCID: PMC6191869 DOI: 10.20524/aog.2018.0316] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background Small bowel bleeding (SBB) accounts for 30% of gastrointestinal bleeding (GIB) episodes in patients with a left ventricular assist device (LVAD). The aim of this study was to determine the outcomes of conservative therapy (CT) compared to balloon-assisted enteroscopy (BAE) in the management of SBB in LVAD patients. Methods A retrospective review was performed of a prospectively maintained LVAD database from January 2003 to July 2015. LVAD patients with SBB were classified into a BAE group or a CT group according to whether they did or did not undergo BAE. Results Forty-two patients (22 BAE, 20 CT) with mean age 66±9.3 years (79% male) were included. The yield of BAE was 64% without reported complications. Overt re-bleeding occurred in 40% of the BAE group compared to 22% of the CT group. The BAE group had a higher mean number of GIB hospitalizations per month compared to the CT group (0.07 vs. 0.03; incidence rate ratio [IRR] 2.72, 95% CI 1.06-6.98; P=0.04). There was no significant difference between the BAE and the CT groups in the number of packed red blood cell (pRBC) transfusions per month (0.42 vs. 0.18; IRR 2.31, 95% CI 0.88-6.04; P=0.09) or all-cause mortality (61% in the CT group and 42% in the BAE group; P=0.90). Conclusion BAE is safe in LVAD patients and has a moderate therapeutic yield. In our cohort of patients, BAE did not appear to improve re-bleeding rate, GIB-related hospitalizations, pRBC transfusions or mortality compared to CT. However, future prospective trials with larger sample sizes are needed to confirm these findings.
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Affiliation(s)
- Badr Al-Bawardy
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Sarah D Schettle
- Department of Cardiology (Sarah D. Schettle, Naveen L. Pereira), Mayo Clinic, Rochester, Rochester, MN, USA
| | - Emmanuel Gorospe
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Louis M Wong Kee Song
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Naveen L Pereira
- Department of Cardiology (Sarah D. Schettle, Naveen L. Pereira), Mayo Clinic, Rochester, Rochester, MN, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - David H Bruining
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Nayantara Coelho-Prabhu
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Jeff L Fidler
- Department of Radiology (Jeff L. Fidler), Mayo Clinic, Rochester, Rochester, MN, USA
| | - William J Mauermann
- Department of Anesthesiology (William J. Mauermann, David W. Barbara), Mayo Clinic, Rochester, Rochester, MN, USA
| | - David W Barbara
- Department of Anesthesiology (William J. Mauermann, David W. Barbara), Mayo Clinic, Rochester, Rochester, MN, USA
| | - Ross Dierkhising
- Division of Biomedical Statistics and Informatics (Ross Dierkhising), Mayo Clinic, Rochester, Rochester, MN, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
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Schmitto JD, Pya Y, Zimpfer D, Krabatsch T, Garbade J, Rao V, Morshuis M, Beyersdorf F, Marasco S, Sood P, Damme L, Netuka I. Long-term evaluation of a fully magnetically levitated circulatory support device for advanced heart failure-two-year results from the HeartMate 3 CE Mark Study. Eur J Heart Fail 2018; 21:90-97. [PMID: 30052304 DOI: 10.1002/ejhf.1284] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 06/11/2018] [Accepted: 06/26/2018] [Indexed: 01/25/2023] Open
Abstract
AIM This study aimed to assess safety and outcomes of patients, 2 years after implantation with the HeartMate 3 Left Ventricular Assist System. METHODS AND RESULTS This study included 50 adults with New York Heart Association (NYHA) class IIIB or IV symptoms or American College of Cardiology/American Heart Association stage D heart failure with an ejection fraction ≤25% and a cardiac index ≤2.2 L/min/m2 without inotropes, or inotrope-dependent with optimal medical management, or listed for heart transplant. The median duration of left ventricular assist device support was 694 days (range: 19-833 days). At baseline, cardiac index was 1.8 ±0.5 L/min/m2 , 58% of patients were receiving inotropes, and 92% were INTERMACS profiles 2-4. At 2 years, Kaplan-Meier survival was 74 ±6%, 5 (10%) patients were transplanted, and 32 patients (64%) remain with support. Adverse event rates include bleeding requiring surgery (16%), gastrointestinal bleeding (20%), driveline infection (24%), ischaemic stroke (16%), haemorrhagic stroke (8%), right heart failure (14%), and outflow graft thrombosis (2%). Notably, no haemolysis, pump thrombosis, or pump malfunction events occurred. At 2 years, 47% of patients remained in NYHA class I and 41% in NYHA class II (P <0.0001). From baseline to 2 years, the mean six-minute walk distance increased from 239 m to 347 m (P <0.0001), and the mean EQ-5D quality of life score improved from 48.2 to 70.6 (P < 0.0001). CONCLUSIONS Two years post-HeartMate 3 implantation, results show expected and acceptable survival, enhanced haemocompatibility, improved patient functional status and quality of life. This corroborates the success of HeartMate 3 since its first-in-man implantation case in Germany. ClinicalTrials.gov: NCT02170363.
