1
|
De Crignis L, Guesnon M, Morin A, Aleksic I, Rivoire M, Meeus P, Dupré A, Peyrat P. Clinical outcomes after inferior vena cava resection for malignant disease. A single center experience of 51 vena cava resections. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108253. [PMID: 38552418 DOI: 10.1016/j.ejso.2024.108253] [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: 12/27/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND AND OBJECTIVE For tumors involving inferior vena cava (IVC), surgery with complete resection remains the first line treatment. Management of IVC after resection, either ligation without reconstruction or primary reconstruction, is debated. Our study aimed to evaluate type of venous reconstruction, anticoagulation management and morbidity. METHODS A French single center database of patients who underwent partial or total circumferencial resection of the IVC for malignant disease was analyzed. Inclusion criteria were any oncologic procedure for a retroperitoneal neoplasm requiring concomitant resection of the IVC with or without venous reconstruction with prosthesis. Exclusion criteria were surgery before year 2000. Data were descriptive and reverse Kaplan Meier was used for follow-up calculation. The endpoints were the rate of prosthetic reconstruction, the use of anticoagulation and the post-operative outcomes. RESULTS Fifty - one patients were included with a median duration of follow-up of 54.8 months. The majority of patients were men (56.9%). Median age of the population was 44.1 years. Most of the patients underwent surgery for primary testicular cancer and for sarcoma. Complete IVC resections were performed in 46 (90,2%) patients, 32 having a concomitant prosthetic replacement. Eight patients underwent aortic resection in the same operative time. Postoperative morbidity was 33.3%. Post-operative anticoagulation was done in 24 patients. At 1 month, four patients developed thrombosis in the prosthesis. CONCLUSIONS IVC resections are feasible and safe. Venous reconstruction and postoperative management were planned according to the preoperative imaging and intraoperative findings. We propose a decision-tree for peri-operative management and anticoagulation.
Collapse
Affiliation(s)
- Lucas De Crignis
- Centre Léon Bérard, Department of Surgical Oncology, Lyon, F-69008, France.
| | - Mathias Guesnon
- Centre Léon Bérard, Department of Surgical Oncology, Lyon, F-69008, France
| | - Axel Morin
- Jean Mermoz Hospital, Department of Vascular Medicine, Lyon, F-69008, France
| | - Ivan Aleksic
- Jean Mermoz Hospital, Department of Vascular Surgery, Lyon, F-69008, France
| | - Michel Rivoire
- Centre Léon Bérard, Department of Surgical Oncology, Lyon, F-69008, France
| | - Pierre Meeus
- Centre Léon Bérard, Department of Surgical Oncology, Lyon, F-69008, France
| | - Aurélien Dupré
- Centre Léon Bérard, Department of Surgical Oncology, Lyon, F-69008, France; Univ Lyon, Inserm, U1032 LabTau, F-69003, Lyon, France
| | - Patrice Peyrat
- Centre Léon Bérard, Department of Surgical Oncology, Lyon, F-69008, France
| |
Collapse
|
2
|
Pereira RM, Magueijo D, Guerra NC, Correia CJ, Rodrigues A, Nobre Â, Brito D, Moita LF, Velho TR. Activated clotting time value as an independent predictor of postoperative bleeding and transfusion. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae092. [PMID: 38718163 PMCID: PMC11109492 DOI: 10.1093/icvts/ivae092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/13/2024] [Accepted: 05/07/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVES Activated clotting time (ACT) is commonly used to monitor anticoagulation during cardiac surgeries. Final ACT values may be essential to predict postoperative bleeding and transfusions, although ideal values remain unknown. Our aim was to evaluate the utility of ACT as a predictor of postoperative bleeding and transfusion use. METHODS Retrospective study (722 patients) submitted to surgery between July 2018-October 2021. We compared patients with final ACT < basal ACT and final ACT ≥ basal ACT and final ACT < 140 s with ≥140 s. Continuous variables were analysed with the Wilcoxon rank-sum test; categorical variables using Chi-square or Fisher's exact test. A linear mixed regression model was used to analyse bleeding in patients with final ACT < 140 and ≥140. Independent variables were analysed with binary logistic regression models to investigate their association with bleeding and transfusion. RESULTS Patients with final ACT ≥ 140 s presented higher postoperative bleeding than final ACT < 140 s at 12 h (P = 0.006) and 24 h (**P = 0.004). Cardiopulmonary bypass (CPB) time [odds ratio (OR) 1.009, 1.002-1.015, 95% confidence interval (CI)] and masculine sex (OR 2.842,1.721-4.821, 95% CI) were significant predictors of bleeding. Patients with final ACT ≥ 140 s had higher risk of UT (OR 1.81, 1.13-2.89, 95% CI; P = 0.0104), compared to final ACT < 140 s. CPB time (OR 1.019,1.012-1.026, 95% CI) and final ACT (OR 1.021,1.010-1.032, 95% CI) were significant predictors of transfusion. Female sex was a predictor of use of transfusion, with a probability for use of 27.23% (21.84-33.39%, 95% CI) in elective surgeries, and 60.38% (37.65-79.36%, 95% CI) in urgent surgeries, higher than in males. CONCLUSIONS Final ACT has a good predictive value for the use of transfusion. Final ACT ≥ 140 s correlates with higher risk of transfusion and increased bleeding. The risk of bleeding and transfusion is higher with longer periods of CPB. Males have a higher risk of bleeding, but females have a higher risk of transfusion.
