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Jahangiri P, Veen KM, van Moort I, Bunge JH, Constantinescu A, Sjatskig J, de Maat M, Kluin J, Leebeek F, Caliskan K. Early Postoperative Changes in Von Willebrand Factor Activity Are Associated With Future Bleeding and Stroke in HeartMate 3 Patients. ASAIO J 2024:00002480-990000000-00505. [PMID: 38896804 DOI: 10.1097/mat.0000000000002250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Hemocompatibility-related adverse events (HRAEs), particularly gastrointestinal bleeding, remain a frequent complication after left ventricular assist device (LVAD) implantation. The current study sought to describe and analyze whether early (<60 days) postoperative von Willebrand factor (VWF) activity assays predict the risk of gastrointestinal bleeding and stroke. A prospective single-center study including 74 HeartMate 3 device recipients between 2016 and 2023 was undertaken. The postoperative trajectory of the VWF profile was analyzed using linear mixed-effect models and Cox models were used to quantify associations between an early postoperative dip (≤0.7) in VWF activity assay measurements and late outcomes. Preoperatively, the mean VWF:Activity (Act)/Antigen (Ag) and VWF:Collagen Binding (CB)/Ag ratios were 0.94 (95% confidence interval [CI] = 0.81-1.02) and 0.95 (95% CI = 0.80-1.03), respectively, decreasing to 0.66 (95% CI = 0.57-0.73) and 0.67 (95% CI = 0.58-0.74) within 40 days (p < 0.05). In patients with VWF:CB/Ag and VWF:Act/Ag ratios ≤0.7 significantly more gastrointestinal bleeding (hazard ratio [HR]: 2.53; 95% CI = 1.1-5.8, and HR: 3.7; 95% CI = 1.5-9.2, respectively) and hemorrhagic stroke events (HR: 3.5; 95% CI = 1.6-7.6 and HR: 4.9; 95% CI = 2.1-11.7, respectively) were observed throughout the entire late (>60 days) postoperative period. In patients with VWF:Act/Ag ratio ≤0.7 less ischemic stroke events were observed (HR: 0.11; 95% CI = 0.01-0.85). In conclusion, VWF:Act/Ag and VWF:CB/Ag ratios ≤0.7 in the early postoperative phase can be used as biomarkers to predict HRAEs during long-term LVAD support.
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Affiliation(s)
| | | | | | - Jeroen H Bunge
- From the Department of Cardiology
- Intensive Care, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
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2
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Inglis SS, Asleh R, Iyer VN, Schettle SD, Spencer PJ, Villavicencio MA, Rodeheffer RJ, Kushwaha SS, Behfar A, Rosenbaum AN. Inhibition of angiogenesis in the management of refractory gastrointestinal bleeding in patients with LVAD support. Artif Organs 2024; 48:646-654. [PMID: 38131635 DOI: 10.1111/aor.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/09/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) in patients with continuous flow left ventricular assist devices (CF-LVADs) is often related to GI angiodysplasia (GIAD). We previously reported data on VEGF inhibition with IV bevacizumab in the treatment of LVAD-associated GIAD bleeding, and now present follow-up data on patients treated with IV bevacizumab and/or low-dose oral pazopanib. METHODS All consecutive adult patients with LVAD-associated GIB from GIAD treated with bevacizumab or pazopanib, from July 20, 2017 to June 22, 2022, were included in the analysis. Data on hospitalizations, GI endoscopic procedures, and blood transfusions were obtained from first admission for GIB up to a median of 35.7 months following treatment initiation (range 1.3-59.8 months). RESULTS Eleven patients (91% male, mean 69.5 ± 8.9 years) were included. Eight patients (73%) received IV bevacizumab, two patients (18%) received oral pazopanib, and one patient (9%) received bevacizumab followed by pazopanib therapy. We observed a significantly decreased number of annualized hospitalizations for GIB (median difference - 2.87, p = 0.002), blood transfusions (median difference - 20.9, p = 0.01), and endoscopies (median difference - 6.95, p = 0.007) in patients pre- and post-anti-angiogenic therapy (bevacizumab and/or pazopanib). Similarly, a significant improvement in these clinical outcomes was noted in the bevacizumab group with decreased annualized hospitalizations (median difference - 2.75, p = 0.014), blood transfusions (median difference - 24.5, p = 0.047), and number of endoscopies (median differences -6.88, p = 0.006). CONCLUSION Anti-angiogenic therapy with IV bevacizumab and/or low-dose oral pazopanib appears to provide benefits in patients with LVAD-associated GIB with reduced hospitalizations, blood transfusions, and need for GI endoscopic procedures.
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Affiliation(s)
- Sara S Inglis
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Rabea Asleh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vivek N Iyer
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Atta Behfar
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew N Rosenbaum
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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3
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Gallone G, Ibero J, Morley-Smith A, Monteagudo Vela M, Fiorelli F, Konicoff M, Edwards G, Raj B, Shanmuganathan M, Pidello S, Frea S, De Ferrari GM, Panoulas V, Stock U, Bowles C, Dunning J, Riesgo Gil F. Association of Renin-Angiotensin-Aldosterone System Inhibitors With Clinical Outcomes, Hemodynamics, and Myocardial Remodeling Among Patients With Advanced Heart Failure on Left Ventricular Assist Device Support. J Am Heart Assoc 2024; 13:e032617. [PMID: 38686903 PMCID: PMC11179874 DOI: 10.1161/jaha.123.032617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND We evaluated the potential benefits of renin-angiotensin-aldosterone system inhibitors (RAASi) in patients with left ventricular assist device support. METHODS AND RESULTS A total of 165 consecutive patients undergoing left ventricular assist device implant and alive at 6-month on support were studied. RAASi status after 6-month visit along with clinical reasons for nonprescription/uptitration were retrospectively assessed. The primary outcome was a composite of heart failure hospitalization or cardiovascular death between 6 and 24 months after left ventricular assist device implant. Remodeling and hemodynamic outcomes were explored by studying the association of RAASi new prescription/uptitration versus unmodified therapy at 6-month visit with the change in echocardiographic parameters and hemodynamics between 6 and 18 months. After the 6-month visit, 76% of patients were on RAASi. Patients' characteristics among those receiving and not receiving RAASi were mostly similar. Of 85 (52%) patients without RAASi new prescription/uptitration at 6-month visit, 62% had no apparent clinical reason. RAASi were independently associated with the primary outcome (adjusted hazard ratio, 0.31 [95% CI, 0.16-0.69]). The baseline rates of optimal echocardiographic profile (neutral interventricular septum, mitral regurgitation less than mild, and aortic valve opening) and hemodynamic profile (cardiac index ≥2.2 L/min per m2, wedge pressure <18 mm Hg, and right atrial pressure <12 mm Hg) were similar between groups. At 18 months, patients receiving RAASi new prescription/uptitration at 6 months had higher rates of optimal hemodynamic profile (57.5% versus 37.0%; P=0.032) and trends for higher rates of optimal echocardiographic profile (39.6% versus 22.9%; P=0.055) compared with patients with 6-month unmodified therapy. Optimal 18-month hemodynamic and echocardiographic profiles were associated with the primary outcome (log-rank=0.022 and log-rank=0.035, respectively). CONCLUSIONS RAASi are associated with improved outcomes and improved hemodynamics among mechanically unloaded patients.
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Affiliation(s)
- Guglielmo Gallone
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
- Division of Cardiology, Cardiovascular and Thoracic Department Città della Salute e della Scienza Hospital Turin Italy
| | - Javier Ibero
- Department of Medical Sciences University of Turin Turin Italy
| | - Andrew Morley-Smith
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - Maria Monteagudo Vela
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - Francesca Fiorelli
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - Mailen Konicoff
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - Gemma Edwards
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - Binu Raj
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - Mayooran Shanmuganathan
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - Stefano Pidello
- Division of Cardiology, Cardiovascular and Thoracic Department Città della Salute e della Scienza Hospital Turin Italy
| | - Simone Frea
- Division of Cardiology, Cardiovascular and Thoracic Department Città della Salute e della Scienza Hospital Turin Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department Città della Salute e della Scienza Hospital Turin Italy
| | - Vasileios Panoulas
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
- Cardiovascular Sciences National Heart and Lung Institute, Imperial College London London United Kingdom
| | - Ulrich Stock
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - Christopher Bowles
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - John Dunning
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
| | - Fernando Riesgo Gil
- Cardiothoracic Transplantation Harefield Hospital, Guy's and St Thomas' National Health Service Foundation Trust London United Kingdom
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4
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Bitar A, Aaronson K. When all Else Fails, Try This: The HeartMate III Left Ventricle Assist Device. Cardiol Clin 2023; 41:593-602. [PMID: 37743081 DOI: 10.1016/j.ccl.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Heart failure (HF) is a progressive disease. It is estimated that more than 250,000 patients suffer from advanced HF with reduced ejection fraction refractory to medical therapy. With limited donor pool for heart transplant, continue flow left ventricle assist device (LVAD) is a lifesaving treatment option for patients with advanced HF. This review will provide an update on indications, contraindications, and associated adverse events for LVAD support with a summary of the current outcomes data.
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Affiliation(s)
- Abbas Bitar
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Cardiovascular Center, 1500 East Medical Center Drive SPC 5853, Ann Arbor, MI 48109, USA.
| | - Keith Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Cardiovascular Center, 1500 East Medical Center Drive SPC 5853, Ann Arbor, MI 48109, USA
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5
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Edwards AL, Wilcox CM, Beasley M, Pamboukian SV, Mannon P, Peter S. Gastrointestinal bleeding and pro-angiogenic shift in the angiopoietin axis with continuous flow left ventricular assist device implantation. Am J Med Sci 2023; 366:278-285. [PMID: 37506847 DOI: 10.1016/j.amjms.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/12/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) affects up to 40% of continuous-flow left ventricular assist device (CF-LVAD) recipients. A higher risk of GIB is seen in CF-LVAD recipients with lower device pulsatility without a known mechanism. One hypothesis is that the novel hemodynamics in CF-LVAD recipients affect angiogenesis signaling. We aimed to (1) measure serum levels of angiopoietin (Ang)-1, Ang-2, and VEGF-A in CF-LVAD recipients with and without GIB and in healthy controls and (2) evaluate correlations of those levels with hemodynamics. METHODS We recruited 12 patients with CF-LVADs (six who developed GIB after device implantation) along with 12 age-matched controls without heart failure or GIB and measured Ang-1, Ang-2, and VEGF-A levels in serum samples from each patient. RESULTS CF-LVAD recipients had significantly higher Ang-2 and lower Ang-1 levels compared to controls with no difference in VEGF-A levels. CF-LVAD recipients with GIB had lower Ang-1 levels than those without GIB. There were trends for pulse pressure to be positively correlated with Ang-1 levels and negatively correlated with Ang-2 levels in CF-LVAD recipients with no correlation observed in healthy controls. CONCLUSION CF-LVAD recipients demonstrated a shift toward a pro-angiogenic phenotype in the angiopoietin axis that is significantly associated with GIB and may be linked to low pulse pressure.
