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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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Tsiouris A, Slaughter MS, Jeyakumar AKC, Protos AN. Left ventricular assist devices: yesterday, today, and tomorrow. J Artif Organs 2024:10.1007/s10047-024-01436-0. [PMID: 38451441 DOI: 10.1007/s10047-024-01436-0] [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: 10/11/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024]
Abstract
The shortcomings of expense, power requirements, infection, durability, size, and blood trauma of current durable LVADs have been recognized for many years. The LVADs of tomorrow aspire to be fully implantable, durable, mitigate infectious risk, mimic the pulsatile nature of the native cardiac cycle, as well as minimize bleeding and thrombosis. Power draw, battery cycle lifespan and trans-cutaneous energy transmission remain barriers to completely implantable systems. Potential solutions include decreases in pump electrical draw, improving battery lifecycle technology and better trans-cutaneous energy transmission, potentially from Free-range Resonant Electrical Energy Delivery. In this review, we briefly discuss the history of LVADs and summarize the LVAD devices in the development pipeline seeking to address these issues.
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Affiliation(s)
- Athanasios Tsiouris
- Department of Surgery, Division of Cardiac Surgery, University of Mississippi Medical Center, 2500 N State St, Jackson, MS, 39216, USA.
| | - Mark S Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, 201 Abraham Flexner Way, Louisville, KY, 40202, USA
| | - Ashok Kumar Coimbatore Jeyakumar
- Department of Surgery, Division of Cardiac Surgery, University of Mississippi Medical Center, 2500 N State St, Jackson, MS, 39216, USA
| | - Adam N Protos
- Department of Surgery, Division of Cardiac Surgery, University of Mississippi Medical Center, 2500 N State St, Jackson, MS, 39216, USA
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Nascimbene A, Bark D, Smadja DM. Hemocompatibility and biophysical interface of left ventricular assist devices and total artificial hearts. Blood 2024; 143:661-672. [PMID: 37890145 PMCID: PMC10900168 DOI: 10.1182/blood.2022018096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
ABSTRACT Over the past 2 decades, there has been a significant increase in the utilization of long-term mechanical circulatory support (MCS) for the treatment of cardiac failure. Left ventricular assist devices (LVADs) and total artificial hearts (TAHs) have been developed in parallel to serve as bridge-to-transplant and destination therapy solutions. Despite the distinct hemodynamic characteristics introduced by LVADs and TAHs, a comparative evaluation of these devices regarding potential complications in supported patients, has not been undertaken. Such a study could provide valuable insights into the complications associated with these devices. Although MCS has shown substantial clinical benefits, significant complications related to hemocompatibility persist, including thrombosis, recurrent bleeding, and cerebrovascular accidents. This review focuses on the current understanding of hemostasis, specifically thrombotic and bleeding complications, and explores the influence of different shear stress regimens in long-term MCS. Furthermore, the role of endothelial cells in protecting against hemocompatibility-related complications of MCS is discussed. We also compared the diverse mechanisms contributing to the occurrence of hemocompatibility-related complications in currently used LVADs and TAHs. By applying the existing knowledge, we present, for the first time, a comprehensive comparison between long-term MCS options.
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Affiliation(s)
- Angelo Nascimbene
- Advanced Cardiopulmonary Therapies and Transplantation, University of Texas, Houston, TX
| | - David Bark
- Division of Hematology and Oncology, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO
| | - David M. Smadja
- Université de Paris-Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Hematology Department, Assistance Publique–Hôpitaux de Paris, Georges Pompidou European Hospital, Paris, France
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Djordjevic A, Jovicic V, Lazovic D, Terzic D, Gacic J, Petrovic M, Matejic A, Salovic B, Radovic I, Jesic-Petrovic T, Ristic A, Soldatovic I. Acquired von Willebrand syndrome and post-operative drainage: a comparison of patients with aortic stenosis versus coronary artery disease. Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-023-02007-5. [PMID: 38280130 DOI: 10.1007/s11748-023-02007-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/29/2023] [Indexed: 01/29/2024]
Abstract
OBJECTIVE Degenerative aortic stenosis and coronary artery disease are considered to be the most prevalent cardiovascular diseases in industrialized countries. This study aims to determine the change over time in von Willebrand factor antigen, von Willebrand factor activity, and factor VIII and where there is a correlation with total post-operative drainage. METHODS The single-center retrospective study included 203 consecutive patients (64.5% male), undergoing coronary artery bypass surgery between March 1, 2019 and June 30, 2020 at the University Clinical Center of Serbia in the Clinic for Cardiac Surgery in Belgrade, Serbia. All patients 18 years or older who presented with isolated, hemodynamically significant aortic stenosis were included. The control group consisted of patients who presented with only coronary artery disease. RESULTS Between patients with only coronary artery disease and patients with coronary artery diseases and aortic stenosis, there was a statistically significant difference between pre-op and 1-month post-op fibrinogen, factor VIII, von Willebrand factor antigen, and von Willebrand factor (p < 0.001), post-op drainage, with overall lower drainage in coronary artery disease patients, and consistent increase in von Willebrand factor antigen, von Willebrand factor activity, and Factor VIII post-operatively in patients with coronary artery diseases and aortic stenosis. CONCLUSION This study has shown that there is a correlation between von Willebrand factor antigen, von Willebrand factor activity and total drainage to the level of statistical significance in aortic stenosis patients and in the overall study population.
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Affiliation(s)
- Aleksandar Djordjevic
- Department of Cardiac Surgery, University of Clinical Center of Serbia, Belgrade, Serbia
| | - Vladimir Jovicic
- Department of Cardiac Surgery, University of Clinical Center of Serbia, Belgrade, Serbia
| | - Dejan Lazovic
- Department of Cardiac Surgery, University of Clinical Center of Serbia, Belgrade, Serbia
| | - Dusko Terzic
- Department of Cardiac Surgery, University of Clinical Center of Serbia, Belgrade, Serbia
| | - Jasna Gacic
- University Hospital Medical Center Bežanijska Kosa, Belgrade, Serbia
| | - Masa Petrovic
- Faculty of Medicine, University of Belgrade, dr Subotića Starijeg 8, 11000, Belgrade, Serbia.
- Institute for Cardiovascular Diseases "Dedinje", Belgrade, Serbia.
| | - Aleksandar Matejic
- Faculty of Medicine, University of Belgrade, dr Subotića Starijeg 8, 11000, Belgrade, Serbia
- Institute for Orthopedic Surgery "Banjica", Belgrade, Serbia
| | - Bojana Salovic
- Faculty of Medicine, University of Belgrade, dr Subotića Starijeg 8, 11000, Belgrade, Serbia
| | - Ivana Radovic
- Faculty of Medicine, University of Belgrade, dr Subotića Starijeg 8, 11000, Belgrade, Serbia
- Blood and Transfusion Institute of Serbia, Belgrade, Serbia
| | - Tanja Jesic-Petrovic
- Public Primary Health Care Center Doboj, Doboj, Republic of Srpska, Bosnia and Herzegovina
| | - Arsen Ristic
- Department of Cardiac Surgery, University of Clinical Center of Serbia, Belgrade, Serbia
| | - Ivan Soldatovic
- Faculty of Medicine, University of Belgrade, dr Subotića Starijeg 8, 11000, Belgrade, Serbia
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Hennessy-Strahs S, Kang J, Krause E, Dowling RD, Rame JE, Bartoli CR. Patient-specific severity of von Willebrand factor degradation identifies patients with a left ventricular assist device at high risk for bleeding. J Thorac Cardiovasc Surg 2024; 167:196-204. [PMID: 35501195 DOI: 10.1016/j.jtcvs.2022.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 02/14/2022] [Accepted: 03/17/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (LVADs) cause an acquired von Willebrand factor (VWF) deficiency and bleeding. Models to risk-stratify for bleeding are urgently needed. We developed a model of continuous-flow LVAD bleeding risk from patient-specific severity of VWF degradation. METHODS In a prospective, longitudinal cohort study, paired blood samples were obtained from patients (n = 67) with a continuous-flow LVAD before and during support. After 640 ± 395 days, patients were categorized as all-cause bleeders, gastrointestinal (GI) bleeders, or nonbleeders. VWF multimers and VWF clotting function were evaluated to determine bleeding risk. RESULTS Of 67 patients, 34 (51%) experienced bleeding, 26 (39%) experienced GI bleeding, and 33 (49%) did not bleed. In all patients, LVAD support significantly reduced high-molecular-weight VWF multimers (P < .001). Bleeders exhibited greater loss of high-molecular-weight VWF multimers (mean ± standard deviation, -10 ± 5% vs -7 ± 4%, P = .008) and reduced VWF clotting function versus nonbleeders (median [interquartile range], -12% [-31% to 4%] vs 0% [-9 to 26%], P = .01). A combined metric of VWF multimers and VWF function generated the All-Cause Bleeding Risk Score, which stratified bleeders versus nonbleeders (86 ± 56% vs 41 ± 48%, P < .001) with a positive predictive value of 86% (95% confidence interval, 66%-95%) and diagnostic odds ratio of 11 (95% confidence interval, 2.9-44). A separate GI Bleeding Risk Score stratified GI bleeders versus nonbleeders (202 ± 114 vs 120 ± 86, P = .003) with a positive predictive value of 88% (64%-97%) and diagnostic odds ratio of 18 (3.1-140). CONCLUSIONS The severity of loss of VWF multimers and VWF clotting function generated Bleeding Risk Scores with high predictive value for LVAD-associated bleeding. This model may guide personalized antithrombotic therapy and patient surveillance.
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Affiliation(s)
| | - Jooeun Kang
- Vanderbilt University School of Medicine, Nashville, Tenn
| | - Eric Krause
- Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Robert D Dowling
- Division of Cardiac Surgery, Penn State College of Medicine, Hershey, Pa
| | - J Eduardo Rame
- Division of Cardiology, Jefferson University Hospital, Philadelphia, Pa
| | - Carlo R Bartoli
- Division of Cardiothoracic Surgery, Geisinger Medical Center, Danville, Pa.