Collapse
Affiliation(s)
- Rafael Maniés Pereira
- Department of Cardiothoracic Surgery, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
- Escola Superior Saúde da Cruz Vermelha Portuguesa, Lisbon, Portugal
| | - Diogo Magueijo
- Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Nuno Carvalho Guerra
- Department of Cardiothoracic Surgery, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Catarina Jacinto Correia
- Transfusion Medicine Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Anabela Rodrigues
- Transfusion Medicine Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Ângelo Nobre
- Department of Cardiothoracic Surgery, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
- Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Dulce Brito
- Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Department of Cardiology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Luís Ferreira Moita
- Innate Immunity and Inflammation Laboratory, Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Tiago R Velho
- Department of Cardiothoracic Surgery, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
- Innate Immunity and Inflammation Laboratory, Instituto Gulbenkian de Ciência, Oeiras, Portugal
- Cardiothoracic Surgery Research Unit, Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| |
Collapse
|
3
|
Lu W, Yon DK, Lee SW, Koyanagi A, Smith L, Shin JI, Rahmati M, Xiao W, Li Y. Safety of Early Surgery in Hip Fracture Patients Taking Clopidogrel and/or Aspirin: A Systematic Review and Meta-Analysis. J Arthroplasty 2024; 39:1374-1383.e3. [PMID: 37972664 DOI: 10.1016/j.arth.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the safety of early surgery in hip fracture patients who took clopidogrel and/or aspirin. METHODS A systematic search was conducted using databases, including PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science, for studies relating to early arthroplasty or internal fixation for femoral neck fractures, intertrochanteric fractures, and subtrochanteric fractures in patients taking clopidogrel and/or aspirin. A total of 20 observational studies involving 3,077 patients were included in this meta-analysis, and analyzed in groups of early surgery versus delayed surgery, and clopidogrel and/or aspirin versus nonantiplatelet agents. RESULTS Patients in the clopidogrel and/or aspirin group who underwent early surgery had significantly more intraoperative blood loss than those in the non-antiplatelet group (mean difference = 17.96, 95% confidence interval [CI] [4.37, 31.55], P = .01), and patients in the clopidogrel and/or aspirin group had a lower overall incidence of complications after early surgery than those in the delayed surgery group (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001) and a shorter length of hospital stay (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001). There was no significant difference in postoperative mortality and other related indicators. CONCLUSIONS Early surgery in hip fracture patients taking clopidogrel and/or aspirin appears to be safe based on the available evidence and needs to be clarified by higher quality studies. However, the increased risk of cardiovascular events associated with discontinuation of clopidogrel or clopidogrel combined with aspirin dual antiplatelet therapy requires attention in the perioperative period.