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Affiliation(s)
- Adam L Edwards
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Mark Beasley
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Salpy V Pamboukian
- Division of Cardiovascular Disease, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Peter Mannon
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Shajan Peter
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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6
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Kim G, Sayer G, Ransom J, Keebler M, Katz J, Kilic A, Lindenfeld J, Egnaczyk G, Shah P, Brieke A, Walenga J, Crandall D, Farrar DJ, Sundareswaran K, Uriel N. Association of Angiopoetin-2 and TNF-α With Bleeding During Left Ventricular Assist Device Support: Analysis From the PREVENT Biorepository. ASAIO J 2023; 69:742-748. [PMID: 37134003 DOI: 10.1097/mat.0000000000001942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
The purpose of this study was to describe the changes in plasma levels of angiogenic and inflammatory biomarkers, specifically Ang-2 and TNF-α, in patients receiving HeartMate II (HMII) left ventricular assist device (LVAD) and correlate them with nonsurgical bleeding. It has been shown that angiopoietin-2 (Ang-2) and tissue necrosis factor-α (TNF-α) may be linked to bleeding in LVAD patients. This study utilized biobanked samples prospectively collected from the PREVENT study, a prospective, multicenter, single-arm, nonrandomized study of patients implanted with HMII. Paired serum samples were obtained in 140 patients before implantation and at 90 days postimplantation. Baseline demographics were as follows: age 57 ± 13 years, 41% had ischemic etiology, 82% male, and 75% destination therapy indication. In the 17 patients with baseline elevation of both TNF-α and Ang-2, 10 (60%) experienced a significant bleeding event within 180 days postimplant compared with 37 of 98 (38%) patients with Ang-2 and TNF-α below the mean ( p = 0.02). The hazard ratio for a bleeding event was 2.3 (95% CI: 1.2-4.6) in patients with elevated levels of both TNF-α and Ang-2. In the PREVENT multicenter study, patients with elevations in serum Angiopoietin-2 and TNF-α at baseline before LVAD implantation demonstrated increased bleeding events after LVAD implantation.
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Affiliation(s)
- Gene Kim
- From the Department of Medicine, University of Chicago, Chicago, Illinois
| | - Gabriel Sayer
- Department of Medicine, Columbia University, New York, New York
| | - John Ransom
- Baptist Health Heart and Transplant Institute, Little Rock, Arkansas
| | - Mary Keebler
- Department Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason Katz
- Department of Medicine, Duke University, Durham, North Carolina
| | - Ahmet Kilic
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Jeanine Walenga
- Health Sciences Division, Cardiovascular Research Institute, Loyola University Medical Center, Maywood, Illinois
| | | | | | | | - Nir Uriel
- Department of Medicine, Columbia University, New York, New York
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7
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Lombardi M, Bonora M, Baldetti L, Pieri M, Scandroglio AM, Landoni G, Zangrillo A, Foglieni C, Consolo F. Left ventricular assist devices promote changes in the expression levels of platelet microRNAs. Front Cardiovasc Med 2023; 10:1178556. [PMID: 37396581 PMCID: PMC10308775 DOI: 10.3389/fcvm.2023.1178556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/16/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction MicroRNAs (miRs) emerged as promising diagnostic and therapeutic biomarkers in cardiovascular diseases. The potential clinical utility of platelet miRs in the setting of left ventricular assist device (LVAD) support is unexplored. Methods We prospectively measured the expression levels of 12 platelet miRs involved in platelet activation, coagulation, and cardiovascular diseases in LVAD patients by quantitative real-time polymerase chain reaction. Data were longitudinally measured before LVAD implant and after 1, 6, and 12 months of LVAD support, and compared with those measured in healthy volunteers (controls). In silico analysis was also performed to identify pathways targeted by differentially expressed miRs. Results Data from 15 consecutive patients and 5 controls were analyzed. Pre-implant expression levels of platelet miR-126, miR-374b, miR-223, and miR-320a were significantly different in patients vs. controls. The expression levels of platelet miR-25, miR-144, miR-320, and miR-451a changed significantly over the course of LVAD support; in silico analysis revealed that these miRs are implicated in both cardiac- and coagulation-associated pathways. Furthermore, the patients who suffered from bleeding (n = 5, 33%) had significantly higher pre-implant expression levels of platelet miR-151a and miR-454 with respect to the patients who did not. The same miRs were also differentially expressed in bleeders following LVAD implantation early before the clinical manifestation of the events. Discussion This study provides a proof-of-concept evidence of significant modulation of platelet miRs expression driven by LVADs. The possible existence of a platelet miRs signature predictive of the development of bleeding events warrants further validation studies.
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Affiliation(s)
- Maria Lombardi
- Cardiovascular Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Marta Bonora
- Università Vita Salute San Raffaele, Milano, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Marina Pieri
- Università Vita Salute San Raffaele, Milano, Italy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Giovanni Landoni
- Università Vita Salute San Raffaele, Milano, Italy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Alberto Zangrillo
- Università Vita Salute San Raffaele, Milano, Italy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Chiara Foglieni
- Cardiovascular Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
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8
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Schlöglhofer T, Marschütz A, Combs P, Stonebraker C, Lupo S, Jeevanandam V, Riebandt J, Schima H, Zimpfer D, Meehan K. Quality of Anticoagulation With Phenprocoumon and Warfarin in Left Ventricular Assist Device Patients: A Multicenter Study. ASAIO J 2023; 69:595-601. [PMID: 36821448 DOI: 10.1097/mat.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
VISUAL ABSTRACT of key results. INR, international normalized ratio; TTR, time in therapeutic range; PTR, percentage of tests in range; HRAE, hemocompatibility-related adverse event; FFUV, first follow-up visit; GIB, gastrointestinal bleeding; HR, hazard ratio.http://links.lww.com/ASAIO/A961.
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Affiliation(s)
- Thomas Schlöglhofer
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Angelika Marschütz
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Pamela Combs
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Corinne Stonebraker
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Sydney Lupo
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Valluvan Jeevanandam
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Julia Riebandt
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Heinrich Schima
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Daniel Zimpfer
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Karen Meehan
- Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois
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Su N, Tang X, Wang X, Wen Y, Feng X, Zhou Q, Zhan X, Shang S. Association of Serum Magnesium with Gastrointestinal Bleeding in Peritoneal Dialysis Patients: a Multicentre Retrospective Study. Biol Trace Elem Res 2023; 201:2775-2783. [PMID: 36008701 DOI: 10.1007/s12011-022-03391-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/11/2022] [Indexed: 11/02/2022]
Abstract
Serum magnesium is involved in the process of blood coagulation, and low serum magnesium is associated with haemorrhagic diseases. No studies have explored the relationship between serum magnesium and gastrointestinal bleeding (GIB). This study aimed to explore the association between serum magnesium and GIB in peritoneal dialysis (PD) patients. This was a multicentre retrospective cohort study. The primary endpoint was GIB. According to the baseline serum magnesium level of 0.7 mmol/L, patients were divided into two groups: the hypomagnesaemia group and the nonhypomagnesaemia group. A multivariate Cox regression model was used to investigate the association between hypomagnesaemia and GIB. A total of 654 PD patients from four Chinese peritoneal dialysis centres were recruited from February 1, 2010 to January 31, 2020. During the follow-up, 47 patients experienced GIB. Kaplan-Meier curves showed that there was a significant difference in the risk of GIB between the two groups (log-rank = 11.82, P < 0.001). The multivariable Cox regression model showed that the risk of GIB was higher in the hypomagnesaemia group than the nonhypomagnesaemia group after adjustment for demographic variables and laboratory indicators (HR = 3.007, 95% CI 1.488-6.079, P = 0.002). A baseline lower serum magnesium level was associated with a higher risk of GIB in PD patients.
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Affiliation(s)
- Ning Su
- Department of Nephrology, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuan-cun, Er-heng Road, Tian-He District, Guangzhou 510000, 510655, China
- Department of Hematology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xingming Tang
- Department of Nephrology, DongGuan SongShan Lake Hospital, Dongguan, China
| | - Xiaoyang Wang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yueqiang Wen
- Department of Nephrology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Xiaoran Feng
- Department of Nephrology, Jiujiang No. 1 People's Hospital, Jiujiang, China
| | - Qian Zhou
- Department of Medical Statistics, Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiaojiang Zhan
- Department of Nephrology, The First Affiliated Hospital, Nanchang University, Nanchang, China
| | - Sijia Shang
- Department of Nephrology, The Sixth Affiliated Hospital, Sun Yat-Sen University, 26 Yuan-cun, Er-heng Road, Tian-He District, Guangzhou 510000, 510655, China.
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10
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Naveed A, Naveed B, Khan MA, Asif T. Gastrointestinal bleeding in recipients of left ventricular assist devices-a systematic review. Heart Fail Rev 2023:10.1007/s10741-023-10313-6. [PMID: 37145271 DOI: 10.1007/s10741-023-10313-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2023] [Indexed: 05/06/2023]
Abstract
The twenty-first century has revolutionized the management of congestive heart failure with the widespread use of left ventricular assist devices and other treatment modalities that improve morbidity and mortality after the failure of medical management. These novel devices come with significant side effects. One of the most common side effects of left ventricular assist devices is the increased frequency of lower gastrointestinal bleeding compared to heart failure patients without left ventricular assist devices. Multiple etiologies of recurrent gastrointestinal bleeding in such patients have been studied. The decreased amount of von Willebrand factor polymers is now recognized as one of the most common causes of increased incidence of gastrointestinal bleeding in patients with left ventricular assist devices alongside increased arteriovenous malformations. Multiple treatment modalities have been identified to prevent and treat gastrointestinal bleeding in these patients. Since the use of left ventricular assist devices is becoming more prevalent in patients with advanced heart failure, we decided to conduct this systematic review. The article summarizes the incidence, pathophysiology, and management of lower gastrointestinal bleeding in patients with left ventricular assist devices.