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Li Y, Xi Y, Wang H, Sun A, Wang L, Deng X, Chen Z, Fan Y. Development and validation of a mathematical model for evaluating shear-induced damage of von Willebrand factor. Comput Biol Med 2023; 164:107379. [PMID: 37597407 DOI: 10.1016/j.compbiomed.2023.107379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 08/21/2023]
Abstract
PURPOSE To develop a mathematical model for predicting shear-induced von Willebrand factor (vWF) function modification which can be used to guide ventricular assist devices (VADs) design, and evaluate the damage of high molecular weight multimers (HMWM)-vWF in VAD patients for reducing clinical complications. METHODS Mathematical models were constructed based on three morphological variations (globular vWF, unfolded vWF and degraded vWF) of vWF under shear stress conditions, in which parameters were obtained from previous studies or fitted by experimental data. Different clinical support modes (pediatric vs. adult mode), different VAD operating states (pulsation vs. constant mode) and different clinical VADs (HeartMate II, HeartWare and CentriMag) were utilized to analyze shear-induced damage of HMWM-vWF based on our vWF model. The accuracy and feasibility of the models were evaluated using various experimental and clinical cases, and the biomechanical mechanisms of HMWM-vWF degradation induced by VADs were further explained. RESULTS The mathematical model developed in this study predicted VAD-induced HMWM-vWF degradation with high accuracy (correlation with experimental data r2 > 0.99). The numerical results showed that VAD in the pediatric mode resulted in more HMWM-vWF degradation per unit time and per unit flow rate than in the adult mode. However, the total degradation of HMWM-vWF is less in the pediatric mode than in the adult mode because the pediatric mode has fewer times of blood circulation than the adult mode in the same amount of time. The ratio of HMWM-vWF degradation was lower in the pulsation mode than in the constant mode. This is due to the increased flushing of VADs in the pulsation mode, which avoids prolonged stagnation of blood in high shear regions. This study also found that the design feature, rotor size and volume of the VADs, and the superimposed regions of high shear stress and long residence time inside VADs affect the degradation of HMWM-vWF. The axial flow VADs (HeartMate II) showed higher degradation of HMWM-vWF compared to centrifugal VADs (HeartWare and CentriMag). Compared to fully magnetically suspended VADs (CentriMag), hydrodynamic suspended VADs (HeartWare) produced extremely high degradation of HWMW-vWF in its narrow hydrodynamic clearance. Finally, the study used a mathematical model of HMWM-vWF degradation to interpret the clinical statistics from a biomechanical perspective and found that minimizing the rotating speed of VADs within reasonable limits helps to reduce HWMW-vWF degradation. All predicted conclusions are supported by the experimental and clinical data. CONCLUSION This study provides a validated mathematical model to assess the shear-induced degradation of HMWM-vWF, which can help to evaluate the damage of HMWM-vWF in patients implanted with VADs for reducing clinical complications, and to guide the optimization of VADs for improving hemocompatibility.
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Affiliation(s)
- Yuan Li
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Yifeng Xi
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Hongyu Wang
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Anqiang Sun
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Lizhen Wang
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Xiaoyan Deng
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Zengsheng Chen
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China.
| | - Yubo Fan
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China.
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Bracey AW. Perioperative Hemotherapy Management in Left Ventricular Assist Device Surgery. Tex Heart Inst J 2023; 50:e238216. [PMID: 37609872 PMCID: PMC10660960 DOI: 10.14503/thij-23-8216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Affiliation(s)
- Arthur W. Bracey
- Department of Cardiovascular Pathology, The Texas Heart Institute, Houston, Texas
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Shetty NS, Parcha V, Abdelmessih P, Patel N, Hasnie AA, Kalra R, Pandey A, Breathett K, Morris AA, Arora G, Arora P. Sex-Associated Differences in the Clinical Outcomes of Left Ventricular Assist Device Recipients: Insights From Interagency Registry for Mechanically Assisted Circulatory Support. Circ Heart Fail 2023; 16:e010189. [PMID: 37232167 PMCID: PMC10421565 DOI: 10.1161/circheartfailure.122.010189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/20/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Sex-associated differences in clinical outcomes among left ventricular assist device recipients in the United States have been recognized. However, an investigation of the social and clinical determinants of sex-associated differences is lacking. METHODS Left ventricular assist device receiving patients enrolled in Interagency Registry for Mechanically Assisted Circulatory Support between 2005 and 2017 were included. The primary outcome was all-cause mortality. Secondary outcomes included heart transplantation and postimplantation adverse event rates. The cohort was stratified by the social subgroup of race and ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic), and clinical subgroups of device strategy (destination therapy, bridge to transplant, and bridge to candidacy), and implantation center volume (low [≤20 implants/y], medium [21-30 implants/y], and high [>30 implants/y]). A multivariable-adjusted Cox proportional hazard model was used to assess the risk of death and heart transplantation with prespecified interaction testing. Poisson regression was used to estimate adverse events by sex across the various subgroups. RESULTS Among 18 525 patients, there were 3968 (21.4%) females. Compared with their male counterparts, Hispanic (adjusted hazard ratio [HRadj], 1.75 [1.23-2.47]) females had the highest risk of death followed by non-Hispanic White females (HRadj, 1.15 [1.07-1.25]; Pinteraction=0.02). Hispanic (HRadj, 0.60 [0.40-0.89]) females had the lowest cumulative incidence of heart transplantation followed by non-Hispanic Black females (HRadj, 0.76 [0.67-0.86]), and non-Hispanic White females (HRadj, 0.88 [0.80-0.96]) compared with their male counterparts (Pinteraction<0.001). Compared with their male counterparts, females on the bridge to candidacy strategy (HRadj, 1.32 [1.18-1.48]) had the highest risk of death (Pinteraction=0.01). The risk of death (Pinteraction=0.44) and cumulative incidence of heart transplantation (Pinteraction=0.40) did not vary by sex in the center volume subgroup. A higher incidence rate of adverse events after left ventricular assist device implantation was also seen in females compared with the males, overall, and across all subgroups. CONCLUSIONS Among left ventricular assist device recipients, the risk of death, the cumulative incidence of heart transplantation, and adverse events differ by sex across the social and clinical subgroups.
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Affiliation(s)
- Naman S. Shetty
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vibhu Parcha
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Abdelmessih
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nirav Patel
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ammar A. Hasnie
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Khadijah Breathett
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alanna A. Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Garima Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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Li Y, Wang H, Xi Y, Sun A, Wang L, Deng X, Chen Z, Fan Y. A mathematical model for assessing shear induced bleeding risk. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 231:107390. [PMID: 36745955 DOI: 10.1016/j.cmpb.2023.107390] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE The objective of this study is to develop a bleeding risk model for assessing device-induced bleeding risk in patients supported with blood contact medical devices (BCMDs). METHODS The mathematical model for evaluating bleeding risk considers the effects of shear stress on von Willebrand factor (vWF) unfolding, high molecular weight multimers-vWF (HMWM-vWF) degradation, platelet activation and receptor shedding and platelet-vWF binding ability. Functions of the effect of shear stress on the above factors are fitted/employed and solved by the Eulerian transport equation. An axial flow-through Couette device and two clinical VADs which are HeartWare Ventricular Assist Device (HVAD) and HeartMate II (HM II) blood pump were employed to perform the simulation to evaluate platelet receptor shedding (GPIbα and GPIIb/IIIa), loss of HWMW-vWF, platelet-vWF binding ability and bleeding risk for validating the accuracy of our model. RESULTS The platelet-vWF binding ability after being subjected to high shear region in the axial flow-through Couette device predicted by our bleeding model was highly consistent with reported experimental data. As indicated by our CFD simulation results in the axial flow-through Couette device, it can find that an increase in shear stress led to a decrease in the adhesion ability of platelets on vWF, while the binding ability of vWF with platelets first increase and then decrease as shear stress elevates gradually beyond a threshold. The factor of exposure time can enhance the effect of shear stress. Additionally, the shear-induced bleeding risk predicted by our model increases with increasing shear stress and exposure time in an axial flow-through Couette device. As indicated by our numerical model, the bleeding risk in HVAD was higher than HMII, which is highly consistent with the meta-analysis based on clinical statistics. Our simulation investigations in these two clinical VADs also found that HVAD caused a higher rate of platelet receptor shedding and lower damage to HWMW-vWF than HeartMate II. The high shear stress generated in the narrow and turbulent regions of both VADs was the underlying cause of device-induced bleeding. CONCLUSION In this study, the shear-induced bleeding risk predicted by our bleeding model in axial flow-through Couette device and two clinical VADs is consistent or highly correlated with experimental and clinical findings, which proves the accuracy of our bleeding model. Our bleeding model can be used to aid the development of new BCMDs with improved functional characteristics and biocompatibility, and help to reduce risk of device-induced adverse events in patients.
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Affiliation(s)
- Yuan Li
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
| | - Hongyu Wang
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
| | - Yifeng Xi
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
| | - Anqiang Sun
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
| | - Lizhen Wang
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
| | - Xiaoyan Deng
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China
| | - Zengsheng Chen
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China.
| | - Yubo Fan
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, China.
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Hanke JS, Merzah AS, Arfai J, Haverich A, Schmitto JD, Dogan G. Der Patient am linksventrikulären Assist Device. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2023. [DOI: 10.1007/s00398-023-00571-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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11
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Decreased Platelet Specific Receptor Expression of P-Selectin and GPIIb/IIIa Predict Future Non-Surgical Bleeding in Patients after Left Ventricular Assist Device Implantation. Int J Mol Sci 2022; 23:ijms231810252. [PMID: 36142161 PMCID: PMC9499488 DOI: 10.3390/ijms231810252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Non-surgical bleeding (NSB) is one of the major clinical complications in patients under continuous-flow left ventricular assist device (LVAD) support. The increased shear stress leads to an altered platelet receptor composition. Whether these changes increase the risk for NSB is unclear. Thus, we compared the platelet receptor composition of patients with (bleeder group, n = 18) and without NSB (non-bleeder group, n = 18) prior to LVAD implantation. Blood samples were obtained prior to LVAD implantation and after bleeding complications in the post-implant period. Platelet receptor expression of GPIbα, GPIIb/IIIa, P-selectin and CD63 as well as intra-platelet oxidative stress levels were quantified by flow cytometry. Bleeders and non-bleeders were comparable regarding clinical characteristics, von Willebrand factor diagnostics and the aggregation capacity before and after LVAD implantation (p > 0.05). LVAD patients in the bleeder group suffered from gastrointestinal bleeding (33%; n = 6), epistaxis (22%; n = 4), hematuria or hematoma (17%; n = 3, respectively) and cerebral bleeding (11%; n = 2). Prior to LVAD implantation, a restricted surface expression of the platelet receptors P-selectin and GPIIb/IIIa was observed in the bleeder group (P-selectin: 7.2 ± 2.6%; GPIIb/IIIa: 26,900 ± 13,608 U) compared to non-bleeders (P-selectin: 12.4 ± 8.1%, p = 0.02; GPIIb/IIIa: 36,259 ± 9914 U; p = 0.02). We hypothesized that the reduced platelet receptor expression of P-selectin and GPIIb/IIIa prior to LVAD implantation may be linked to LVAD-related NSB.