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Affiliation(s)
| | - Yuriy Pya
- National Research Cardiac Surgery Center, Astana, Kazakhstan
| | | | | | | | - Vivek Rao
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada
| | - Michiel Morshuis
- Thoracic and Cardiovascular Surgery Clinic, Bad Oeynhausen, Germany
| | - Friedhelm Beyersdorf
- University Heart Center Freiburg-Bad Krozingen, Medical Faculty, Albert Ludwigs-University, Freiburg, Germany
| | | | | | | | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Association of Pulsatility with Gastrointestinal Bleeding in a Cohort of HeartMate II Recipients. ASAIO J 2018; 64:472-479. [PMID: 29489463 DOI: 10.1097/mat.0000000000000766] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Preoperative Right-Sided Cardiac Congestion Is Associated with Gastrointestinal Bleeding in Patients with Continuous-Flow Left Ventricular Assist Devices. Dig Dis Sci 2018; 63:1518-1524. [PMID: 29417325 DOI: 10.1007/s10620-018-4916-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 01/06/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Large scale data on preoperative risk stratification for gastrointestinal bleeding (GIB) following continuous-flow left ventricular assist device (CF-LVAD) implantation are scarce. AIMS To identify independent predictors for GIB following CF-LVAD implantation. METHODS We conducted a retrospective cohort study of consecutive 243 patients who underwent CF-LVAD implantation (HeartMateII) from January 2009 to March 2015 at the University of Chicago Medical Center. GIB was defined as the presence of overt bleeding or occult GIB with ≥ 2 g/dl drop in hemoglobin (Hgb) from recorded baseline values and hemoccult-positive stool. The preoperative and postoperative data were reviewed. RESULTS Within a median follow-up duration of 408 (IQR 113-954) days, 83 (34%) patients developed GIB after a median of 149 (IQR 27-615) days after implantation of CF-LVAD. There were no significant differences between the groups of GIB and non-GIB with respect to preoperative demographics and comorbidity except for ethnicity. The source of bleeding was identified in 39 (47%) patients and arteriovenous malformation or submucosal streaming vessel was the most frequent cause of bleeding (18/39, 46%). Multivariate-adjusted analysis demonstrated preoperative central venous pressure (CVP) ≥ 18 mmHg (HR 3.56; 95% CI 1.16-10.9; p = 0.026), mean pulmonary artery pressure (mPA) ≥ 36 mmHg (HR 4.14; 95% CI 1.35-12.7; p = 0.013), and the presence of moderate/severe tricuspid valve disease (HR 1.01; 95% CI 1.01-3.86; p = 0.046) were associated with the risk of GIB. CONCLUSIONS In this study, preoperative right-sided cardiac congestion (i.e., increased CVP, mPA and the presence of moderate/severe tricuspid valve disease) was associated with GIB in patients with CF-LVAD.
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Chung M. Perioperative Management of the Patient With a Left Ventricular Assist Device for Noncardiac Surgery. Anesth Analg 2018; 126:1839-1850. [DOI: 10.1213/ane.0000000000002669] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Increased Risk of Bleeding in Left Ventricular Assist Device Patients Treated with Enoxaparin as Bridge to Therapeutic International Normalized Ratio. ASAIO J 2018; 64:140-146. [DOI: 10.1097/mat.0000000000000612] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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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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Inhaled Desmopressin for Refractory Gastrointestinal Bleeding in a Patient With a HeartMate II Left Ventricular Assist Device. ASAIO J 2018; 63:e47-e49. [PMID: 27556142 DOI: 10.1097/mat.0000000000000433] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Patients with a durable, continuous-flow left ventricular assist device (LVAD) are commonly prescribed the combination of an oral anticoagulant and an oral antiplatelet agent as prophylaxis against device thrombosis and systemic embolic events. Current International Society of Heart and Lung (ISHLT) guidelines recommend warfarin with an INR goal of 2-3 and concomitant aspirin 81-325 mg daily for patients with a HeartMate II LVAD. Unfortunately, gastrointestinal (GI) bleeding is very common in these patients because of multiple factors including the development of arteriovenous malformations and acquired von Willebrand syndrome. If this bleeding cannot be corrected through interventional measures, it then requires at least temporary, and potentially permanent, cessation of antiplatelet or anticoagulant therapy. Patients who continue to bleed while off all antithrombotic therapies present a clinical challenge. We describe the successful management of a patient with refractory GI bleeding through the use of inhaled desmopressin.