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Affiliation(s)
- Ali Naveed
- University of Missouri, Kansas City, USA.
| | | | | | - Talal Asif
- University of Missouri, Kansas City, USA
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11
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Kawanami S, Egami Y, Sugae H, Ukita K, Kawamura A, Nakamura H, Matsuhiro Y, Yasumoto K, Tsuda M, Okamoto N, Matsunaga‐Lee Y, Yano M, Nishino M, Tanouchi J. Predictors of bleeding events in acute decompensated heart failure patients with antithrombotic therapy: AURORA study. ESC Heart Fail 2023; 10:1114-1121. [PMID: 36585753 PMCID: PMC10053354 DOI: 10.1002/ehf2.14277] [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: 02/28/2022] [Revised: 10/18/2022] [Accepted: 12/15/2022] [Indexed: 01/01/2023] Open
Abstract
AIMS Heart failure (HF) is reported to be one of the major risks of bleeding events. On the other hand, HF patients frequently receive anticoagulants or antiplatelet therapy to manage various co-morbidities. However, predictors of bleeding events in patients with HF have rarely been reported. This study aimed to evaluate the predictors of bleeding events and relationship between bleeding events and HF re-hospitalizations. METHODS AND RESULTS We included 1660 acute decompensated heart failure (ADHF) patients from the AURORA registry between January 2015 and December 2020. A total of 1429 patients were excluded because of history of HF admission, missing echocardiographic data at discharge, lost to follow-up, haemodialysis and no antithrombotic drugs. Finally, we evaluated 231 patients from AURORA registry. The bleeding events were defined as Type 2 to 5 bleeding according to the Bleeding Academic Research Consortium definition. We divided our patients into the bleeding group and non-bleeding group. We compared the baseline characteristics, medications, laboratory data, and echocardiographic data between the two groups. Median age was 78 (IQR 71-82) years old and male accounted for 59%. Approximately half of the patients had an antiplatelet therapy and 70% had an anticoagulant therapy. During a median follow-up of 651 (IQR 357-1139) days, 32 patients (13.8%) suffered from bleeding events. The major driver of the registered events was gastrointestinal bleeding (n = 21, 65.6%), and the other events were cerebral bleeding (n = 4, 12.5%), intraarticular bleeding (n = 2, 6.3%), urogenital bleeding (n = 2, 6.3%), haemorrhagic pericardial effusions (n = 1, 3.1%), subcutaneous hematomas (n = 1, 3.1%), and haemothorax (n = 1, 3.1%). There was a significantly lower haemoglobin level (P < 0.01), higher proportion of inferior vena cava (IVC) diameter ≥21 mm (P < 0.01), and higher furosemide equivalent doses per kilogram (P < 0.01) in the bleeding group than non-bleeding group. A multivariate analysis revealed an equivalent dose of furosemide per kilogram ≥0.66 mg/kg (hazard ratios (HR) of 2.64, 95% confidence interval (CI) 1.26-5.68, P = 0.01), haemoglobin ≤10.3 g/dL (HR of 2.43, 95% CI 1.14-5.03, P = 0.02), and IVC diameter ≥21 mm (HR of 2.79, 95% CI 1.16-6.29, P = 0.02) were independently associated with bleeding events. The Kaplan-Meier analysis showed that HF re-hospitalization rates were higher in the bleeding group than non-bleeding group (P = 0.04). CONCLUSIONS High doses of oral loop diuretics, IVC dilatation, and anaemia were predictors of bleeding events in patients hospitalized with ADHF patients. In addition, bleeding events were associated with HF re-hospitalizations.
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Affiliation(s)
- Shodai Kawanami
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Yasuyuki Egami
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Hiroki Sugae
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Kohei Ukita
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Akito Kawamura
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Hitoshi Nakamura
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Yutaka Matsuhiro
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Koji Yasumoto
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Masaki Tsuda
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Naotaka Okamoto
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Yasuharu Matsunaga‐Lee
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Masamichi Yano
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Masami Nishino
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
| | - Jun Tanouchi
- Division of CardiologyOsaka Rosai Hospital3‐1179 Nagasonecho, Kita‐kuSakaiOsaka591‐8025Japan
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12
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Khalil F, Asleh R, Perue RK, Weinstein JM, Solomon A, Betesh-Abay B, Briasoulis A, Alnsasra H. Vascular Function in Continuous Flow LVADs: Implications for Clinical Practice. Biomedicines 2023; 11:biomedicines11030757. [PMID: 36979735 PMCID: PMC10045906 DOI: 10.3390/biomedicines11030757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
Left ventricular assist devices (LVADs) have been increasingly used in patients with advanced heart failure, either as a destination therapy or as a bridge to heart transplant. Continuous flow (CF) LVADs have revolutionized advanced heart failure treatment. However, significant vascular pathology and complications have been linked to their use. While the newer CF-LVAD generations have led to a reduction in some vascular complications such as stroke, no major improvement was noticed in the rate of other vascular complications such as gastrointestinal bleeding. This review attempts to provide a comprehensive summary of the effects of CF-LVAD on vasculature, including pathophysiology, clinical implications, and future directions.
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Affiliation(s)
- Fouad Khalil
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD 57105, USA
| | - Rabea Asleh
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem P.O. Box 12000, Israel
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Radha Kanneganti Perue
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jean-Marc Weinstein
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
| | - Adam Solomon
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Batya Betesh-Abay
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Alexandros Briasoulis
- Department of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Hilmi Alnsasra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
- Correspondence: ; Tel.: +972-507107535
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13
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Mo ZZ, Yuan Z, Peng YY, Zhou WL, Dai W, Wang G, Tang J, Zhang W, Chen BL. miR-6076 rs1463411 polymorphisms are associated with bleeding during clopidogrel treatment in patients with acute coronary syndrome. Eur J Med Res 2023; 28:96. [PMID: 36829258 PMCID: PMC9951409 DOI: 10.1186/s40001-023-01068-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
Bleeding is a major adverse event during clopidogrel treatment in patients with acute coronary syndrome (ACS). However, the potential mechanism affecting bleeding among individuals is unclear. Herein, we investigated the involvement of CYP2C19*2 and CYP2C19*3, as well as 10 miRNA polymorphisms, in bleeding in Chinese patients with ACS during the first year of clopidogrel treatment. The miR-6076 rs1463411 G polymorphism was significantly associated with the risk of bleeding (P < 0.001), and the rs1463411 GT + GG genotype significantly increased the risk of bleeding (adjusted odds ratio, 6.09; 95% confidence interval, 1.09-34.0; P < 0.001). Dual luciferase assay showed that miR-6076 significantly decreased the mRNA expression of P2RY12 (P < 0.05). P2RY12 mRNA and protein levels were significantly lower in cells transfected with miR-6076-G than in cells transfected with miR-6076-T (P < 0.05). The findings indicate that miR-6076 targets P2RY12 mRNA and that miR-6076 rs1463411 T/G polymorphisms differentially regulate P2RY12 mRNA and protein levels in cells. rs1463411 G polymorphism may increase the risk of bleeding during clopidogrel treatment in patients with ACS.
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Affiliation(s)
- Zhen-Zhen Mo
- grid.216417.70000 0001 0379 7164Department of Geriatrics, National Geriatrics Clinic Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 People’s Republic of China
| | - Zhen Yuan
- grid.216417.70000 0001 0379 7164Department of Geriatrics, National Geriatrics Clinic Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 People’s Republic of China
| | - Yuan-Yuan Peng
- grid.216417.70000 0001 0379 7164Department of Geriatrics, National Geriatrics Clinic Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 People’s Republic of China
| | - Wan-Lu Zhou
- grid.216417.70000 0001 0379 7164Department of Geriatrics, National Geriatrics Clinic Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 People’s Republic of China
| | - Wei Dai
- grid.216417.70000 0001 0379 7164Department of Geriatrics, National Geriatrics Clinic Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 People’s Republic of China
| | - Guo Wang
- grid.216417.70000 0001 0379 7164Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, 410008 People’s Republic of China
| | - Jie Tang
- grid.216417.70000 0001 0379 7164Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, 410008 People’s Republic of China
| | - Wei Zhang
- grid.216417.70000 0001 0379 7164Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, 410008 People’s Republic of China
| | - Bi-Lian Chen
- Department of Geriatrics, National Geriatrics Clinic Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, People's Republic of China.
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14
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Yang A, Shi M, Lau ES, Wu H, Zhang X, Fan B, Kong AP, Luk AO, Ma RC, Chan JC, Chow E. Clinical outcomes following discontinuation of renin-angiotensin-system inhibitors in patients with type 2 diabetes and advanced chronic kidney disease: A prospective cohort study. EClinicalMedicine 2023; 55:101751. [PMID: 36457651 PMCID: PMC9706514 DOI: 10.1016/j.eclinm.2022.101751] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/01/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Renin-angiotensin-system inhibitors (RASi), that include angiotensin converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) reduce proteinuria, delay chronic kidney disease (CKD) progression, protect against cardiovascular events and heart failure hospitalizations. We examined the associations of discontinuation of ACEi/ARBs with risk of clinical outcomes in Chinese patients with type 2 diabetes (T2D) and advanced-CKD (estimated-glomerular filtration rate [eGFR] <30 ml/min/1.73 m2). METHODS We conducted a prospective, population-based cohort study including 10,400 patients with T2D in Hong Kong stratified by continuation of ACEi/ARBs within 6 months after reaching eGFR <30 ml/min/1.73 m2 from January 01, 2002 to December 31, 2018 and observed until December 31, 2019. The primary outcomes were death, major-adverse cardiovascular events (MACE), heart failure, end-stage kidney disease (ESKD), and all-cause mortality. Cox-model with time-dependent exposure and covariates was used to estimate the hazard ratio (HR) of outcomes in a propensity-score overlap-weighted cohort. The risk of occurrence of hyperkalemia (plasma potassium >5.5 mmol/L) in discontinued-ACEi/ARBs versus continued-ACEi/ARBs users was assessed in a register-based cohort. FINDINGS In the population-based cohort of 10,400 ACEi/ARBs users with new-onset eGFR<30 ml/min/1.73 m2, 1766 (17.0%) discontinued ACEi/ARBs and 8634 (83.0%) persisted with treatment. During a median follow-up of 3.6 (interquartile range, IQR: 2.11-5.8) years (41,623 person-years), 13.5%, 12.9%, and 27.6% had incident MACE, heart failure and ESKD respectively, and 35.8% died. Discontinued-ACEi/ARBs use was associated with higher risk of MACE (HR = 1.27, 95% CI: 1.08-1.49), heart failure (HR = 1.85, 95% CI: 1.53-2.25) and ESKD (HR = 1.30, 95% CI: 1.17-1.43), and neutral risk of all-cause mortality (HR = 0.93, 95% CI: 0.86-1.01) compared to counterparts with continued use. In the register-based cohort (583 discontinued-ACEi/ARBs users and 3817 continued-ACEi/ARBs users), discontinued-ACEi/ARBs had neutral risk of hyperkalemia (HR = 0.95, 95% CI: 0.84-1.08). INTERPRETATION Discontinuation of ACEi/ARBs was associated with increased risk of cardiovascular-renal events supporting their continued use in patients with T2D and advanced-CKD. FUNDING CUHK Impact Research Fellowship Scheme.