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12
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Staessens S, Moussa MD, Pierache A, Rauch A, Rousse N, Boulleaux E, Ung A, Desender L, Pradines B, Vincentelli A, Mercier O, Labreuche J, Duhamel A, Van Belle E, Vincent F, Dupont A, Vanhoorelbeke K, Corseaux D, De Meyer SF, Susen S. Thrombus formation during ECMO: Insights from a detailed histological analysis of thrombus composition. J Thromb Haemost 2022; 20:2058-2069. [PMID: 35703468 PMCID: PMC9349827 DOI: 10.1111/jth.15784] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVES Intra-device thrombosis remains one of the most common complications during extracorporeal membrane oxygenation (ECMO). Despite anticoagulation, approximately 35% of patients develop thrombi in the membrane oxygenator, pump heads, or tubing. The aim of this study was to describe the molecular and cellular features of ECMO thrombi and to study the main drivers of thrombus formation at different sites in the ECMO circuits. APPROACH AND RESULTS Thrombi (n = 85) were collected immediately after veno-arterial-(VA)-ECMO circuit removal from 25 patients: 23 thrombi from the pump, 25 from the oxygenator, and 37 from the tubing. Quantitative histological analysis was performed for the amount of red blood cells (RBCs), platelets, fibrin, von Willebrand factor (VWF), leukocytes, and citrullinated histone H3 (H3Cit). ECMO thrombi consist of a heterogenous composition with fibrin and VWF being the major thrombus components. A clustering analysis of the four major histological parameters identified two typical thrombus types: RBC-rich and RBC-poor/fibrin-rich thrombi with no significant differences in VWF and platelet content. Thrombus composition was not associated with the thrombus location, except for higher amounts of H3Cit that were found in pump and oxygenator thrombi compared to tubing samples. We observed higher blood leukocyte count and lactate dehydrogenase levels in patients with fibrin-rich thrombi. CONCLUSION We found that thrombus composition is heterogenous, independent of their location, consisting of two types: RBC-rich and a fibrin-rich types. We also found that NETs play a minor role. These findings are important to improve current anticoagulation strategies in ECMO.
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Affiliation(s)
- Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Mouhamed D Moussa
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Adeline Pierache
- ULR 2694-METRICS (Evaluation des technologies de santé et des pratiques médicales), University of Lille, Centre Hospitalier Universitaire Lille, Lille, France
| | - Antoine Rauch
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Natacha Rousse
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Eric Boulleaux
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Alexandre Ung
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Linda Desender
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Bénédicte Pradines
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - André Vincentelli
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Olaf Mercier
- Research and Innovation Laboratory, INSERM U999, Marie Lannelongue Hospital, Paris Sud Saclay University, Le Plessis Robinson, France
| | - Julien Labreuche
- ULR 2694-METRICS (Evaluation des technologies de santé et des pratiques médicales), University of Lille, Centre Hospitalier Universitaire Lille, Lille, France
| | - Alain Duhamel
- ULR 2694-METRICS (Evaluation des technologies de santé et des pratiques médicales), University of Lille, Centre Hospitalier Universitaire Lille, Lille, France
| | - Eric Van Belle
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Flavien Vincent
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Annabelle Dupont
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Delphine Corseaux
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Sophie Susen
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
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13
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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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14
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Berardi C, Bravo CA, Li S, Khorsandi M, Keenan JE, Auld J, Rockom S, Beckman JA, Mahr C. The History of Durable Left Ventricular Assist Devices and Comparison of Outcomes: HeartWare, HeartMate II, HeartMate 3, and the Future of Mechanical Circulatory Support. J Clin Med 2022; 11:2022. [PMID: 35407630 PMCID: PMC9000165 DOI: 10.3390/jcm11072022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/25/2022] [Accepted: 03/31/2022] [Indexed: 12/13/2022] Open
Abstract
The utilization of left ventricular assist devices (LVADs) in end-stage heart failure has doubled in the past ten years and is bound to continue to increase. Since the first of these devices was approved in 1994, the technology has changed tremendously, and so has the medical and surgical management of these patients. In this review, we discuss the history of LVADs, evaluating survival and complications over time. We also aim to discuss practical aspects of the medical and surgical management of LVAD patients and future directions for outcome improvement in this population.
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Affiliation(s)
- Cecilia Berardi
- Division of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA 01199, USA;
| | - Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Song Li
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, USA; (M.K.); (J.E.K.)
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, USA; (M.K.); (J.E.K.)
| | - Jonathan Auld
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Sunny Rockom
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Jennifer A. Beckman
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; (C.A.B.); (S.L.); (J.A.); (S.R.); (J.A.B.)
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15
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Ahmed MM, Meece LE, Handberg EM, Pepine CJ. Intravenous administration of umbilical cord lining stem cells in left ventricular assist device recipient: Rationale and design of the uSTOP LVAD BLEED pilot study. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 16:100142. [PMID: 38559284 PMCID: PMC10976302 DOI: 10.1016/j.ahjo.2022.100142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 04/04/2024]
Abstract
Background Left ventricular assist device (LVAD) implantation provides a robust survival advantage, however despite improvements in mortality, the adverse event burden of durable mechanical circulatory support remains high. Bleeding complications are one such significant complication. The uSTOP LVAD BLEED (Utilization of umbilical cord lining Stem cells TO Prevent LVAD associated angiodysplastic BLEEDing) pilot study is designed to evaluate the safety and tolerability of escalating doses of umbilical cord lining stem cells (ULSCs) in LVAD recipients to ameliorate the dysregulation of angiogenic factors seen in this population. Design This Phase Ia single-ascending dose pilot study will evaluate the IV administration of ULSCs in stable out-patients supported with an LVAD. In a 3 + 3 design, a maximum of 18 patients will receive an IV infusion of ULSCs. Main outcome measures The primary endpoints are safety and tolerability, secondary exploratory endpoints will include biomarker evaluation of angiogenic dysregulation. Summary This represents a novel cell type and route of administration in this population, while collecting initial data regarding the magnitude and duration of effects of cell therapy, and assessing the possibility of decreasing bleeding by a strategy of vascular stabilization. Clinical trial registration ClinicalTrials.gov Identifier: NCT04811261. https://clinicaltrials.gov/ct2/show/NCT04811261.
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Affiliation(s)
- Mustafa M. Ahmed
- University of Florida, Division of Cardiovascular Medicine, Gainesville, FL, United States of America
| | - Lauren E. Meece
- University of Florida, Division of Cardiovascular Medicine, Gainesville, FL, United States of America
| | - Eileen M. Handberg
- University of Florida, Division of Cardiovascular Medicine, Gainesville, FL, United States of America
| | - Carl J. Pepine
- University of Florida, Division of Cardiovascular Medicine, Gainesville, FL, United States of America
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16
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Kanji R, Vandenbriele C, Arachchillage DRJ, Price S, Gorog DA. Optimal Tests to Minimise Bleeding and Ischaemic Complications in Patients on Extracorporeal Membrane Oxygenation. Thromb Haemost 2022; 122:480-491. [PMID: 33984868 DOI: 10.1055/a-1508-8230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Patients supported with extracorporeal membrane oxygenation (ECMO) experience a very high frequency of bleeding and ischaemic complications, including stroke and systemic embolism. These patients require systemic anticoagulation, mainly with unfractionated heparin (UFH) to prevent clotting of the circuit and reduce the risk of arterial or venous thrombosis. Monitoring of UFH can be very challenging. While most centres routinely monitor the activated clotting time and activated partial thromboplastin time (aPTT) to assess UFH, measurement of anti-factor Xa (anti-Xa) level best correlates with heparin dose, and appears to be predictive of circuit thrombosis, although aPTT may be a better predictor of bleeding. Although monitoring of prothrombin time, platelet count and fibrinogen is routinely undertaken to assess haemostasis, there is no clear guidance available regarding the optimal test.Additional tests, including antithrombin level and thromboelastography, can be used for risk stratification of patients to try and predict the risks of thrombosis and bleeding. Each has their specific role, strengths and limitations. Increased thrombin generation may have a role in predicting thrombosis. Acquired von Willebrand syndrome is frequent with ECMO, contributing to bleeding risk and can be detected by assessing the von Willebrand factor activity-to-antigen ratio, while the platelet function analyser can be used in urgent situations to detect this, with a high negative predictive value. Tests of platelet aggregation can aid in the prediction of bleeding.To personalise management, a selection of complementary tests to collectively assess heparin-effect, coagulation, platelet function and platelet aggregation is proposed, to optimise clinical outcomes in these high-risk patients.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | - Deepa R J Arachchillage
- Haematology Department, Royal Brompton Hospital, London, United Kingdom.,Centre for Haematology, Imperial College Healthcare NHS Trust & Imperial College, London, United Kingdom
| | - Susanna Price
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom.,Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | - Diana Adrienne Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
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17
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Yang M, Houck KL, Dong X, Hernandez M, Wang Y, Nathan SS, Wu X, Afshar-Kharghan V, Fu X, Cruz MA, Zhang J, Nascimbene A, Dong JF. Hyperadhesive von Willebrand Factor Promotes Extracellular Vesicle-Induced Angiogenesis: Implication for LVAD-Induced Bleeding. JACC Basic Transl Sci 2022; 7:247-261. [PMID: 35411318 PMCID: PMC8993768 DOI: 10.1016/j.jacbts.2021.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 11/22/2022]
Abstract
VWF in patients on LVAD supports was hyperadhesive, activated platelets, and generated platelet-derived extracellular vesicles. Extracellular vesicles from LVAD patients and those from shear-activated platelets promoted aberrant angiogenesis in a VWF-dependent manner. The activated VWF exposed the A1 domain through the synergistic actions of oxidative stress and HSS generated in LVAD-driven circulation.
Bleeding associated with left ventricular assist device (LVAD) implantation has been attributed to the loss of large von Willebrand factor (VWF) multimers to excessive cleavage by ADAMTS-13, but this mechanism is not fully supported by the current evidence. We analyzed VWF reactivity in longitudinal samples from LVAD patients and studied normal VWF and platelets exposed to high shear stress to show that VWF became hyperadhesive in LVAD patients to induce platelet microvesiculation. Platelet microvesicles activated endothelial cells, induced vascular permeability, and promoted angiogenesis in a VWF-dependent manner. Our findings suggest that LVAD-driven high shear stress primarily activates VWF, rather than inducing cleavage in the majority of patients.