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Loyaga-Rendon RY, Jani M, Fermin D, McDermott JK, Vancamp D, Lee S. Prevention and Treatment of Thrombotic and Hemorrhagic Complications in Patients Supported by Continuous-Flow Left Ventricular Assist Devices. Curr Heart Fail Rep 2018; 14:465-477. [PMID: 29075955 DOI: 10.1007/s11897-017-0367-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the current knowledge in prevention and treatment of thrombotic (pump thrombosis and ischemic stroke) and bleeding (gastrointestinal and hemorrhagic stroke) complications in patients supported by continuous-flow left ventricular assist devices (CF-LVAD). RECENT FINDINGS Left ventricular assist devices (LVADs) are now widely used for the management of end-stage heart failure. Unfortunately, in spite of the indisputable positive impact LVADs have on patients, the frequency and severity of complications are limitations of this therapy. Stroke, pump thrombosis, and gastrointestinal bleeding are among the most serious and frequent complications in these patients. The balance between hemorrhagic and thrombotic complications in patients supported with CF-LVAD is difficult as most patients do not necessarily fit a "bleeder" or a "clotter" profile but rather move from one side to the other of the thrombotic/bleeding spectrum. Further research is necessary to better understand the risk factors and mechanisms involved in the development of these complications.
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Affiliation(s)
- Renzo Y Loyaga-Rendon
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA.
| | - Milena Jani
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - David Fermin
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - Jennifer K McDermott
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - Diane Vancamp
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
| | - Sangjin Lee
- Advanced Heart Failure and Heart Transplantation Section, Spectrum Health, 330 Barclay Avenue NE, Suite 200, MC258, Grand Rapids, MI, 49503, USA
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Axelrad JE, Pinsino A, Trinh PN, Thanataveerat A, Brooks C, Demmer RT, Effner L, Parkis G, Cagliostro B, Han J, Garan AR, Topkara V, Takeda K, Takayama H, Naka Y, Ramirez I, Garcia-Carrasquillo R, Colombo PC, Gonda T, Yuzefpolskaya M. Limited usefulness of endoscopic evaluation in patients with continuous-flow left ventricular assist devices and gastrointestinal bleeding. J Heart Lung Transplant 2017; 37:723-732. [PMID: 29402604 DOI: 10.1016/j.healun.2017.12.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/06/2017] [Accepted: 12/17/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a frequent cause of re-admission in patients with continuous-flow left ventricular assist devices (CF-LVADs) and is associated with multiple endoscopic procedures and high resource utilization. Our aim was to determine the diagnostic and therapeutic yield of endoscopy and to develop a more cost-effective approach for the management of GIB in CF-LVAD recipients. METHODS We retrospectively reviewed 428 patients implanted with a CF-LVAD between 2009 and 2016 at the Columbia University Medical Center and identified those hospitalized for GIB. Patients were categorized into upper GIB (UGIB), lower GIB (LGIB) and occult GIB (OGIB), based on clinical presentation. RESULTS Eighty-seven CF-LVAD patients underwent a total of 164 GIBs, resulting in 239 endoscopies. Index presentation was consistent with UGIB in 30 (34.5%), LGIB in 19 (21.8%) and OGIB in 38 (43.7%) patients. On the first GIB, 147 endoscopies localized a bleeding source in 49 (30%), resulting in 24 (16.3%) endoscopic interventions. Of 45 lesions identified, arteriovenous malformations (AVMs) were the most common (22, 48.9%). A gastric or small bowel source (HR 2.8, p = 0.003) and an endoscopic intervention (HR 1.9, p = 0.04) predicted recurrent GIB. The proposed algorithm may reduce the number of endoscopic procedures by 45% and costs by 35%. CONCLUSIONS Occult GIB is the most common presentation in CF-LVAD patients and carries the lowest diagnostic and therapeutic yield of endoscopy. Performing an intervention was among the strongest predictors of recurrent GIB. Our proposed algorithm may decrease the number of low-yield procedures and improve resource utilization.
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Affiliation(s)
- Jordan E Axelrad
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University, New York, New York, USA
| | - Alberto Pinsino
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Pauline N Trinh
- Department of Epidemiology, Columbia University, New York, New York, USA
| | - Anusorn Thanataveerat
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Christian Brooks
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University, New York, New York, USA
| | - Ryan T Demmer
- Department of Epidemiology, Columbia University, New York, New York, USA
| | - Lisa Effner
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - Grant Parkis
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - Barbara Cagliostro
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - Jiho Han
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - A Reshad Garan
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Veli Topkara
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Koji Takeda
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - Hiroo Takayama
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York, USA
| | - Ivonne Ramirez
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University, New York, New York, USA
| | - Reuben Garcia-Carrasquillo
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University, New York, New York, USA
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Tamas Gonda
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University, New York, New York, USA
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA.
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Warfarin and Aspirin Versus Warfarin Alone for Prevention of Embolic Events in Patients with a HeartMate II Left Ventricular Assist Device. ASAIO J 2017; 63:731-735. [DOI: 10.1097/mat.0000000000000561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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