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Affiliation(s)
- Aimin Yang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Mai Shi
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Eric S.H. Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Hongjiang Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Xinge Zhang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Baoqi Fan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Alice P.S. Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Andrea O.Y. Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Ronald C.W. Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Juliana C.N. Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Corresponding author. Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China.
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15
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Effect of Angiotensin II Antagonism on Gastrointestinal Bleeding in Patients With Left Ventricular Assist Devices: A Systematic Review and Meta-Analysis. ASAIO J 2022; 68:1470-1474. [PMID: 36469446 DOI: 10.1097/mat.0000000000001688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The importance of medical therapy to ameliorate the incidence and impact of left ventricular assistance device-related gastrointestinal bleeding has been highlighted recently with several single-center studies. Electronic databases were searched for studies that compared the incidence of gastrointestinal bleeding for those people on left ventricular assist support with and without angiotensin II inhibition. Angiotensin II inhibition was associated with a lower incidence of gastrointestinal bleeding (pooled RR 0.58, 95% confidence interval (CI): 0.34-0.98; p = 0.04], with a trend toward toward lower incidence with arteriovenous malformation-associated gastrointestinal bleeding (pooled RR 0.50, 95% CI: 0.25-1.03; p = 0.06).
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16
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Weingarten N, Song C, Iyengar A, Herbst DA, Helmers M, Meldrum D, Guevara-Plunkett S, Dominic J, Atluri P. Antithrombotic therapy for durable left ventricular assist devices - current strategies and future directions. Indian J Thorac Cardiovasc Surg 2022; 38:628-636. [PMID: 36258825 PMCID: PMC9569275 DOI: 10.1007/s12055-022-01409-z] [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: 04/28/2022] [Revised: 07/31/2022] [Accepted: 08/21/2022] [Indexed: 10/14/2022] Open
Abstract
Left ventricular assist devices (LVADs) improve survival and quality of life for patients with advanced heart failure but are associated with high rates of thromboembolic and hemorrhagic complications. Antithrombotic therapy is required following LVAD implantation, though practices vary. Identifying a therapeutic strategy that minimizes the risks of thromboembolic and hemorrhagic complications is critical to optimizing patient outcomes and is an area of active investigation. This paper reviews strategies for initiating and maintaining antithrombotic therapy in durable LVAD recipients, focusing on those with centrifugal-flow devices.
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Affiliation(s)
- Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Cindy Song
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - David Alan Herbst
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Mark Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Danika Meldrum
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Sara Guevara-Plunkett
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Jessica Dominic
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
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17
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LVAD as a Bridge to Remission from Advanced Heart Failure: Current Data and Opportunities for Improvement. J Clin Med 2022; 11:jcm11123542. [PMID: 35743611 PMCID: PMC9225013 DOI: 10.3390/jcm11123542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 02/04/2023] Open
Abstract
Left ventricular assist devices (LVADs) are an established treatment modality for advanced heart failure (HF). It has been shown that through volume and pressure unloading they can lead to significant functional and structural cardiac improvement, allowing LVAD support withdrawal in a subset of patients. In the first part of this review, we discuss the historical background, current evidence on the incidence and assessment of LVAD-mediated cardiac recovery, and out-comes including quality of life after LVAD support withdrawal. In the second part, we discuss current and future opportunities to promote LVAD-mediated reverse remodeling and improve our pathophysiological understanding of HF and recovery for the benefit of the greater HF population.
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18
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Gerrald JE, Ather A, Schadler A, Birks EJ, Kolodziej AR, Kuan W. Retrospective Review of Secondary Prevention Strategies for Gastrointestinal Bleeding and Associated Clinical Outcomes in Left Ventricular Assist Device Patients. Artif Organs 2022; 46:2423-2431. [PMID: 35578786 DOI: 10.1111/aor.14316] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/06/2022] [Accepted: 04/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is one of the most common bleeding complications associated with Left Ventricular Assist Devices (LVAD). Currently, there is no strong evidence or clear guidance for which secondary GIB prophylaxis strategy should be implemented after the discontinuation of aspirin. METHODS Our single-center study describes the outcomes of 26 LVAD patients who experienced a total of 49 GIB events, these individuals were either in Group-1) lower INR target range or Group-2) lower INR target plus a hemostatic agent as the secondary prophylaxis strategy. Each GIB event was considered an independent event. Outcomes assessed were bleeding reoccurrence rates, time to next GIB, acute GIB strategies, GIB-free days, thromboembolic events, survival, coagulation, and hematologic parameters. RESULTS GIB reoccurrence rates were not statistically different, Group-1) 9 (40.9%) vs Group-2) 15 (55.6%), p = 0.308. Danazol was utilized 81.5% of the time as the designated hemostatic agent. Additionally, no significant differences were observed with all of our secondary outcome measures for bleeding, ischemic events, or survival. CONCLUSION While our study was not powered to assess the clinical outcomes related to survival and thromboembolic events, no discernable increased risk of ischemic events including pump thrombosis was observed. Our data suggest that a lower INR target range plus danazol does not confer any additional benefit over a lower INR target range only approach. The results of this report are hypothesis-generating and additional studies are warranted to elucidate the optimal antithrombotic strategy and role of hemostatic agents in reducing the risk of recurrent GIB events.
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Affiliation(s)
| | - Ayesha Ather
- Pharmacy Department, University of Kentucky Medical Center, Lexington, KY, USA
| | - Aric Schadler
- Department of Pediatrics, Kentucky Children's Hospital, Lexington, KY, USA
| | - Emma Jane Birks
- Division of Cardiology, Gill Heart and Vascular Institute, Lexington, KY, USA
| | | | - William Kuan
- Pharmacy Department, University of Kentucky Medical Center, Lexington, KY, USA
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19
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Chen R, Liu C, Zhou P, Li J, Zhou J, Wang Y, Zhao X, Chen Y, Yan S, Song L, Zhao H, Yan H. Prognostic Impacts of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Acute Coronary Syndrome Patients Without Heart Failure. Front Pharmacol 2022; 13:663811. [PMID: 35479321 PMCID: PMC9037138 DOI: 10.3389/fphar.2022.663811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/03/2022] [Indexed: 12/14/2022] Open
Abstract
Background: Despite the recommendations from mainstream guidelines, the use of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) for acute coronary syndrome (ACS) patients without heart failure (HF) is controversial, as its evidence is lacking in the era of reperfusion and intensive secondary preventions. This study aimed to investigate the impacts of ACEI/ARB on outcomes of ACS patients without HF treated by percutaneous coronary intervention (PCI). Methods: A total of 2,397 non-HF ACS patients treated by PCI were retrospectively recruited. Prognostic impacts of ACEI/ARB were assessed by unadjusted analysis, followed by propensity score matching (PSM) and propensity score matching weight (PSMW) analysis to control the between-group differences. The primary outcome was a composite of all-cause death and recurrent myocardial infarction (MI). Results: Among the included patients, 1,805 (75.3%) were prescribed with ACEI/ARB at discharge. The median follow-up time was 727 (433–2016) days, with 129 (5.4%) primary endpoint events, consisting of 55 (2.3%) cases of all-cause death and 74 (3.1%) cases of recurrent MI. The use of ACEI/ARB was not associated with significant risk reduction of primary endpoint events in unadjusted analysis (hazard ratio [HR]: 0.95, 95% confidence interval [CI]: 0.64–1.39, p = 0.779), PSM analysis (HR: 0.94, 95% CI: 0.60–1.47, p = 0.784), and PSMW analysis (HR: 0.91, 95% CI: 0.55–1.49, p = 0.704). Similar results were observed for secondary outcomes of all-cause death, cardiac death, and recurrent MI. Conclusion: For ACS patients without HF, the use of ACEI/ARB was not associated with lower risk of death or recurrent MI after PCI.
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Affiliation(s)
- Runzhen Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
| | - Chen Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
| | - Peng Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jiannan Li
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jinying Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoxiao Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Shaodi Yan
- Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
| | - Li Song
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hanjun Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongbing Yan
- Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, China.,Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
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20
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(Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology). COR ET VASA 2022. [DOI: 10.33678/cor.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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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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22
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Olsen C, Mandawat A, Sun JL, Triana T, Chiswell K, Karra R. Recovery of left ventricular function is associated with improved outcomes in LVAD recipients. J Heart Lung Transplant 2022; 41:1055-1062. [DOI: 10.1016/j.healun.2022.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 12/26/2021] [Accepted: 03/08/2022] [Indexed: 11/26/2022] Open
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23
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Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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24
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Brinkley DM, Wang L, Yu C, Grandin EW, Kiernan MS. Impact of renin-angiotensin-aldosterone system inhibition on morbidity and mortality during long-term continuous-flow left ventricular assist device support: An IMACS report. J Heart Lung Transplant 2021; 40:1605-1613. [PMID: 34663529 DOI: 10.1016/j.healun.2021.08.015] [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] [Received: 10/29/2020] [Revised: 08/21/2021] [Accepted: 08/31/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Inhibition of the renin angiotensin aldosterone system (RAAS) improves survival and reduces adverse cardiac events in heart failure with reduced ejection fraction, but the benefit is not well-defined following left ventricular assist device (LVAD). METHODS We analyzed the ISHLT IMACS registry for adults with a primary, continuous-flow LVAD from January 2013 to September 2017 who were alive at postoperative month 3 without a major adverse event, and categorized patients according to treatment an angiotensin converting enzyme inhibitor (ACEI/ARB) or mineralocorticoid receptor antagonist (MRA). Propensity score matching was performed separately for ACEI/ARB vs none (n = 4,118 each) and MRA vs none (n = 3,892 each). RESULTS Of 11,494 patients included, 50% were treated with ACEI/ARB and 38% with MRA. Kaplan-Meier survival was significantly better for patients receiving ACEI/ARB (p < 0.001) but not MRA (p = 0.31). In Cox proportional hazards analyses adjusted for known predictors of mortality following LVAD, ACEI/ARB use (hazard ratio 0.81 [95% confidence interval 0.71-0.93], p < 0.0001) but not MRA use (hazard ratio 1.03 [95% confidence interval 0.88-1.21], p = 0.69) was independently associated with lower mortality. Among patients treated with an ACEI/ARB, there was a significantly lower unadjusted risk of cardiovascular death (p < 0.001), risk of gastrointestinal bleeding (p = 0.01), and creatinine level (p < 0.001). MRA therapy was associated with lower risk of gastrointestinal bleeding (p = 0.01) but higher risk of hemolysis (p < 0.01). Potential limitations include residual confounding and therapy crossover. CONCLUSION These findings suggest a benefit for ACEI/ARB therapy in patients with heart failure after LVAD implantation.