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Key Words
- ADAMTS-13:Ag, ADAMTS-13 antigen
- AVS, aortic vascular segment
- EC, endothelial cell
- EV, extracellular vesicle
- EVFP, extracellular vesicle–free plasma
- GI, gastrointestinal
- GOF, gain of function
- GP, glycoprotein
- GPM, growth factor-poor medium
- GRM, growth factor-rich medium
- HSS, high shear stress
- LVAD, left ventricular assist device
- PS, phosphatidylserine
- SIPA, shear-induced platelet aggregation
- ULVWF, ultra-large von Willebrand factor
- VEGF, vascular endothelial growth factor
- VWF, von Willebrand factor
- VWF:Ag, von Willebrand factor antigen
- VWF:CB, von Willebrand factor binding to collagen
- VWF:pp, von Willebrand factor propeptide
- aVWS, acquired von Willebrand syndrome
- angiogenesis
- extracellular vesicles
- left ventricular assist devices
- pEV, extracellular vesicle from von Willebrand factor-activated platelets
- platelets
- shear stress
- von Willebrand factor
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Affiliation(s)
- Mengchen Yang
- Bloodworks Research Institute, Seattle, Washington, USA.,Department of Urology, Tianjin Medical University General Hospital, Tianjin, China
| | - Katie L Houck
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Xinlong Dong
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Maria Hernandez
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
| | - Yi Wang
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Sriram S Nathan
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
| | - Xiaoping Wu
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vahid Afshar-Kharghan
- Division of Internal Medicine, Department of Pulmonary Medicine, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Xiaoyun Fu
- Bloodworks Research Institute, Seattle, Washington, USA
| | - Miguel A Cruz
- Cardiovascular Research Section, Department of Medicine, Baylor College of Medicine.,Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Angelo Nascimbene
- Center for Advanced Heart Failure, University of Texas at Houston, Houston, Texas, USA
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, Washington, USA.,Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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18
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Truong VT, Shreenivas S, Mazur W, Egnaczyk GF, Palmer C, Rao SD, Rame JE, Chung ES. Left Ventricular End-Diastolic Dimension and Clinical Outcomes After Centrifugal Flow Left Ventricular Assist Device Implantation. ASAIO J 2022; 68:220-225. [PMID: 33927084 DOI: 10.1097/mat.0000000000001449] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The impact of preoperative end-diastolic left ventricular dimension (preLVEDD) on long-term outcomes with centrifugal continuous-flow left ventricular assist device (CF-LVAD) is not well established. Accordingly, we performed an analysis of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry to study this relationship. All patients with centrifugal CF-LVAD in the INTERMACS registry from June 2006 to December 2017 were screened. The final study group consisted of 3,304 patients. After a median follow-up of 9.0 months (interquartile range [IQR], 4.2-18.8 months), 2,596 (79%) patients were alive. After adjusting for significant covariates, increased preLVEDD was associated with lower mortality (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84-0.98; p = 0.01), stroke (HR, 0.85; 95% CI, 0.77-0.93; p < 0.001), and gastrointestinal bleeding (HR, 0.88; 95% CI, 0.80-0.97; p = 0.01), although there were more arrhythmias (HR, 1.14; 95% CI, 1.05-1.24; p = 0.003). Our study suggests that preLVEDD is an independent predictor of mortality and adverse events in patients treated with centrifugal CF-LVAD. preLVEDD should be considered an important preimplant variable for risk stratification when considering a CF-LVAD.
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Affiliation(s)
- Vien T Truong
- From the The Christ Hospital Health Network, Cincinnati, Ohio
- The "Lindner" Research Center, Cincinnati, Ohio
| | | | - Wojciech Mazur
- From the The Christ Hospital Health Network, Cincinnati, Ohio
| | | | - Cassady Palmer
- From the The Christ Hospital Health Network, Cincinnati, Ohio
| | - Sriram D Rao
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Advanced Cardiac and Pulmonary Vascular Disease, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Eugene S Chung
- From the The Christ Hospital Health Network, Cincinnati, Ohio
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19
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Ozturk C, Rosalia L, Roche ET. A Multi-Domain Simulation Study of a Pulsatile-Flow Pump Device for Heart Failure With Preserved Ejection Fraction. Front Physiol 2022; 13:815787. [PMID: 35145432 PMCID: PMC8822361 DOI: 10.3389/fphys.2022.815787] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/05/2022] [Indexed: 12/02/2022] Open
Abstract
Mechanical circulatory support (MCS) devices are currently under development to improve the physiology and hemodynamics of patients with heart failure with preserved ejection fraction (HFpEF). Most of these devices, however, are designed to provide continuous-flow support. While it has been shown that pulsatile support may overcome some of the complications hindering the clinical translation of these devices for other heart failure phenotypes, the effects that it may have on the HFpEF physiology are still unknown. Here, we present a multi-domain simulation study of a pulsatile pump device with left atrial cannulation for HFpEF that aims to alleviate left atrial pressure, commonly elevated in HFpEF. We leverage lumped-parameter modeling to optimize the design of the pulsatile pump, computational fluid dynamic simulations to characterize hydraulic and hemolytic performance, and finite element modeling on the Living Heart Model to evaluate effects on arterial, left atrial, and left ventricular hemodynamics and biomechanics. The findings reported in this study suggest that pulsatile-flow support can successfully reduce pressures and associated wall stresses in the left heart, while yielding more physiologic arterial hemodynamics compared to continuous-flow support. This work therefore supports further development and evaluation of pulsatile support MCS devices for HFpEF.
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Affiliation(s)
- Caglar Ozturk
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Luca Rosalia
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, United States
- Health Sciences and Technology Program, Harvard – Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Ellen T. Roche
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, United States
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States
- *Correspondence: Ellen T. Roche,
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20
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Pan Q, Feng W, Wang R, Tabuchi A, Li P, Nitzsche B, Fang L, Kuebler WM, Pries AR, Ning G. Pulsatility damping in the microcirculation: Basic pattern and modulating factors. Microvasc Res 2022; 139:104259. [PMID: 34624307 DOI: 10.1016/j.mvr.2021.104259] [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: 07/18/2021] [Revised: 09/13/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
Blood flow pulsatility is an important determinant of macro- and microvascular physiology. Pulsatility is damped largely in the microcirculation, but the characteristics of this damping and the factors that regulate it have not been fully elucidated yet. Applying computational approaches to real microvascular network geometry, we examined the pattern of pulsatility damping and the role of potential damping factors, including pulse frequency, vascular viscous resistance, vascular compliance, viscoelastic behavior of the vessel wall, and wave propagation and reflection. To this end, three full rat mesenteric vascular networks were reconstructed from intravital microscopic recordings, a one-dimensional (1D) model was used to reproduce pulsatile properties within the network, and potential damping factors were examined by sensitivity analysis. Results demonstrate that blood flow pulsatility is predominantly damped at the arteriolar side and remains at a low level at the venular side. Damping was sensitive to pulse frequency, vascular viscous resistance and vascular compliance, whereas viscoelasticity of the vessel wall or wave propagation and reflection contributed little to pulsatility damping. The present results contribute to our understanding of mechanical forces and their regulation in the microcirculation.
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Affiliation(s)
- Qing Pan
- College of Information Engineering, Zhejiang University of Technology, 310023 Hangzhou, China
| | - Weida Feng
- College of Information Engineering, Zhejiang University of Technology, 310023 Hangzhou, China
| | - Ruofan Wang
- Department of Biomedical Engineering, Key Laboratory of Biomedical Engineering of MOE, Zhejiang University, 310027 Hangzhou, China
| | - Arata Tabuchi
- Institute of Physiology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Peilun Li
- Department of Biomedical Engineering, Key Laboratory of Biomedical Engineering of MOE, Zhejiang University, 310027 Hangzhou, China
| | - Bianca Nitzsche
- Institute of Physiology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Luping Fang
- College of Information Engineering, Zhejiang University of Technology, 310023 Hangzhou, China
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Axel R Pries
- Institute of Physiology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany.
| | - Gangmin Ning
- Department of Biomedical Engineering, Key Laboratory of Biomedical Engineering of MOE, Zhejiang University, 310027 Hangzhou, China.
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21
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Buja LM, Schoen FJ. The pathology of cardiovascular interventions and devices for coronary artery disease, vascular disease, heart failure, and arrhythmias. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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22
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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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23
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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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24
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Abstract
Acquired von Willebrand syndrome can occur in the setting of myeloproliferative neoplasms; plasma cell dyscrasias and other lymphoproliferative disorders; autoimmune conditions; and causes of increased shear forces, such as aortic stenosis or other structural heart disease and mechanical circulatory support. The depletion of von Willebrand factor, especially high-molecular-weight multimers, can lead to mucocutaneous bleeding and the formation of arteriovenous malformations, particularly in the gastrointestinal tract. Management focuses on correction of the underlying cause when possible, but may include intravenous immunoglobulins, von Willebrand factor concentrate, rituximab, or antiangiogenic therapy depending on the clinical context.
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Affiliation(s)
- Arielle L Langer
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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25
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In vitro Hemocompatibility Evaluation of the HeartWare Ventricular Assist Device Under Systemic, Pediatric and Pulmonary Support Conditions. ASAIO J 2021; 67:270-275. [PMID: 33627600 DOI: 10.1097/mat.0000000000001222] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The development of adult use right ventricular assist devices (RVADs) and pediatric left ventricular assist devices (pediatric LVADs) have significantly lagged behind compared to adult use left ventricular assist devices (LVADs). The HeartWare ventricular assist device (HVAD) intended to be used for adult's systemic support, is increasingly used off-label for adult pulmonary and pediatric systemic support. Due to different hemodynamics and physiology, however, the HVAD's hemocompatibility profiles can be drastically different when used in adult pulmonary circulation or in children, compared to its intended usage state, which could have a direct clinical and developmental relevance. Taking these considerations in mind, we sought to conduct in vitro hemocompatibility testing of HVAD in adult systemic, pediatric systemic and adult pulmonary support conditions. Two HVADs coupled to custom-built blood circulation loops were tested for 6 hours using bovine blood at 37°C under adult systemic, pediatric systemic, and adult pulmonary flow conditions (flow rate = 5.0, 2.5, and 4.5 L/min; differential pressure = 100, 69, and 20 mm Hg, respectively). Normalized index of hemolysis for adult systemic, pediatric systemic, and adult pulmonary conditions were 0.0083, 0.0039, and 0.0017 g/100 L, respectively. No significant difference was seen in platelet activation for these given conditions. High molecular weight von Willebrand factor multimer degradation was evident in all conditions (p < 0.05). In conclusion, alterations in the usage mode produce substantial differences in hemocompatibility of the HVAD. These findings would not only have clinical relevance but will also facilitate future adult use RVAD and pediatric LVAD development.
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26
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Complications in children with ventricular assist devices: systematic review and meta-analyses. Heart Fail Rev 2021; 27:903-913. [PMID: 33661404 DOI: 10.1007/s10741-021-10093-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
Heart failure is a significant cause of mortality in children with cardiovascular diseases. Treatment of heart failure depends on patients' symptoms, age, and severity of their condition, with heart transplantation required when other treatments are unsuccessful. However, due to lack of fitting donor organs, many patients are left untreated, or their transplant is delayed. In these patients, ventricular assist devices (VADs) are used to bridge to heart transplant. However, VAD support presents various complications in patients. The aim of this study was to compile, review, and analyse the studies reporting risk factors and aetiologies of complications of VAD support in children. Random effect risk ratios (RR) with 95% confidence intervals were calculated to analyse relative risk of thrombosis (RR = 3.53 [1.04, 12.06] I2 = 0% P = 0.04), neurological problems (RR = 0.95 [0.29, 3.15] I2 = 53% P = 0.93), infection (RR = 0.31 [0.05, 2.03] I2 = 86% P = 0.22), bleeding (RR = 2.57 [0.76, 8.66] I2 = 0% P = 0.13), and mortality (RR = 2.20 [1.36, 3.55] I2 = 0% P = 0.001) under pulsatile-flow and continuous-flow VAD support, relative risk of mortality (RR = 0.45 [0.15, 1.37] I2 = 36% P = 0.16) under left VAD and biVAD support, relative risk of thrombosis (RR = 1.72 [0.46, 6.44] I2 = 0% P = 0.42), infection (RR = 1.77 [0.10, 32.24] I2 = 46% P = 0.70) and mortality (RR = 0.92 [0.14, 6.28] I2 = 45% P = 0.93) in children with body surface area < 1.2 m2 and > 1.2 m2 under VAD support, relative risk of mortality in children supported with VAD and diagnosed with cardiomyopathy and congenital heart diseases (RR = 1.31 [0.10, 16.61] I2 = 73% P = 0.84), and cardiomyopathy and myocarditis (RR = 0.91 [0.13, 6.24] I2 = 58% P = 0.92). Meta-analyses results show that further research is necessary to reduce complications under VAD support.
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27
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Wang S, Griffith BP, Wu ZJ. Device-Induced Hemostatic Disorders in Mechanically Assisted Circulation. Clin Appl Thromb Hemost 2021; 27:1076029620982374. [PMID: 33571008 PMCID: PMC7883139 DOI: 10.1177/1076029620982374] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Mechanically assisted circulation (MAC) sustains the blood circulation in the body of a patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) or on ventricular assistance with a ventricular assist device (VAD) or on extracorporeal membrane oxygenation (ECMO) with a pump-oxygenator system. While MAC provides short-term (days to weeks) support and long-term (months to years) for the heart and/or lungs, the blood is inevitably exposed to non-physiological shear stress (NPSS) due to mechanical pumping action and in contact with artificial surfaces. NPSS is well known to cause blood damage and functional alterations of blood cells. In this review, we discussed shear-induced platelet adhesion, platelet aggregation, platelet receptor shedding, and platelet apoptosis, shear-induced acquired von Willebrand syndrome (AVWS), shear-induced hemolysis and microparticle formation during MAC. These alterations are associated with perioperative bleeding and thrombotic events, morbidity and mortality, and quality of life in MCS patients. Understanding the mechanism of shear-induce hemostatic disorders will help us develop low-shear-stress devices and select more effective treatments for better clinical outcomes.
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Affiliation(s)
- Shigang Wang
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
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28
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Briasoulis A, Ueyama H, Kuno T, Asleh R, Alvarez P, Malik AH. Trends and outcomes of device-related 30-day readmissions after left ventricular assist device implantation. Eur J Intern Med 2021; 84:56-62. [PMID: 33039191 DOI: 10.1016/j.ejim.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Left ventricular assist devices (LVAD) improve morbidity and mortality in end-stage heart failure patients, but high rates of readmissions remain a problem after implantation. We aimed to assess the incidence, trends, outcomes, and predictors of device-related 30-day readmissions after LVAD implantation. METHODS The National Readmission Database was used to identify patients who underwent LVAD implantation between 2012 and 2017 and those with 30-day readmissions. RESULTS The analysis included a total of 16499 adults who survived the index hospitalization for LVAD implantation. Among those, 28.1% were readmitted at 30 days, and the readmission rate has been grossly stable during the study period. Most of the readmissions occurred in the first 15 days after discharge from the index admission. The most frequent cause of readmissions was gastrointestinal bleeding (14.9% of readmissions), followed by heart failure, arrhythmias, device infection, and device thrombosis. Among reasons for readmission, intracranial bleeding was associated with highest mortality (37.6%), followed by device thrombosis (13.1%), and ischemic stroke (7.6%). Intracranial bleeding and device thrombosis were associated with lengthier stay (20.4 and 15.5 days, respectively). Readmission rates for gastrointestinal bleeding decreased, whereas device infection increased. Multivariate logistic regression model revealed the length of stay, oxygen dependence, gastrointestinal bleeding at index admission, depression and ECMO, private insurance as independent predictors of 30-day readmission. CONCLUSION Over one-fourth of LVAD recipients have 30-day readmissions, with most of them occurring within 15 days. Most frequent cause of readmission was gastrointestinal bleeding, which was associated with the lowest in-hospital mortality among other complications.
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Affiliation(s)
- Alexandros Briasoulis
- Division of Cardiovascular medicine, Section of Heart failure and Transplantation, University of Iowa, IA, USA.
| | - Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA
| | - Rabea Asleh
- Division of Cardiovascular medicine, Section of Heart failure and Transplantation, University of Iowa, IA, USA; Department of Cardiology, Hadassah University Medical Center, Jerusalem, Israel
| | | | - Aaqib H Malik
- Department of Cardiology, Westchester Medical Center & New York Medical College, NY, USA
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29
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Acquired von Willebrand syndrome in ECMO patients: A 3-year cohort study. Blood Cells Mol Dis 2020; 87:102526. [PMID: 33338698 DOI: 10.1016/j.bcmd.2020.102526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bleeding is a common but possibly underreported side effect of Extracorporeal Membrane Oxygenation (ECMO). Impairment of primary hemostasis by acquired von Willebrand syndrome (aVWS) and platelet dysfunction as well as activation and consumption of plasmatic coagulation factors contribute to hemorrhage. The aim of the present cohort study of consecutively enrolled patients admitted to our ECMO center was to collect demographic, medical and laboratory data possibly associated with i) development of clinically relevant bleeding and/or ii) death during a 12-months follow-up. RESULTS Within a 3-year period 338 white patients aged 18-89 years (median: 60; male 64.5%) were enrolled. 78 of 338 patients (23%) presented with clinical relevant bleeding symptoms. The overall death rate was 74.6% within a median time of 9 days (1-229) post intervention. Logistic-regression analysis adjusted for age and gender revealed that i) the presence of blood group O versus non-O (Odds ratio (OR)/95%CI: 1.9/1.007-3.41), ECMO duration per day (1.1/1.06-1.14), veno-venous versus veno-arterial ECMO cannulation (2.33/1.2-4.5) and the overall need for blood product administered per unit (1.02/1.016-1.028) was independenly associated with bleeding in patients suffering from aVWS. ii) Older age (increase per year) at ECMO start (1.015/1.012-1.029) and an increasing amount of blood product units were significantly related with death (1.007/1.001-1.013). Patients with veno-venous versus veno-arterial cannulation survived longer (0.48/0.24-0.94). CONCLUSION In the present cohort study we found a clinical relevant bleeding rate of 23% in subjects with aVWS associated with blood group O, a longer ECMO duration and veno-venous cannulation.
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30
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Carroll AH, Ramirez MP, Dowlati E, Mueller KB, Borazjani A, Chang JJ, Felbaum DR. Management of Intracranial Hemorrhage in Patients with a Left Ventricular Assist Device: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2020; 30:105501. [PMID: 33271486 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intracranial hemorrhage (ICH) has been reported to occur in up to 23% of patients with left ventricular assist devices (LVADs). Currently, limited data exists to guide neurosurgical management strategies to optimize outcomes in patients with an LVAD who develop ICH. METHODS A systematic review and meta-analysis of the literature was performed to evaluate the mortality rate in these patients following medical and/or surgical management and to evaluate antithrombotic reversal and resumption strategies after hemorrhage. RESULTS 17 studies reporting on 3869 LVAD patients and 545 intracranial hemorrhages spanning investigative periods from 1996 to 2019 were included. The rate of ICH in LVAD patients was 10.6% (411/3869) with 58.6% (231/394) being intraparenchymal hemorrhage (IPH), 23.6% (93/394) subarachnoid hemorrhage (SAH), and 15.5% (61/394) subdural hemorrhage (SDH). Total mortality rates for surgical management 65.6% (40/61) differed from medical management at 45.2% (109/241). There was an increased relative risk of mortality (RR=1.45, 95% CI: 1.10-1.91, p = 0.01) for ICH patients undergoing surgical intervention. The hemorrhage subtype most frequently managed with anticoagulation reversal was IPH 81.8% (63/77), followed by SDH 52.2% (12/23), and SAH 39.1% (18/46). Mean number of days until antithrombotic resumption ranged from 6 to 10.5 days. CONCLUSION Outcomes remain poor, specifically for those undergoing surgery. As experience with this population increases, prospective studies are warranted to contribute to management and prognostication .
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Affiliation(s)
| | | | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA.
| | - Kyle B Mueller
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School at Brown University, Providence, R.I., USA
| | - Ali Borazjani
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington D.C., USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, D.C., USA; Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA
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31
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Hennessy-Strahs S, Bermudez CA, Acker MA, Bartoli CR. Toward a Standard Practice to Quantify von Willebrand Factor Degradation During Left Ventricular Assist Device Support. Ann Thorac Surg 2020; 112:1257-1264. [PMID: 33227272 DOI: 10.1016/j.athoracsur.2020.09.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/24/2020] [Accepted: 09/20/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (LVADs) cause degradation of von Willebrand factor (VWF) multimers and bleeding. Multiple techniques exist to characterize VWF deficiency. However, a standard methodology has not been established in LVAD patients. Toward this goal, we evaluated 4 methods to quantify VWF multimers. METHODS We collected paired blood samples from patients (n = 48) before and after 1 week of LVAD support. After 652 ± 59 days of support, patients were classified as bleeders (≥1 bleeding episode) or nonbleeders. VWF multimers were resolved with electrophoresis and immunoblotting, the gold-standard to evaluate VWF multimers. We evaluated 4 quantification methods. RESULTS Each method demonstrated significant VWF degradation during LVAD support vs a paired, pre-LVAD sample (method 1, VWF length: 48 of 48 patients, -10% ± 1%, P < .0001; method 2, VWF density: 40 of 48, -34% (interquartile range, -46% to -8%), P < .0001; method 3, pre-LVAD to LVAD ratio: 46 of 48, 17 ± 5: 10 ± 1, P < .0001; method 4, LVAD/pre-LVAD index: 46 of 48, 57% (interquartile range, 50% to 73%), P < .0001). Bleeding occurred in 27 of 48 patients. Method 1 demonstrated significantly fewer VWF multimers in bleeders compared with nonbleeders (-11% ± 1% vs -8% ± 1%; P = .01). Other methods did not demonstrate this potentially important clinical relationship. CONCLUSIONS A standardized methodology is needed to quantify VWF multimer degradation with mechanical circulatory support devices. Novel method 1 successfully quantified the patient-specific change in VWF multimer length during LVAD support and demonstrated a difference in VWF multimers between bleeders and nonbleeders. Adoption of consensus methodology will assist to standardize patient-specific bleeding risk, inform anticoagulation and antiplatelet therapy, and evaluate LVAD hemocompatibility.