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Affiliation(s)
- D Marshall Brinkley
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E Wilson Grandin
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael S Kiernan
- Cardiovascular Division, Tufts Medical Center, Boston, Massachusetts
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25
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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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26
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Briasoulis A, Ruiz Duque E, Mouselimis D, Tsarouchas A, Bakogiannis C, Alvarez P. The role of renin-angiotensin system in patients with left ventricular assist devices. J Renin Angiotensin Aldosterone Syst 2021; 21:1470320320966445. [PMID: 33084480 PMCID: PMC7871286 DOI: 10.1177/1470320320966445] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
End-stage heart failure is a condition in which the up-regulation of the systemic and local renin-angiotensin-aldosterone system (RAAS) leads to end-organ damage and is largely irreversible despite optimal medication. Left ventricular assist devices (LVADs) can downregulate RAAS activation by unloading the left ventricle and increasing the cardiac output translating into a better end-organ perfusion improving survival. However, the absence of pulsatility brought about by continuous-flow devices may variably trigger RAAS activation depending on left ventricular (LV) intrinsic contractility, the design and speed of the pump device. Moreover, the concept of myocardial recovery is being tested in clinical trials and in this setting LVAD support combined with intense RAAS inhibition can promote recovery and ensure maintenance of LV function after explantation. Blood pressure control on LVAD recipients is key to avoiding complications as gastrointestinal bleeding, pump thrombosis and stroke. Furthermore, emerging data highlight the role of RAAS antagonists as prevention of arteriovenous malformations that lead to gastrointestinal bleeds. Future studies should focus on the role of angiotensin receptor inhibitors in preventing myocardial fibrosis in patients with LVADs and examine in greater details the target blood pressure for these patients.
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Affiliation(s)
- Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Ernesto Ruiz Duque
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Dimitrios Mouselimis
- 3rd Department of Cardiology Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasios Tsarouchas
- 3rd Department of Cardiology Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Constantinos Bakogiannis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Paulino Alvarez
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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27
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Jennings DL, Truby LK, Littlefield AJ, Ciolek AM, Marshall D, Jain R, Topkara VK. Impact of heart failure drug therapy on rates of gastrointestinal bleeding in LVAD recipients: An INTERMACS analysis. Int J Artif Organs 2021; 44:965-971. [PMID: 33977770 DOI: 10.1177/03913988211013366] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Gastrointestinal bleeding (GIB) remains a common and vexing complication of left ventricular assist device (LVAD) support. Recent single-center analyses suggest that ACE inhibitors (ACEi)/angiotensin receptor blockers (ARB) and digoxin may prevent GIB in LVAD patients. Here we evaluate the effect of guideline-directed medical therapies (GDMT) for heart failure (HF) on rates of GIB through analysis of the INTERMACS registry database. METHODS Thirteen thousand seven hundred thirty-two patients who received a continuous-flow LVAD and were on antiplatelet therapy and anticoagulation with warfarin after 3 months of pump support were included in the analysis. GIB events following implant were assessed based on receipt of ACEi/ARB, beta-blockers (BB), mineralocorticoid receptor antagonist (MRA), amiodarone, digoxin, loop diuretics, and phosphiesterase-5 inhibitors (PDE5). Backwards stepwise cox regression was used to control for confounding of each drug class on each other, as well as for clinical variables like age, gender, renal function, HF etiology, and device strategy. RESULTS After 3 months of pump support medications used in LVAD patients were BB (65.0%), ACEi/ARB (51.7%), Amio (43.7%), MRA (37.9%), and loop diuretics (70.1%). In patients with available data, PDE and digoxin use were 18.2% and 16.9%, respectively. The overall incidence of GIB was 19.5% at 2 years of support. After adjustment for other clinical variables, loop diuretics (HR 1.274, p < 0.001) and PDE5 (HR 1.241, p < 0.001) use were associated with increased risk of GIB, while use of BB (HR 0.871, p = 0.006) was associated with lower risk of GIB. ACEi/ARB (HR 1.002, p = 0.971), Amio (HR 1.083, p = 0.106), AA (HR 0.967, p = 0.522) or digoxin (HR 1.087, p = 0.169) did not affect GIB rates on LVAD support (Figure). CONCLUSION Despite recent reports, ACEi/ARB, MRA, Amio, and digoxin use does not appear to be associated with GIB during LVAD support. The heightened risk seen in those on loop diuretics may reflect venous congestion in these patients, while antiplatelet effects of PDE5 could drive the higher risk of GIB.
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Affiliation(s)
- Douglas L Jennings
- Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, NY, USA.,Department of Pharmacy, NewYork-Presbyterian Hospital Columbia University Irving Medical Center, New York, NY, USA
| | - Lauren K Truby
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Audrey J Littlefield
- Department of Pharmacy, NewYork-Presbyterian Hospital Weill Cornell Medical Center, New York, NY, USA
| | - Alana M Ciolek
- Department of Pharmacy, NewYork-Presbyterian Hospital Columbia University Irving Medical Center, New York, NY, USA
| | - Dylan Marshall
- Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Rashmi Jain
- Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, NY, USA
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28
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Jakstaite AM, Luedike P, Schmack B, Pizanis N, Riebisch M, Weymann A, Kamler M, Ruhparwar A, Rassaf T, Papathanasiou M. Increased bleeding risk with phosphodiesterase-5 inhibitors after left ventricular assist device implantation. ESC Heart Fail 2021; 8:2419-2427. [PMID: 33821578 PMCID: PMC8318463 DOI: 10.1002/ehf2.13322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 12/26/2022] Open
Abstract
Aims Therapy with phosphodiesterase‐5 inhibitors (PDE5Is) after left ventricular assist device (LVAD) implantation has been associated with lower mortality and device thrombosis but increased risk for post‐operative and gastrointestinal bleeding. We aimed to evaluate the impact of long‐term PDE5Is on the overall bleeding risk after LVAD implantation. Methods and results We retrospectively included patients who received a continuous‐flow LVAD at our site and were prescribed with long‐term oral PDE5Is after discharge from the index hospitalization. The primary endpoint was the occurrence of bleeding at 12 month follow‐up. Secondary endpoints were all‐cause death and the combination of bleeding and all‐cause death. Our analysis included 109 patients of whom 75 (69%) received long‐term PDE5Is. Mean age was 56 years, and 85% were male. At 12 months, 19 (17%) patients experienced at least one bleeding event. Patients on PDE5Is had higher bleeding rates (23% vs. 6%, P = 0.03) and more bleeding events per patient‐year (0.32 vs. 0.06, P = 0.03) compared with patients not on PDE5Is. While overall bleeding incidence was excessively higher in the PDE5I group, there were no significant differences in the incidence of major bleeding (19% vs. 6%, P = 0.08) and gastrointestinal bleeding (11% vs. 3%, P = 0.18). Kaplan–Meier analysis revealed higher cumulative incidence of bleeding for the PDE5I group (log rank = 0.04) with no difference on all‐cause death (log rank = 0.67) and the combination of bleeding and all‐cause death (log rank = 0.13). Hospitalizations for bleeding and their duration were numerically higher in the PDE5I group (0.28 vs. 0.03, P = 0.07 and 2.4 vs. 0.2, P = 0.07, respectively). Conclusions Phosphodiesterase‐5 inhibitor treatment after LVAD implantation is associated with increased bleeding risk after LVAD implantation. The safety of long‐term PDE5Is in LVAD patients remains unclear and needs to be further clarified in prospective studies with randomized study design.
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Affiliation(s)
- Aiste-Monika Jakstaite
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Nikolaus Pizanis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Matthias Riebisch
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
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29
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Cole RM, Lam LD. Anticoagulation in Mechanical Circulatory Support. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00328-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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Primary and Secondary Prevention Strategies for Gastrointestinal Bleeding in Patients with Left Ventricular Assist Device: A Systematic Review and Network Meta-analysis. Curr Probl Cardiol 2021; 46:100835. [PMID: 33992428 DOI: 10.1016/j.cpcardiol.2021.100835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 12/21/2022]
Abstract
Recurrent gastrointestinal bleeding (GIB) is a common complication following left ventricular assist device (LVAD) implantation. Our study aimed to estimate the comparative efficacy of different pharmacologic interventions for the prevention of GIB, through a network meta-analysis (NMA). A total of 13 observational studies comparing six strategies. Among those, 4 were for primary, and 9 were for secondary prevention of GIB. On NMA, thalidomide (Hazard ratio [HR]: 0.016, Credible interval [CrI]I: 0.00053-0.12), omega-3-fatty acid (HR:0.088, CrI: 0.026-0.77), octreotide (HR: 0.17, CrI: 0.0589-0.41) and danazol (HR:0.17, CrI: 0.059-0.41) reduced the risk of GIB. The use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blocker (ACEi/ARB) and digoxin were not associated with any significant reduction. Based on NMA, combining indirect treatment comparisons, thalidomide, danazol, and octreotide treatments were associated with decreased risk of recurrent GIB. Additionally, Omega 3 fatty acids were associated with a lower risk of the primary episode of GIB in the LVAD patient population.
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31
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Hollis IB, Doligalski CT, Jennings DJ. Pharmacotherapy for durable left ventricular assist devices. Pharmacotherapy 2021; 41:14-27. [PMID: 33278842 DOI: 10.1002/phar.2491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 12/12/2022]
Abstract
Left ventricular assist devices (LVADs) have revolutionized the care of patients with advanced heart failure, yet still require concomitant medications in order to achieve the best possible clinical outcomes. Since the outset of routine placement of durable, continuous-flow LVADs, much of the medication management of these patients to date has been based on International Society of Heart and Lung Transplantation (ISHLT) guidance, most recently published in 2013. Since 2013, numerous multidisciplinary pharmacotherapy publications have increased the LVAD community's understanding of best practices with respect to medications. We identified the major domains of LVAD medication management and conducted a comprehensive search of US National Library of Medicine MEDLINE® database using keywords chosen to identify medication-related publications of significance dated 2013 or later. Trials pertaining to the HeartMate II™ and the HeartMate™ 3 LVADs (Abbott, Chicago, IL) and the HeartWare™ HVAD™ System (Medtronic, Minneapolis, MN) were chosen for inclusion. Highest priority for inclusion was given to prospective, randomized, controlled studies. Absent these, controlled trials (retrospective or prospective observational) were given next-highest consideration, followed by retrospective uncontrolled studies, and finally case series. Reference lists of qualified publications were reviewed to find any other publications of interest that were not discovered on initial search. Case reports were generally excluded, except where the insight gained was deemed to be uniquely pertinent. This document serves to provide a comprehensive review of the current understanding of optimal medication management in patients with durable, continuous-flow LVADs.