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Affiliation(s)
- Samson Hennessy-Strahs
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Acker
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carlo R Bartoli
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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32
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Jurney PL, Glynn JJ, Dykan IV, Hagen MW, Kaul S, Wampler RK, Hinds MT, Giraud GD. Characterization of a pulsatile rotary total artificial heart. Artif Organs 2020; 45:135-142. [PMID: 32857895 DOI: 10.1111/aor.13810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 11/27/2022]
Abstract
This article describes the properties and performance of a rotary total artificial heart (TAH) that produces inherently pulsatile flow. The hydraulic performance of the TAH was characterized using a mock circulatory loop to simulate four physiologically relevant conditions: baseline flow, increased flow, systemic hypertension, and pulmonary hypertension. The pump has a variable shuttle rate (beats per minute), percentage dwell time, and angular velocity on either side (revolutions per minute), which allows for full control of the flow rate and pulsatility over a range of healthy and pathologic pressures and flow rates. The end-to-end length and displacement volume of the TAH are 9.8 cm and 130 mL, respectively, allowing it to fit in smaller chest cavities including those of smaller adults and juvenile humans.
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Affiliation(s)
- Patrick L Jurney
- Department of Biomedical Engineering, San José State University, San Jose, CA, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | | | - Igor V Dykan
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Matthew W Hagen
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Sanjiv Kaul
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Richard K Wampler
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Monica T Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA.,Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - George D Giraud
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
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33
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Kitano T, Sakaguchi M, Yamagami H, Ishikawa T, Ishibashi-Ueda H, Tanaka K, Okazaki S, Sasaki T, Kadono Y, Takagaki M, Nishida T, Nakamura H, Yanase M, Fukushima N, Shiozawa M, Toyoda K, Takahashi JC, Funatsu T, Ryu B, Yoshioka D, Toda K, Murayama S, Kawamata T, Kishima H, Sawa Y, Mochizuki H, Todo K. Mechanical thrombectomy in acute ischemic stroke patients with left ventricular assist device. J Neurol Sci 2020; 418:117142. [PMID: 32977225 DOI: 10.1016/j.jns.2020.117142] [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] [Received: 06/18/2020] [Revised: 08/24/2020] [Accepted: 09/14/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVES As the number of patients with left ventricular assist device (LVAD) implantation has been increasing, treatment of LVAD-related ischemic stroke is becoming a critical issue. We sought to clarify the features of mechanical thrombectomy in LVAD-related stroke with large vessel occlusion. METHODS In a multi-center, retrospective case-control study, we compared 20 LVAD-related strokes with 33 non-LVAD strokes, all of which had large vessel occlusion in the anterior circulation treated with mechanical thrombectomy. A comparative histopathological examination of the retrieved thrombi was also performed. RESULTS Successful reperfusion was achieved in 75% of the LVAD-related strokes. The time from onset to reperfusion was similar to that of non-LVAD strokes, but the total number of device passes required for reperfusion (median, 2.5 versus 1, P = 0.01) and the incidences of post-procedural parenchymal and subarachnoid hemorrhage (25% versus 3%, P = 0.02 and 55% versus 15%, P = 0.01, respectively) were higher in LVAD-related strokes. Symptomatic intracranial hemorrhage occurred in 4 patients (20%) with LVAD-related strokes. The histopathological analysis revealed that the ratio of erythrocyte components was significantly lower in thrombi retrieved from patients with LVAD-related stroke than in those with non-LVAD stroke (19 ± 6% versus 41 ± 17%, P = 0.01). CONCLUSIONS Mechanical thrombectomy is feasible in patients with LVAD-related stroke. However, repetitive device passes are needed to achieve successful reperfusion mainly because of the structurally organized thrombi, and the higher risk of hemorrhagic complications should be considered, while offering this therapeutic alternative.
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Affiliation(s)
- Takaya Kitano
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Manabu Sakaguchi
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yamagami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshinori Kadono
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masatoshi Takagaki
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeo Nishida
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takayuki Funatsu
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Bikei Ryu
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shigeo Murayama
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
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Kocabeyoglu SS, Kervan U, Sert DE, Karahan M, Unal EU, Catav Z, Pac M. A Stepwise Approach to Left Ventricular Assist Device Pump Thrombosis. Heart Lung Circ 2020; 30:567-576. [PMID: 32843296 DOI: 10.1016/j.hlc.2020.07.009] [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: 04/24/2020] [Accepted: 07/19/2020] [Indexed: 11/16/2022]
Abstract
AIM Pump thrombosis (PT) is a detrimental complication of left ventricular assist device (LVAD) therapy. There is no consensus on optimal PT treatment. The aim of this study was to present a treatment strategy for patients with PT. METHOD The hospital records of patients who underwent isolated LVAD implantation between May 2013 and October 2018 were retrospectively evaluated. Pump thrombosis was suspected in the setting of impaired flow/power parameters and haemolysis. Protocols for the management of suspected PT varied by patient presentation. Parameters that increased the PT risk were investigated by dividing the patients into two groups according to the presence of PT. Preoperative and operative data were analysed. RESULTS Pump thrombosis was observed in 20 of 81 patients. All patients with PT presented elevated lactate dehydrogenase levels and higher power and/or low-/high-flow alarm at admission. All patients were treated initially with intravenous unfractionated heparin infusion; three patients did not require further treatment, one patient died due to sudden cardiac arrest, and three patients underwent urgent surgery for LVAD exchange. Thirteen (13) patients received tissue plasminogen activator infusion; eight were discharged without any signs of thrombosis, and three were bridged to transplant. One (1) major bleeding event leading to death was observed. Freedom from second PT was found in 91% cases at 6 months and in 68.2% at 1 year. We found that a larger left ventricle and the type of pump determined the risk of PT. CONCLUSIONS Low-dose thrombolytic therapy should be considered as a feasible treatment option for patients with PT.
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Affiliation(s)
| | - Umit Kervan
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Dogan Emre Sert
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Mehmet Karahan
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Ertekin Utku Unal
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Zeki Catav
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Mustafa Pac
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
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35
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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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36
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Chan CHH, Inoue M, Ki KK, Murashige T, Fraser JF, Simmonds MJ, Tansley GD, Watanabe N. Shear-dependent platelet aggregation size. Artif Organs 2020; 44:1286-1295. [PMID: 32735693 PMCID: PMC7818454 DOI: 10.1111/aor.13783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Nonsurgical bleeding is the most frequent complication of left ventricular assist device (LVAD) support. Supraphysiologic shear rates generated in LVAD causes impaired platelet aggregation, which increases the risk of bleeding. The effect of shear rate on the formation size of platelet aggregates has never been reported experimentally, although platelet aggregation size can be considered to be directly relevant to bleeding complications. Therefore, this study investigated the impact of shear rate and exposure time on the formation size of platelet aggregates, which is vital in predicting bleeding in patients with an LVAD. Human platelet‐poor plasma (containing von Willebrand factor, vWF) and fluorochrome‐labeled platelets were subjected to a range of shear rates (0‐10 000 s−1) for 0, 5, 10, and 15 minutes using a custom‐built blood‐shearing device. Formed sizes of platelet aggregates under a range of shear‐controlled environment were visualized and measured using microscopy. The loss of high molecular weight (HMW) vWF multimers was quantified using gel electrophoresis and immunoblotting. An inhibition study was also performed to investigate the reduction in platelet aggregation size and HMW vWF multimers caused by either mechanical shear or enzymatic (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13—ADAMTS13, the von Willebrand factor protease) mechanism under low and high shear conditions (360 and 10 000 s−1). We found that the average size of platelet aggregates formed under physiological shear rates of 360‐3000 s−1 (200‐300 μm2) was significantly larger compared to those sheared at >6000 s−1 (50‐100 μm2). Furthermore, HMW vWF multimers were reduced with increased shear rates. The inhibition study revealed that the reduction in platelet aggregation size and HWM vWF multimers were mainly associated with ADAMTS13. In conclusion, the threshold of shear rate must not exceed >6000 s−1 in order to maintain the optimal size of platelet aggregates to “plug off” the injury site and stop bleeding.
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Affiliation(s)
- Chris Hoi Houng Chan
- School of Engineering and Built Environment, Griffith University, Gold Coast, QLD, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Masataka Inoue
- School of Engineering and Built Environment, Griffith University, Gold Coast, QLD, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Life Sciences, Systems Engineering and Science, Graduate School of Engineering and Science, Shibaura Institute of Technology, Saitama, Japan
| | - Katrina K Ki
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Tomotaka Murashige
- School of Engineering and Built Environment, Griffith University, Gold Coast, QLD, Australia.,School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia.,School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Michael J Simmonds
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Geoff D Tansley
- School of Engineering and Built Environment, Griffith University, Gold Coast, QLD, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Nobuo Watanabe
- Department of Life Sciences, Systems Engineering and Science, Graduate School of Engineering and Science, Shibaura Institute of Technology, Saitama, Japan
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Bartoli CR, Kang J, Motomura T. Decreased RPM reduces von Willebrand factor degradation with the EVAHEART LVAS: implications for device-specific LVAD management. J Card Surg 2020; 35:1477-1483. [PMID: 32652785 DOI: 10.1111/jocs.14620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 04/16/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (LVADs) produces supraphysiologic shear stress that causes von Willebrand factor (VWF) degradation and a bleeding diathesis. Reduction of revolutions per minute (RPM) with axial-flow LVADs does not decrease shear stress enough to reduce VWF degradation and bleeding. However, it is unknown if RPM reduction with centrifugal flow LVADs may minimize VWF degradation. We tested the hypothesis that RPM reduction preserves VWF multimers in the centrifugal-flow EVAHEART left ventricular assist system (LVAS), which is designed to minimize shear stress and blood trauma. METHODS Whole blood samples were collected from humans (n = 28). Blood was circulated in ex vivo mock circulatory loops for 6 hours with an EVAHEART LVAS at 2300 (n = 12), 2100 (n = 8), or 1800 RPM (n = 8). Immunoblotting was used to resolve and quantify VWF multimers and degradation fragments. RESULTS RPM reduction from 2300 to 2100 to 1800 RPM significantly decreased EVAHEART blood flow from 5.8 ± 0.4 to 4.3 ± 0.6 to 4.1 ± 0.5 L/min (analysis of variance [ANOVA], P = .03). RPM reduction protected VWF from pathologic degradation. At lower RPMs, significantly greater levels of VWF multimers were observed (ANOVA, P = .001). Similarly, at lower RPMs, significantly fewer VWF fragments, a product of VWF degradation, were observed (ANOVA, P = .007). CONCLUSIONS RPM reduction significantly reduced VWF degradation with the centrifugal-flow EVAHEART LVAS, an LVAD specifically designed with low shear stress. Different LVADs have unique hematologic footprints and should be managed with device-specific protocols. Adjustment of RPM to minimize blood trauma while still maintaining physiologic hemodynamics has the potential to decrease complications related to LVAD-associated von Willebrand's disease, such as gastrointestinal bleeding and hemorrhagic stroke.