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Affiliation(s)
- Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Christina T Doligalski
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Douglas J Jennings
- Department of Pharmacy Practice, Long Island University, New York-Presbyterian Hospital Columbia University Irving Medical Center, New York, New York, USA
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Oussalah A, Gleye S, Clerc Urmes I, Laugel E, Callet J, Barbé F, Orlowski S, Malaplate C, Aimone-Gastin I, Caillierez BM, Merten M, Jeannesson E, Kormann R, Olivier JL, Rodriguez-Guéant RM, Namour F, Bevilacqua S, Losser MR, Levy B, Kimmoun A, Gibot S, Thilly N, Frimat L, Schvoerer E, Guéant JL. Long-term ACE Inhibitor/ARB Use Is Associated With Severe Renal Dysfunction and Acute Kidney Injury in Patients With Severe COVID-19: Results From a Referral Center Cohort in the Northeast of France. Clin Infect Dis 2020; 71:2447-2456. [PMID: 32623470 PMCID: PMC7454376 DOI: 10.1093/cid/ciaa677] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background In patients with severe coronavirus disease 2019 (COVID-19), data are scarce and conflicting regarding whether chronic use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) influences disease outcomes. In patients with severe COVID-19, we assessed the association between chronic ACEI/ARB use and the occurrence of kidney, lung, heart, and liver dysfunctions and the severity of the inflammatory reaction as evaluated by biomarkers kinetics, and their association with disease outcomes. Methods We performed a retrospective longitudinal cohort study on consecutive patients with newly diagnosed severe COVID-19. Independent predictors were assessed through receiver operating characteristic analysis, time-series analysis, logistic regression analysis, and multilevel modeling for repeated measures. Results On the 149 patients included in the study 30% (44/149) were treated with ACEI/ARB. ACEI/ARB use was independently associated with the following biochemical variations: phosphorus >40 mg/L (odds ratio [OR], 3.35, 95% confidence interval [CI], 1.83–6.14), creatinine >10.1 mg/L (OR, 3.22, 2.28–4.54), and urea nitrogen (UN) >0.52 g/L (OR, 2.65, 95% CI, 1.89–3.73). ACEI/ARB use was independently associated with acute kidney injury stage ≥1 (OR, 3.28, 95% CI, 2.17–4.94). The daily dose of ACEI/ARB was independently associated with altered kidney markers with an increased risk of +25 to +31% per each 10 mg increment of lisinopril-dose equivalent. In multivariable multilevel modeling, UN >0.52 g/L was independently associated with the risk of acute respiratory failure (OR, 3.54, 95% CI, 1.05–11.96). Conclusions Patients chronically treated with ACEI/ARB who have severe COVID-19 are at increased risk of acute kidney injury. In these patients, the increase in UN associated with ACEI/ARB use could predict the development of acute respiratory failure.
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Affiliation(s)
- Abderrahim Oussalah
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France.,University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
| | - Stanislas Gleye
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - Isabelle Clerc Urmes
- Department of Methodology, Promotion, and Investigation, University Hospital of Nancy, University of Lorraine, Nancy, France
| | - Elodie Laugel
- Department of Virology, University Hospital of Nancy, Nancy, France, Laboratory of Physical Chemistry and Microbiology for the Environment, Villers-les-Nancy, France
| | - Jonas Callet
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - Françoise Barbé
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - Sophie Orlowski
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - Catherine Malaplate
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - Isabelle Aimone-Gastin
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France.,University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
| | - Beatrice Maatem Caillierez
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - Marc Merten
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - Elise Jeannesson
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - Raphaël Kormann
- Department of Nephrology, University Hospital of Nancy, Nancy, France
| | - Jean-Luc Olivier
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - Rosa-Maria Rodriguez-Guéant
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France.,University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
| | - Farès Namour
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France.,University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
| | - Sybille Bevilacqua
- Department of Infectious Diseases, University Hospital of Nancy, Nancy, France
| | - Marie-Reine Losser
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Nancy, Nancy, France
| | - Bruno Levy
- Medical Intensive Care Unit, University Hospital of Nancy, Brabois Hospital, Nancy, France
| | - Antoine Kimmoun
- Medical Intensive Care Unit, University Hospital of Nancy, Brabois Hospital, Nancy, France
| | - Sébastien Gibot
- Medical Intensive Care Unit, University Hospital of Nancy, Central Hospital, Nancy, France
| | - Nathalie Thilly
- Department of Methodology, Promotion, and Investigation, University Hospital of Nancy, University of Lorraine, Nancy, France
| | - Luc Frimat
- Department of Nephrology, University Hospital of Nancy, Nancy, France
| | - Evelyne Schvoerer
- Department of Virology, University Hospital of Nancy, Nancy, France, Laboratory of Physical Chemistry and Microbiology for the Environment, Villers-les-Nancy, France
| | - Jean-Louis Guéant
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France.,University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
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Birks EJ, Drakos SG, Patel SR, Lowes BD, Selzman CH, Starling RC, Trivedi J, Slaughter MS, Alturi P, Goldstein D, Maybaum S, Um JY, Margulies KB, Stehlik J, Cunningham C, Farrar DJ, Rame JE. Prospective Multicenter Study of Myocardial Recovery Using Left Ventricular Assist Devices (RESTAGE-HF [Remission from Stage D Heart Failure]). Circulation 2020; 142:2016-2028. [DOI: 10.1161/circulationaha.120.046415] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Left ventricular assist device (LVAD) unloading and hemodynamic support in patients with advanced chronic heart failure can result in significant improvement in cardiac function allowing LVAD removal; however, the rate of this is generally considered to be low. This prospective multicenter nonrandomized study (RESTAGE-HF [Remission from Stage D Heart Failure]) investigated whether a protocol of optimized LVAD mechanical unloading, combined with standardized specific pharmacological therapy to induce reverse remodeling and regular testing of underlying myocardial function, could produce a higher incidence of LVAD explantation.
Methods:
Forty patients with chronic advanced heart failure from nonischemic cardiomyopathy receiving the Heartmate II LVAD were enrolled from 6 centers. LVAD speed was optimized with an aggressive pharmacological regimen, and regular echocardiograms were performed at reduced LVAD speed (6000 rpm, no net flow) to test underlying myocardial function. The primary end point was the proportion of patients with sufficient improvement of myocardial function to reach criteria for explantation within 18 months with sustained remission from heart failure (freedom from transplant/ventricular assist device/death) at 12 months.
Results:
Before LVAD, age was 35.1±10.8 years, 67.5% were men, heart failure mean duration was 20.8±20.6 months, 95% required inotropic and 20% temporary mechanical support, left ventricular ejection fraction was 14.5±5.3%, end-diastolic diameter was 7.33±0.89 cm, end-systolic diameter was 6.74±0.88 cm, pulmonary artery saturations were 46.7±9.2%, and pulmonary capillary wedge pressure was 26.2±7.6 mm Hg. Four enrolled patients did not undergo the protocol because of medical complications unrelated to the study procedures. Overall, 40% of all enrolled (16/40) patients achieved the primary end point,
P
<0.0001, with 50% (18/36) of patients receiving the protocol being explanted within 18 months (pre-explant left ventricular ejection fraction, 57±8%; end-diastolic diameter, 4.81±0.58 cm; end-systolic diameter, 3.53±0.51 cm; pulmonary capillary wedge pressure, 8.1±3.1 mm Hg; pulmonary artery saturations 63.6±6.8% at 6000 rpm). Overall, 19 patients were explanted (19/36, 52.3% of those receiving the protocol). The 15 ongoing explanted patients are now 2.26±0.97 years after explant. After explantation survival free from LVAD or transplantation was 90% at 1-year and 77% at 2 and 3 years.
Conclusions:
In this multicenter prospective study, this strategy of LVAD support combined with a standardized pharmacological and cardiac function monitoring protocol resulted in a high rate of LVAD explantation and was feasible and reproducible with explants occurring in all 6 participating sites.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01774656.
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Affiliation(s)
- Emma J. Birks
- Division of Cardiovascular Medicine (E.J.B.), University of Louisville, KY
- Division of Cardiovascular Medicine, University of Kentucky, Lexington (E.J.B.)
| | - Stavros G. Drakos
- Division of Cardiovascular Medicine (S.G.D., J.S.), University of Utah, Salt Lake City
| | - Snehal R. Patel
- Department of Cardiovascular Medicine (S.R.P.), Montefiore Medical Center, New York
| | - Brian D. Lowes
- Division of Cardiovascular Medicine (B.D.L.), University of Nebraska, Omaha
| | - Craig H. Selzman
- Division of Cardiothoracic Surgery (C.H.S.), University of Utah, Salt Lake City
| | | | - Jaimin Trivedi
- Department of Cardiovascular Surgery (J.T., M.S.S.), University of Louisville, KY
| | - Mark S. Slaughter
- Department of Cardiovascular Surgery (J.T., M.S.S.), University of Louisville, KY
| | - Pavin Alturi
- Department of Surgery, University of Pennsylvania, Philadelphia (P.A.)
| | - Daniel Goldstein
- Department of Cardiovascular Surgery (D.G.), Montefiore Medical Center, New York
| | - Simon Maybaum
- Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, NY (S.M.)
| | - John Y. Um
- Department of Cardiovascular Surgery (J.Y.U.), University of Nebraska, Omaha
| | - Kenneth B. Margulies
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia (K.B.M., J.E.R.)
| | - Josef Stehlik
- Division of Cardiovascular Medicine (S.G.D., J.S.), University of Utah, Salt Lake City
| | | | | | - Jesus E. Rame
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia (K.B.M., J.E.R.)
- Department of Medicine, Jefferson University Hospital, Philadelphia, PA (J.E.R.)
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34
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A reappraisal of the pharmacologic management of gastrointestinal bleeding in patients with continuous flow left ventricular assist devices. Heart Fail Rev 2020; 26:277-288. [PMID: 32870436 DOI: 10.1007/s10741-020-10019-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2020] [Indexed: 12/28/2022]
Abstract
Advancements in the design and functionality of continuous flow left ventricular assist devices (CF-LVADs), as well as a limited number of donor hearts, have resulted in an increased utilization of this therapy among advanced heart failure (HF) patients. Despite these advancements, gastrointestinal bleeding (GIB) remains a common complication after CF-LVAD implantation. The mechanism of GIB in these patients is complex and includes a combination of angiodysplasia, platelet dysfunction, acquired von Willebrand disease, and a variety of patient-specific factors including advanced age and history of GIB. Several pharmacotherapy options have been reported in the literature, though studies supporting the use of these agents are often small, retrospective reports. Within this review, we discuss the various pharmacologic agents, their proposed mechanisms of action, and the available literature pertaining to their effectiveness and tolerability. Additionally, we propose an evidence-based treatment algorithm, encompassing the updated literature, cost of therapy, medication side effects, and ease of administration.