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Affiliation(s)
- Carlo R Bartoli
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jooeun Kang
- MD-PhD Program, Vanderbilt University, Nashville, Tennessee
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38
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Michelis KC, Zhong L, Peltz M, Pandey A, Tang WHW, Rohatgi A, Young JB, Drazner MH, Grodin JL. Dynamic Forecasts of Survival for Patients Living With Destination Left Ventricular Assist Devices: Insights From INTERMACS. J Am Heart Assoc 2020; 9:e016203. [PMID: 32648531 PMCID: PMC7660737 DOI: 10.1161/jaha.119.016203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Left ventricular assist devices (LVADs) improve outcomes in patients with end-stage heart failure and are increasingly implanted for destination therapy. We describe dynamic estimates of event-free survival with conditional survival probabilities in a destination therapy LVAD population. Methods and Results We studied 8245 adult patients in INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) implanted with a continuous-flow destination therapy LVAD. The composite primary end point was death, device exchange or removal, or heart transplantation. Conditional survival probabilities were calculated and stratified by implantation characteristics and nonfatal adverse events experienced within the first year after implant. Probabilities of surviving an additional 1 to 3 years were numerically higher after longer prior event-free survival. INTERMACS profile 1, extracorporeal membrane oxygenation support, prior or concomitant surgery, and dialysis within 48 hours of implantation were associated with significantly lower event-free survival in the first year but did not impact event-free survival beyond then. For patients who experienced a nonfatal adverse event within the first year, subsequent 1-year conditional survival was lower than in the absence of that event for stroke (65% [95% CI, 57%-73%] versus 75% [95% CI, 73%-77%]; P<0.001), device-related infection (64% [95% CI 57%-71%] versus 76% [95% CI, 74%-78%]; P<0.001), and pump thrombosis or malfunction (64% [95% CI, 57%-70%] versus 76% [95% CI, 74%-78%]; P<0.001). Conclusions Conditional survival in patients with destination therapy LVADs improves over time, even for patients with unfavorable implantation characteristics. However, LVAD-related complications including stroke, device-related infection, and pump thrombosis or malfunction have an enduring negative influence on dynamic estimates of long-term prognosis.
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Affiliation(s)
- Katherine C Michelis
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Lin Zhong
- Division of Bioinformatics Department of Clinical Sciences University of Texas Southwestern Medical Center Dallas TX
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery University of Texas Southwestern Medical Center Dallas TX
| | - Ambarish Pandey
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - W H Wilson Tang
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland OH
| | - Anand Rohatgi
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - James B Young
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland OH
| | - Mark H Drazner
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Justin L Grodin
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
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39
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Kobayashi Y, Imai Y, Mizutani S, Higo T, Shiose A, Kashiwazaki H. Opportune Time of Tooth Extraction in Individuals Requiring Ventricular Assist Device Implantation: A Retrospective Cohort Study. J Oral Maxillofac Surg 2020; 78:1921.e1-1921.e9. [PMID: 32574607 DOI: 10.1016/j.joms.2020.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/29/2020] [Accepted: 05/06/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Individuals with implantable ventricular assist devices (VADs) are at extremely high risk of bleeding, thromboembolism, and infection after undergoing invasive dental procedures. This study aimed to investigate the systemic and local complications of tooth extraction before and after VAD implantation. PATIENTS AND METHODS This retrospective cohort study was conducted at a single center. Oral surgical procedures were performed in patients before and/or after left VAD implantation for bridge-to-heart transplantation between April 2013 and December 2017. In this study, the medical charts of the patients were retrospectively reviewed. Data about pre-extraction complete blood count, coagulation profile, biochemical profile, and incidence of local and systemic complications were compared in patients undergoing tooth extraction before VAD implantation (b-VAD group) versus after VAD implantation (a-VAD group). RESULTS In total, 28 inpatients underwent 36 oral surgical procedures before and/or after VAD implantation. Moreover, 24 tooth extractions were performed in the b-VAD group, and 12 were performed in the a-VAD group. The incidence of post-extraction bleeding was higher in the a-VAD group (P = .001, Mann-Whitney U test), and a significant difference was observed in terms of activated partial thromboplastin time (P = .010, Mann-Whitney U test). Systemic complications associated with VADs included cerebral infarction (n = 2) and driveline infection (n = 1). Post-extraction bleeding was observed within 90 days after VAD implantation in all patients who underwent tooth extraction. CONCLUSIONS The risk of bleeding after tooth extraction was higher in the a-VAD group (67%) than in the b-VAD group (13%). In 3 cases, VAD-related systemic complications developed within a short period after tooth extraction. The extraction management in the b-VAD group could be controlled without causing any problem. Hence, the opportune time of tooth extraction is before VAD implantation.
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Affiliation(s)
- Yoshihiro Kobayashi
- Postgraduate Student, Section of Geriatric Dentistry and Perioperative Medicine in Dentistry, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan; and Geriatric Dentistry and Perioperative Medicine in Dentistry, Kyushu University Hospital, Fukuoka, Japan
| | - Yuko Imai
- Research Associate, Geriatric Dentistry and Perioperative Medicine in Dentistry, Kyushu University Hospital, Fukuoka, Japan.
| | - Shinsuke Mizutani
- Associate Professor, Section of Geriatric Dentistry and Perioperative Medicine in Dentistry, Division of Maxillofacial Diagnostic and Surgical Sciences, and Oral Health, Brain Health, Total Health Research Center, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Taiki Higo
- Lecturer, Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Shiose
- Professor, Department of Cardiovascular Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Haruhiko Kashiwazaki
- Professor, Section of Geriatric Dentistry and Perioperative Medicine in Dentistry, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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40
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Koycu A, Vural O, Bahcecitapar M, Jafarov S, Beyazpinar G, Beyazpinar DS. Device-related epistaxis risk: continuous-flow left ventricular assist device-supported patients. Eur Arch Otorhinolaryngol 2020; 277:2767-2773. [PMID: 32556786 DOI: 10.1007/s00405-020-06127-z] [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: 04/06/2020] [Accepted: 06/10/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to analyze the effect of device-dependent factors on epistaxis episodes comparing patients supported with a continuous-flow left ventricular assist device (CF-LVAD) to patients under the same antithrombotic therapy. METHODS Patients who underwent CF-LVAD between 2012 and 2018 were reviewed retrospectively from the institutionally adopted electronic database. Patients who underwent mitral valve replacement (MVR) surgery receiving the same anticoagulant and antiaggregant therapy were included as a control group. Demographics, epistaxis episodes, and nonepistaxis bleeding between the two groups were compared. RESULTS A total of 179 patients met the inclusion criteria (61 patients CF-LVAD group, 118 patients MVR group). The median (range) follow-up periods for the study (CF-LVAD) and control (MVR) groups were 370 (2819) and 545.70 (2356) days, respectively. There was a significant difference for frequency of bleeding episodes per month between CF-LVAD and MVR groups (p = 0.003 < 0.05). The most common site of bleeding was the anterior septum in both groups (90.9% for the CF-MVR group and 100% for the MVR group). While 14 patients (23%) had nonepistaxis bleeding in the CF-LVAD group, only two patients (1.7%) had nonepistaxis bleeding in the MVR group. There were significant differences in nonepistaxis bleeding rates between the CF-LVAD and MVR groups (χ2=19.79, p < 0.001). CONCLUSION Both epistaxis and nonepistaxis bleeding rates were higher in the CF-LVAD group than in the MVR group. This suggests that the use of CF-LVAD support could directly increase the risk of hemorrhagic complications. LEVEL OF EVIDENCE 2A (Etiology/Harm).
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Affiliation(s)
- Alper Koycu
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
| | - Omer Vural
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey.
| | - Melike Bahcecitapar
- Department of Statistics, Faculty of Science, Hacettepe University, Ankara, 06800, Turkey
| | - Sabuhi Jafarov
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
| | - Gulfem Beyazpinar
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
| | - Deniz Sarp Beyazpinar
- Department of Cardiovascular Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
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den Exter PL, Beeres SLMA, Eikenboom J, Klok FA, Huisman MV. Anticoagulant treatment and bleeding complications in patients with left ventricular assist devices. Expert Rev Cardiovasc Ther 2020; 18:363-372. [PMID: 32449431 DOI: 10.1080/14779072.2020.1773803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The treatment options for advanced heart failure patients drastically changed with the introduction of left ventricular assist devices (LVADs), either as bridge to transplant or as destination therapy for patients ineligible for transplant. Despite major benefits in terms of survival, functional status and quality of life, managing patients with LVADs comes with several challenges. The most significant challenge is balancing between the risks of thrombotic and bleeding complications. AREAS COVERED The present review describes the pathophysiological mechanisms explaining the alterations in the hemostatic profile of LVAD patients, and summarizes current evidence to guide clinical decision making with regard to anticoagulant treatment and management of bleeding complications. EXPERT OPINION LVAD patients require life-long anticoagulant therapy to reduce the risk of pump thrombosis. However, exposing LVAD patients to anticoagulant therapy, in combination with common acquired coagulopathies after LVAD implantation such as acquired von Willebrand syndrome, comes with high risks of bleeding. There is a need for randomized controlled trials in LVAD patients to determine the optimal antithrombotic regimen and find the most effective balance between thrombotic and bleeding complications. In addition, strategies to specifically target the acquired von Willebrand syndrome and its associated angiodysplasias need to be evaluated in the LVAD population.
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Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| | - Saskia L M A Beeres
- Department of Cardiology, Leiden University Medical Center , Leiden, The Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
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Review and reflections about pulsatile ventricular assist devices from history to future: concerning safety and low haemolysis-still needed. J Artif Organs 2020; 23:303-314. [PMID: 32367384 PMCID: PMC7666270 DOI: 10.1007/s10047-020-01170-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/13/2020] [Indexed: 11/23/2022]
Abstract
Since the first use of a ventricular assist device in 1963 many extracorporeal and implantable pulsatile blood pumps have been developed. After the invention of continuous flow blood pumps the implantable pulsatile pumps are not available anymore. The new rotary pumps spend a better quality of life because many of the patients can go home. Nevertheless, the extracorporeal pulsatile pumps have some advantages. They are low-cost systems, produce less haemolysis and heart-recovery can be tested easily. Pump failure is easy to realize because the pumps can be observed visually. Pump exchange can be done easily without any chirurgic surgery. As volume displacement pumps they can produce high blood pressure, so they are the only ones suitable for pediatric patients. Therefore, they are indispensable for clinical use today and in the future. In this work, nearly all pulsatile blood pumps used in clinical life are described.
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Benchtop von Willebrand Factor Testing: Comparison of Commercially Available Ventricular Assist Devices and Evaluation of Variables for a Standardized Test Method. ASAIO J 2020; 65:481-488. [PMID: 30004942 DOI: 10.1097/mat.0000000000000849] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Gastrointestinal bleeding occurs in 20-30% of patients receiving ventricular assist devices (VADs) due, in part, to acquired von Willebrand syndrome. We examined factors to optimize a benchtop method to quantify changes in von Willebrand Factor (VWF) multimer distribution and function in VADs, then applied them to evaluate commercially available devices. Human plasma was circulated through flow loops with VADs. Several experimental conditions were examined, including temperature, viscosity, and enzyme inhibition. Samples were analyzed for VWF collagen-binding activity (VWF:CB) and VWF antigen level. von Willebrand Factor multimer profiles were quantified using gel electrophoresis, near-infrared in-gel visualization, and densitometric analysis. The VWF:CB/antigen ratio in the HeartMate II, CentriMag, and HVAD exhibited average decreases of 46%, 44%, and 36% from baseline after 360 minutes of operation. High molecular weight (hVWF) multimer loss occurred within 30 minutes, although the Levacor and control loop profiles were unchanged. Varying temperature and viscosity altered hVWF degradation rate, but not the final results. Inhibition of a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13 (ADAMTS13) can potentially distinguish mechanoenzymatic cleavage of VWF from mechanical degradation. We developed a repeatable benchtop method to evaluate VWF compatibility of VADs similar to hemolysis testing that can be adopted for preclinical VAD evaluation.
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Miller L, Birks E, Guglin M, Lamba H, Frazier OH. Use of Ventricular Assist Devices and Heart Transplantation for Advanced Heart Failure. Circ Res 2020; 124:1658-1678. [PMID: 31120817 DOI: 10.1161/circresaha.119.313574] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There are only 2 treatments for the thousands of patients who progress to the most advanced form of heart failure despite the application of guideline-based medical therapy, use of ventricular assist devices and heart transplantation. There has been a great deal of progress in both of these therapies that have led to improved outcomes including significant improvement in survival and functional capacity. Heart transplantation offers the best short- and long-term survival for patients with end-stage heart failure, and the majority of these recipients achieve relatively limitless functional capacity for their age. However, the chronic shortage of available donors limits the number of recipients in the United States to an only 2500 patients/y or only a fraction of potential candidates. The significant improvement in outcomes now possible with durable ventricular assist devices has led to a significant increase in their use, which now exceeds the volume of heart transplants in the United States, with the greatest growth in use for those not considered to be candidates for heart transplantation, previously referred to as destination therapy. This article will review the substantial progress that has taken place for both of these life-saving treatment options, as well as the future directions.
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Affiliation(s)
- Leslie Miller
- From the Division of Cardiovascular Medicine, Texas Heart Institute, Houston (L.M., H.L., O.H.F.)
| | - Emma Birks
- Division of Cardiology, University of Louisville, KY (E.B.)
| | - Maya Guglin
- Division of Cardiology, University of Kentucky, Lexington (M.G.)
| | - Harveen Lamba
- From the Division of Cardiovascular Medicine, Texas Heart Institute, Houston (L.M., H.L., O.H.F.)
| | - O H Frazier
- From the Division of Cardiovascular Medicine, Texas Heart Institute, Houston (L.M., H.L., O.H.F.)
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Gastrointestinal Bleeding After HeartMate II or HVAD Implantation: Incidence, Location, Etiology, and Effect on Survival. ASAIO J 2020; 66:283-290. [DOI: 10.1097/mat.0000000000000998] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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46
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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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Mehta R, Athar M, Girgis S, Hassan A, Becker RC. Acquired Von Willebrand Syndrome (AVWS) in cardiovascular disease: a state of the art review for clinicians. J Thromb Thrombolysis 2019; 48:14-26. [PMID: 31004311 DOI: 10.1007/s11239-019-01849-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Von Willebrand Factor (vWF) is a large glycoprotein with a broad range of physiological and pathological functions in health and disease. While vWF is critical for normal hemostasis, vascular integrity and repair, quantitative and qualitative abnormalities in the molecule can predispose to serious bleeding and thrombosis. The heritable form of von Willebrand Disease was first described nearly a century ago, but more recently, recognition of an acquired condition known as acquired von Willebrand Syndrome (AVWF) has emerged in persons with hematological, endocrine and cardiovascular diseases, disorders and conditions. An in-depth understanding of the causes, diagnostic approach and management of AVWS is important for practicing clinicians.
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Affiliation(s)
- Radha Mehta
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Muhammad Athar
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameh Girgis
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Atif Hassan
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard C Becker
- Stonehill Professor of Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, CVC 4th Floor, Room 4936, Cincinnati, 45267, OH, USA.
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Leebeek FWG, Muslem R. Bleeding in critical care associated with left ventricular assist devices: pathophysiology, symptoms, and management. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:88-96. [PMID: 31808855 PMCID: PMC6913502 DOI: 10.1182/hematology.2019000067] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Chronic heart failure (HF) is a growing health problem, and it is associated with high morbidity and mortality. Left ventricular assist devices (LVADs) are nowadays an important treatment option for patients with end-stage HF not only as a bridging tool to heart transplantation but also, as a permanent therapy for end-stage HF (destination therapy). The use of LVAD is associated with a high risk for bleeding complications and thromboembolic events, including pump thrombosis and ischemic stroke. Bleeding is the most frequent complication, occurring in 30% to 60% of patients, both early and late after LVAD implantation. Although the design of LVADs has improved over time, bleeding complications are still the most common complication and occur very frequently. The introduction of an LVAD results in an altered hemostatic balance as a consequence of blood-pump interactions, changes in hemodynamics, acquired coagulation abnormalities, and the strict need for long-term anticoagulant treatment with oral anticoagulants and antiplatelet therapy. LVAD patients may experience an acquired coagulopathy, including platelet dysfunction and impaired von Willebrand factor activity, resulting in acquired von Willebrand syndrome. In this educational manuscript, the epidemiology, etiology, and pathophysiology of bleeding in patients with LVAD will be discussed. Because hematologist are frequently consulted in cases of bleeding problems in these individuals in a critical care setting, the observed type of bleeding complications and management strategies to treat bleeding are also reviewed.
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Affiliation(s)
| | - R Muslem
- Cardio-Thoracic Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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Outcomes of Infants Supported With Extracorporeal Membrane Oxygenation Using Centrifugal Versus Roller Pumps: An Analysis From the Extracorporeal Life Support Organization Registry. Pediatr Crit Care Med 2019; 20:1177-1184. [PMID: 31567621 PMCID: PMC7175473 DOI: 10.1097/pcc.0000000000002103] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine whether mortality differs between roller and centrifugal pumps used during extracorporeal membrane oxygenation in infants weighing less than 10 kg. DESIGN Retrospective propensity-matched cohort study. SETTING All extracorporeal membrane oxygenation centers reporting to the Extracorporeal Life Support Organization. PATIENTS All patients less than 10 kg supported on extracorporeal membrane oxygenation during 2011-2016 within Extracorporeal Life Support Organization Registry. INTERVENTIONS Centrifugal and roller pump recipients were propensity matched (1:1) based on predicted probability of receiving a centrifugal pump using demographic variables, indication for extracorporeal membrane oxygenation, central versus peripheral cannulation, and pre-extracorporeal membrane oxygenation patient management. MEASUREMENTS AND MAIN RESULTS A total of 12,890 patients less than 10 kg were supported with extracorporeal membrane oxygenation within the Extracorporeal Life Support Organization registry during 2011-2016. Patients were propensity matched into a cohort of 8,366. Venoarterial and venovenous extracorporeal membrane oxygenation runs were propensity matched separately. The propensity-matched cohorts were similar except earlier year of extracorporeal membrane oxygenation (standardized mean difference, 0.49) in the roller pump group. Within the propensity-matched cohort, survival to discharge was lower in the centrifugal pump group (57% vs 59%; odds ratio, 0.91; 95% CI, 0.83-0.99; p = 0.04). Hemolytic, infectious, limb injury, mechanical, metabolic, neurologic, pulmonary, and renal complications were more frequent in the centrifugal pump group. Hemorrhagic complications were similar between groups. Hemolysis mediated the relationship between centrifugal pumps and mortality (indirect effect, 0.023; p < 0.001). CONCLUSIONS In this propensity score-matched cohort study of 8,366 extracorporeal membrane oxygenation recipients weighing less than 10 kg, those supported with centrifugal pumps had increased mortality and extracorporeal membrane oxygenation complications. Hemolysis was evaluated as a potential mediator of the relationship between centrifugal pump use and mortality and met criteria for full mediation.
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Miniaturized Test Loop for the Assessment of Blood Damage by Continuous-Flow Left-Ventricular Assist Devices. Ann Biomed Eng 2019; 48:768-779. [PMID: 31724071 DOI: 10.1007/s10439-019-02404-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/06/2019] [Indexed: 01/22/2023]
Abstract
Although the hemocompatibility of left-ventricular assist devices (LVADs) has continuously improved, assessment of hemolysis remains mandatory in pre-clinical testing. The ASTM-F1841 has standardized this assessment since 1997. However, the recommended usage of fresh, non-pooled human blood is hardly feasible with the test loop volume specified therein, when testing the device under test versus a predicate device as required by the international standard 10993-4. In this study, we compared ASTM-conforming (ASTM) and downscaled (mini) test loops with a one-third priming volume for the assessment of blood damage at the ASTM operating point. Blood damage was assessed for HeartMate 3 and BPX-80 in 6 experiments with heparinized porcine slaughterhouse blood for 6 h. We analyzed plasma free hemoglobin (pfHb), von Willebrand factor (vWF) concentration and collagen-binding functionality and calculated indices of hemolysis and vWF-ratios. The mini test loops provided significantly higher pfHb increase and consistently stronger vWF-ratio decrease and yielded a significantly better differentiation of the pumps. Interestingly, indices of hemolysis were generally lower in the mini set-up, indicating less adverse effects by the mini loop itself. Thus, we propose our mini test loop as suitable tool for clinically relevant standardized assessment of blood damage by future LVADs with single-donation human blood.
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