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35
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Kittipibul V, Vutthikraivit W, Kewcharoen J, Rattanawong P, Tantrachoti P, Putthapiban P, Nair N. Angiotensin II antagonists and gastrointestinal bleeding in left ventricular assist devices: A systematic review and meta-analysis. Int J Artif Organs 2020; 44:215-220. [PMID: 32842844 DOI: 10.1177/0391398820951811] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gastrointestinal bleeding (GIB) especially from arteriovenous malformations (AVM) remains one of the devastating complications following continuous-flow left ventricular device (CF-LVAD) implantation. Blockade of angiotensin II pathway using angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) was reported to mitigate the risk of GIB and AVM-related GIB by suppressing angiogenesis. We performed a systematic review and meta-analysis to evaluate the association between ACEI/ARB treatment and GIB in CF-LVAD population. Comprehensive literature search was performed through December 2019. We included studies reporting risk of GIB and/or AVM-related GIB events in LVAD patients who received ACEI/ARB with those who did not. Data from each study were combined using the random-effects to calculate odd ratios and 95% confidence intervals. Three retrospective cohort studies were included in this meta-analysis involving 619 LVADs patients (467 patients receiving ACEI/ARB). The use of ACEI/ARB was statistically associated with decreased incidence of overall GIB (pooled OR 0.35, 95% CI 0.22-0.56, I2 = 0.0%, p < 0.001). There was a non-significant trend toward lower risk for AVM-related GIB in patients who received ACEI/ARB (pooled OR 0.46, 95% CI 0.19-1.07, I2 = 51%, p = 0.07). Larger studies with specific definitions of ACEI/ARB use and GIB are warranted to accurately determine the potential non-hemodynamic benefits of ACEI/ARB in CF-LVAD patients.
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Affiliation(s)
- Veraprapas Kittipibul
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Wasawat Vutthikraivit
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jakrin Kewcharoen
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | | | - Pakpoom Tantrachoti
- Department of Cardiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Nandini Nair
- Department of Cardiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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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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37
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Hanff TC, Birati EY. Left Ventricular Assist Device as Destination Therapy: a State of the Science and Art of Long-Term Mechanical Circulatory Support. Curr Heart Fail Rep 2020; 16:168-179. [PMID: 31631240 DOI: 10.1007/s11897-019-00438-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize and summarize recent developments in the care of patients with end-stage heart failure being managed with a left ventricular assist device (LVAD) as destination therapy. RECENT FINDINGS Although the survival of patients treated with LVAD continues to improve, the rates of LVAD-associated complication, such as right ventricular failure, bleeding complications, and major infection, remain high, and management of these patients remains challenging. The durability and hemocompatibility of LVAD support have greatly increased in recent years as a result of new technologies and novel management strategies. Challenges remain in the comprehensive care of patients with destination therapy LVADs, including management of comorbidities and optimizing patient function and quality of life.
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Affiliation(s)
- Thomas C Hanff
- Department of Medicine Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edo Y Birati
- Department of Medicine Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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38
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Imamura T, Mehta P, Nguyen A, Chung B, Narang N, Rodgers D, Raikhelkar J, Smith B, Song T, Ota T, Jeevanandam V, Kim G, Sayer G, Uriel N. Neurohormonal Blockade During Left Ventricular Assist Device Support. ASAIO J 2020; 66:881-885. [PMID: 32740347 DOI: 10.1097/mat.0000000000001104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Neurohormonal blockade (NHB) is the mainstay of therapy for patients with systolic heart failure (HF). However, the efficacy in patients with left ventricular assist devices (LVADs) remains unknown. Of all, 114 LVAD patients (57 [48, 65] years old and 78% male) were enrolled and followed during the early period (6 months after index discharge), and 98 were followed during the late period (6-12 months following index discharge). Of them, 46% were on beta-blocker (BB), 49% on angiotensin-converting enzyme inhibitor (ACEi) and/or angiotensin II receptor blocker (ARB), and 51% on aldosterone antagonist at baseline. Prevalence of BB and ACEi/ARB use increased during the study period. During the early period, similar event rates were found irrespective of the NHB uses. During the late period, BB was associated with reduced HF readmission, and ACEi/ARB was associated with reduced HF readmission and gastrointestinal bleeding (p < 0.05 for all). In conclusion, BB and ACEi/ARB use during the late period was associated with a reduction in HF recurrence in LVAD patients. Further prospective randomized control trials are warranted to clarify the utility of NHB therapy in LVAD patients.
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Affiliation(s)
- Teruhiko Imamura
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Priya Mehta
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Nikhil Narang
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Smith
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Section of Cardiothoracic Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Valluvan Jeevanandam
- Section of Cardiothoracic Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Gabriel Sayer
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
| | - Nir Uriel
- From the Section of Cardiology, University of Chicago Medical Center, Chicago, Illinois
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Vedachalam S, Balasubramanian G, Haas GJ, Krishna SG. Treatment of gastrointestinal bleeding in left ventricular assist devices: A comprehensive review. World J Gastroenterol 2020; 26:2550-2558. [PMID: 32523310 PMCID: PMC7265145 DOI: 10.3748/wjg.v26.i20.2550] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/02/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Left ventricular assist devices (LVAD) are increasingly become common as life prolonging therapy in patients with advanced heart failure. Current devices are now used as definitive treatment in some patients given the improved durability of continuous flow pumps. Unfortunately, continuous flow LVADs are fraught with complications such as gastrointestinal (GI) bleeding that are primarily attributed to the formation of arteriovenous malformations. With frequent GI bleeding, antiplatelet and anticoagulation therapies are usually discontinued increasing the risk of life-threatening events. Small bowel bleeds account for 15% as the source and patients often undergo multiple endoscopic procedures. Treatment strategies include resuscitative measures and endoscopic therapies. Medical treatment is with octreotide. Novel treatment options include thalidomide, angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, estrogen-based hormonal therapies, doxycycline, desmopressin and bevacizumab. Current research has explored the mechanism of frequent GI bleeds in this population, including destruction of von Willebrand factor, upregulation of tissue factor, vascular endothelial growth factor, tumor necrosis factor-α, tumor growth factor-β, and angiopoetin-2, and downregulation of angiopoetin-1. In addition, healthcare resource utilization is only increasing in this patient population with higher admissions, readmissions, blood product utilization, and endoscopy. While some of the novel endoscopic and medical therapies for LVAD bleeds are still in their development stages, these tools will yet be crucial as the number of LVAD placements will likely only increase in the coming years.
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Affiliation(s)
- Srikanth Vedachalam
- Department of Internal Medicine, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| | - Garrie J Haas
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
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40
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Affiliation(s)
- Emma J Birks
- From the Department of Cardiology, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky
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41
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Converse MP, Sobhanian M, Taber DJ, Houston BA, Meadows HB, Uber WE. Effect of Angiotensin II Inhibitors on Gastrointestinal Bleeding in Patients With Left Ventricular Assist Devices. J Am Coll Cardiol 2020; 73:1769-1778. [PMID: 30975293 DOI: 10.1016/j.jacc.2019.01.051] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Angiotensin II receptor activation may result in angiogenesis, and ultimately arteriovenous malformations (AVM), through transforming growth factor (TGF)-β and angiopoietin-2 pathway activation. OBJECTIVES The goal of this study was to determine whether angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) were associated with lower risk of major gastrointestinal bleeds (GIB) and AVM-related GIBs in continuous-flow left ventricular assist device (CF-LVAD) patients. METHODS The authors reviewed HeartMate II CF-LVAD recipients between January 2009 and July 2016. Major GIBs were endoscopically confirmed requiring ≥2 U of packed red blood cells or resulting in death. ACE inhibitor/ARB dose was abstracted from medical records. ACE inhibitor/ARB exposure status was landmarked at 30 days post-operatively to avoid immortal time bias. Fine and Gray hazard models assessed the impact of ACE inhibitor/ARB therapy on major GIB and AVM-related GIB, whereas standard Cox regression assessed the impact on mortality, adjusting for baseline variables. RESULTS One-hundred and eleven patients were included with a mean 2.1 ± 1.4 years follow-up. Patients who received an ACE inhibitor/ARB within 30 days post-operatively had a 57% reduction in the risk of major GIB (adjusted hazard ratio [aHR]: 0.43; 95% confidence interval [CI]: 0.19 to 0.97; p = 0.042) and a 63% reduction in the risk of AVM-related GIB (aHR: 0.37; 95% CI: 0.16 to 0.84; p = 0.017). When the mean daily post-operative lisinopril-equivalent ACE inhibitor/ARB dose was >5 mg, the risk of major GIB decreased in a dose-threshold manner (aHR: 0.28; 95% CI: 0.09 to 0.85; p = 0.025). CONCLUSIONS ACE inhibitor/ARB therapy is associated with a protective effect of developing GIBs in CF-LVAD patients, with a dose threshold of >5 mg of daily lisinopril equivalence, possibly due to prevention of AVM formation.
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Affiliation(s)
- Maureen P Converse
- Department of Pharmacy Services, University of Florida Health Shands Hospital, Gainesville, Florida.
| | - Minoosh Sobhanian
- Department of Pharmacy Services, Memorial Hermann Hospital-Texas Medical Center, Houston, Texas
| | - David J Taber
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Holly B Meadows
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina
| | - Walter E Uber
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina
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42
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The Predicament of Gastrointestinal Bleeding in Patients With a Continuous-Flow Left Ventricular Assist Device: Pathophysiology, Evaluation, and Management. Cardiol Rev 2020; 27:222-229. [PMID: 30365405 DOI: 10.1097/crd.0000000000000235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Heart failure affects over 5 million Americans, with numbers expected to rise. While heart transplantation is the most effective long-term strategy for end-stage heart failure, there is a limited cardiac donor pool, and these organs are often unavailable at the time of need. Left ventricular assist devices, therefore, continue to be used to bridge this gap. Originally implanted as a bridge to transplant, these devices are now additionally utilized as destination therapy for patients ineligible for transplant. With the widespread applicability of these devices for not just temporary measures, but also for prolonged use, the short- and long-term impact on other organ systems has become more evident. For example, gastrointestinal (GI) bleeding, with an incidence approaching 30%, is one such complication post-continuous-flow left ventricular assist device implantation. This high incidence of GI bleeding is thought to stem from a combination of factors, including the need for concomitant anticoagulant and antiplatelet therapy, and intrinsic device-related properties resulting in acquired Von Willebrand disease and arteriovenous malformations. Due to the significant morbidity associated with these GI bleeding events, a standardized protocol optimizing medical and endoscopic management, alongside close coordination between the gastroenterology and cardiology services, should be advocated for and ultimately employed.
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Ahmed MM, Roukoz H, Trivedi JR, Bhan A, Ravichandran A, Dhawan R, Cowger J, Bhat G, Birks EJ, Slaughter MS, Gopinathannair R. Questionable utility of digoxin in left-ventricular assist device recipients: A multicenter, retrospective analysis. PLoS One 2019; 14:e0225628. [PMID: 31765397 PMCID: PMC6876793 DOI: 10.1371/journal.pone.0225628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/29/2019] [Indexed: 11/19/2022] Open
Abstract
Background While clinical experience with left ventricular assist devices (LVAD) continues to grow and evolve, little is known regarding the ongoing use of certain medications in this population. We sought to evaluate the utility of digoxin in LVAD recipients and its association with outcomes. Methods A total of 505 patients who underwent continuous-flow LVAD implantation at 5 centers from 2007–2015 were included. Patients were divided into 4 groups: not on digoxin at any time (ND; n = 257), received digoxin pre implant (PreD; n = 144), received digoxin pre and post implant (ContD; n = 55), and received digoxin only post implant (PostD; n = 49). Survival and all-cause readmission were compared between the 4 groups. Results There was no difference in survival at 1 year nor at 3 years between groups (ND = 88%, 66%, respectively; PreD = 85%, 66%; ContD = 86%, 57%; PostD = 90%, 51%; p = 0.7). Readmission per 100 days also was not different between groups (ND = 0.5, PreD = 0.6, ContD = 0.5, PostD = 0.7; p = 0.1). Conclusions In this large, multicenter cohort, use of digoxin was not associated with any significant benefit in regard to mortality or hospitalization in patients supported with a continuous-flow LVAD. Importantly, its discontinuation post implant did not worsen all-cause hospitalization or survival.
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Affiliation(s)
- Mustafa M. Ahmed
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States of America
- * E-mail:
| | - Henri Roukoz
- Cardiovascular Division, Electrophysiology Section, University of Minnesota, Minneapolis, MN, United States of America
| | - Jaimin R. Trivedi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Adarsh Bhan
- Heart Institute, Advocate Christ Medical Center, Oak Lawn, IL, United States of America
| | - Ashwin Ravichandran
- St. Vincent Heart Center of Indiana, Indianapolis, IN, United States of America
| | - Rahul Dhawan
- University of Nebraska, Omaha, Nebraska, United States of America
| | - Jennifer Cowger
- Henry Ford Hospital, Detroit, Michigan, United States of America
| | - Geetha Bhat
- Heart Institute, Advocate Christ Medical Center, Oak Lawn, IL, United States of America
| | - Emma J. Birks
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, United States of America
| | - Mark S. Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas, United States of America
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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: 39] [Impact Index Per Article: 7.8] [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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SSRI/SNRI Therapy is Associated With a Higher Risk of Gastrointestinal Bleeding in LVAD Patients. Heart Lung Circ 2019; 29:1241-1246. [PMID: 31635997 DOI: 10.1016/j.hlc.2019.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 04/29/2019] [Accepted: 07/15/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is common in left ventricular assist device (LVAD) patients. Serotonin release from platelets promotes platelet aggregation, and selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) therapy inhibits the transporter responsible for re-uptake. METHODS We reviewed the records of LVAD (HeartMateII™, Abbott Medical, Lake Bluff, IL, USA and Heartware™, Medtronic, Minneapolis, MN, USA) patients at the Medical University of South Carolina and Johns Hopkins Hospital between January 2009 and January 2016. After exclusions, 248 patients were included for analysis. After univariate analysis, logistic regression multivariate analysis was performed to adjust for any demographic, cardiovascular, and laboratory data variables found to be associated with GI bleeding post-LVAD. RESULTS Gastrointestinal bleeding occurred in 85 patients (35%) with 55% of GIBs due to arteriovenous malformations (AVMs). Of the total cohort, 105 patients received an SSRI or SNRI during LVAD support. Forty-four (44) SSRI/SNRI (41.9%) and 41 non-SSRI/SNRI (28.7%) patients had a GIB (RR 1.46, p = 0.03). Twenty-six (26) (24.8%) of the SSRI/SNRI patients had a GIB due to AVMs versus 21 (14.7%) of the non-SSRI/SNRI patients (RR 1.69, p = 0.05). In fully-adjusted multivariate regression analysis, SSRI/SNRI therapy was independently associated with GIB (OR 1.78, p = 0.045). For GIB, the number needed to harm (NNH) was 7.6. CONCLUSION In conclusion, SSRI/SNRI therapy is independently associated with an increased risk of GIB in LVAD patients.
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Bansal A, Uriel N, Colombo PC, Narisetty K, Long JW, Bhimaraj A, Cleveland JC, Goldstein DJ, Stulak JM, Najjar SS, Lanfear DE, Adler ED, Dembitsky WP, Somo SI, Crandall DL, Chen D, Connors JM, Mehra MR. Effects of a fully magnetically levitated centrifugal-flow or axial-flow left ventricular assist device on von Willebrand factor: A prospective multicenter clinical trial. J Heart Lung Transplant 2019; 38:806-816. [DOI: 10.1016/j.healun.2019.05.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 01/13/2023] Open
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Yousefzai R, Brambatti M, Tran HA, Pedersen R, Braun OÖ, Baykaner T, Ghashghaei R, Sulemanjee NZ, Cheema OM, Rappelt M, Baeza C, Alkhayyat A, Shi Y, Pretorius V, Greenberg B, Adler E, Thohan V. Benefits of Neurohormonal Therapy in Patients With Continuous-Flow Left Ventricular Assist Devices. ASAIO J 2019; 66:409-414. [PMID: 31192845 DOI: 10.1097/mat.0000000000001022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Left ventricular assist devices (LVADs) have dramatically improved short-term outcomes among patients with advanced heart failure. While neurohormonal blockade (NHB) is the cornerstone of treatment for patients with heart failure with reduced ejection fraction, its effect after LVAD placement has not been established. We reviewed medical records of 307 patients who underwent primary LVAD implantation from January 2006 to September 2015 at two institutions in the United States. Patients were followed for at least 2 years post-LVAD implantation or until explantation, heart transplantation, or death. Cox regression analysis stratifying on center was used to assess associations with mortality. Neurohormonal blockade use was treated as a time-dependent predictor. Stepwise selection indicated treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) (hazard ratio [HR] = 0.53 [0.30-0.95], p = 0.03), age at the time of implantation (HR = 1.28 [1.05-1.56] per decade, p = 0.02), length of stay postimplantation (HR = 1.16 [1.11-1.21] per week, p < 0.01) and INTERMACS profile of 1 or 2 (HR = 1.86 [1.17-2.97], p < 0.01) were independent predictors of mortality. In this large, retrospective study, treatment with ACEIs or ARBs was an independent factor associated with decreased mortality post-LVAD placement.
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Affiliation(s)
- Rayan Yousefzai
- From the Lifespan Cardiovascular Institute, Rhode Island Hospital, Brown University, Providence, Rhode Island.,Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Michela Brambatti
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Hao A Tran
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Rachel Pedersen
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin
| | - Oscar Ö Braun
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Tina Baykaner
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Roxana Ghashghaei
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Nasir Z Sulemanjee
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin
| | - Omar M Cheema
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin
| | - Matthew Rappelt
- Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin. Dr. Shi is now with the National Institutes of Health, Rockville, Maryland
| | - Carmela Baeza
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Abdulaziz Alkhayyat
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Yang Shi
- Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin. Dr. Shi is now with the National Institutes of Health, Rockville, Maryland
| | - Victor Pretorius
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Barry Greenberg
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Eric Adler
- Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California
| | - Vinay Thohan
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin
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Affiliation(s)
- Emma J Birks
- From the Department of Cardiovascular Medicine, University of Louisville, KY.
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Veasey TM, Floroff CK, Strout SE, McElray KL, Brisco-Bacik MA, Cook JL, Toole JM, Craig ML, Van Bakel AB, Meadows HB, Uber WE. Evaluation of anticoagulation and nonsurgical major bleeding in recipients of continuous-flow left ventricular assist devices. Artif Organs 2019; 43:736-744. [PMID: 30868618 DOI: 10.1111/aor.13456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 02/13/2019] [Accepted: 02/28/2019] [Indexed: 12/11/2022]
Abstract
Continuous-flow left ventricular assist device (LVAD) placement has become a standard of care in advanced heart failure treatment. Bleeding is the most frequently reported adverse event after LVAD implantation and may be increased by antithrombotic agents used for prevention of pump thrombosis. This retrospective cohort included 85 adult patients implanted with a Heartmate II LVAD. Major bleeding was defined as occurring >7 days after implant and included intracranial hemorrhage, events requiring 2 units of packed red blood cells within a 24-h period, and death from bleeding. Primary outcome was intensity of anticoagulation between patients with or without at least one incidence of nonsurgical major bleeding. Major bleeding occurred in 35 (41%) patients with 0.48 events per patient year and a median (IQR) time to first bleed of 134.5 (39.3, 368.5) days. The median (IQR) INR at time of bleed was 1.7 (1.4, 2.5). Median INR during follow-up did not differ between groups and patients with major bleeding were not more likely to have a supra-therapeutic INR. Patients who bled were more likely to have received LVAD for destination therapy, to have lower weight, worse renal function, and lower hemoglobin at baseline. Duration of LVAD support and survival were similar between groups with no difference in occurrence of thrombosis. Incidence of nonsurgical major bleeding was not significantly associated with degree of anticoagulation. Certain baseline characteristics may be more important than anticoagulation intensity to identify patients at risk for bleeding after LVAD implant. Modification of anticoagulation alone is not a sufficient management strategy and early intervention may be required to mitigate bleeding impact.
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Affiliation(s)
- Tara M Veasey
- Department of Pharmacy Services, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Catherine K Floroff
- Department of Pharmacy Services, Sentara Norfolk General Hospital, Norfolk, Virginia
| | - Sara E Strout
- Department of Pharmacy Services, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Krista L McElray
- Department of Pharmacy Services, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Meredith A Brisco-Bacik
- Heart Failure and Cardiac Transplantation, The Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | | | - John M Toole
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Michael L Craig
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Adrian B Van Bakel
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Holly B Meadows
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina
| | - Walter E Uber
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina
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Rogers JG, DeVore AD. RAAS Inhibition to Prevent GI Bleeding: Another Reason to Do the Right Thing. J Am Coll Cardiol 2019; 73:1779-1780. [PMID: 30975294 DOI: 10.1016/j.jacc.2019.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Joseph G Rogers
- Department of Medicine and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
| | - Adam D DeVore
- Department of Medicine and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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