Collapse
Affiliation(s)
- Wenhao Lu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Dong Keon Yon
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Seung Won Lee
- Department of Precision Medicine, Sungkyunkwan University College of Medicine, Suwon, Republic of Korea
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Lee Smith
- Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge, UK
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Masoud Rahmati
- Department of Physical Education and Sport Sciences, Faculty of Literature and Human Sciences, Lorestan University, Khoramabad, Iran; Department of Physical Education and Sport Sciences, Faculty of Literature and Humanities, Vali-E-Asr University of Rafsanjan, Rafsanjan, Iran
| | - Wenfeng Xiao
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yusheng Li
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
4
|
Randhawa MK, Sultana S, Stib MT, Nagpal P, Michel E, Hedgire S. Role of Radiology in Assessment of Postoperative Complications of Heart Transplantation. Radiol Clin North Am 2024; 62:453-471. [PMID: 38553180 DOI: 10.1016/j.rcl.2023.12.002] [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] [Indexed: 04/02/2024]
Abstract
Heart transplantation is a pivotal treatment of end-stage heart failure, and recent advancements have extended median posttransplant life expectancy. However, despite the progress in surgical techniques and medical treatment, heart transplant patients still face complications such as rejection, infections, and drug toxicity. CT is a reliable tool for detecting most of these complications, whereas MR imaging is particularly adept at identifying pericardial pathologies and signs of rejection. Awareness of these nuances by radiologists, cardiologists, and surgeons is desired to optimize care, reduce morbidities, and enhance survival.
Collapse
Affiliation(s)
- Mangun K Randhawa
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sadia Sultana
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew T Stib
- Division of Cardiothoracic Imaging, Department of Radiology, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Prashant Nagpal
- Division of Cardiovascular Imaging, Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Eriberto Michel
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sandeep Hedgire
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
5
|
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]
|
6
|
Hermann SA, Mikus G, Chobanyan-Jürgens K, Gorenflo M, Ziesenitz VC. Pharmacokinetics of a microdosed cocktail of three direct oral anticoagulants in children with congenital heart defects: study protocol for a single-centre clinical trial (DOAC-Child). BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2022-001662. [PMID: 36720501 PMCID: PMC9890763 DOI: 10.1136/bmjpo-2022-001662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/20/2022] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) are direct inhibitors of coagulation factor Xa and are frequently used in adults for different indications such as deep vein thrombosis or non-valvular atrial fibrillation. Paediatric patients might benefit as well from DOACs because the simplicity and convenience of their use is likely to decrease physical and psychological stress related to invasive procedures associated with phenprocoumon and heparin therapy. Thus, it is expected that the future use of DOACs will ultimately improve compliance and overall safety of anticoagulant therapies in paediatric populations. To assure safe and effective use the clinical pharmacology and pharmacokinetics (PK) of these drugs need to be evaluated in children. METHODS AND ANALYSIS This study is a single-centre, open-label, clinical trial in a paediatric population with non-cyanotic congenital heart defects. After having obtained informed consent from the parents, each participant will receive a single oral administration of a drinkable solution of a microdose cocktail of three FXa inhibitors consisting of apixaban (12.5 µg), rivaroxaban (12.5 µg), edoxaban (50 µg), plus a microdose of the two probe drugs midazolam (10 µg) and yohimbine (25 µg). Serial blood samples (n=up to 20) will be collected at specified time points before and up to 25 hours after cocktail administration. The primary PK endpoint will be the area under the plasma concentration time curve of apixaban, rivaroxaban and edoxaban. Secondary PK outcomes will be Cmax, tmax, t1/2, Cl/F and Vss/F. Safety and tolerability of the microdose cocktail will be evaluated as well by a collection of adverse events. ETHICS This study has been approved by the responsible Ethics Committee of the Medical Faculty of Heidelberg University. DISSEMINATION Study results will be presented at international scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER EudraCT 2019-001759-38 16, DRKS00021455.
Collapse
Affiliation(s)
- Simon A Hermann
- Department of Clinical Pharmacology and Pharmacoepidemiology, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Kristine Chobanyan-Jürgens
- Department of Clinical Pharmacology and Pharmacoepidemiology, UniversitätsKlinikum Heidelberg, Heidelberg, Germany.,Pediatric Clinical-Pharmacological Trial Centre, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Matthias Gorenflo
- Department of Paediatric and Congenital Cardiology, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Victoria C Ziesenitz
- Department of Paediatric and Congenital Cardiology, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| |
Collapse
|
7
|
Amin Muhammad A, Kumar S, Khatri M. Impact of aortic valve disease on outcomes of aortic root replacement. J Card Surg 2022; 37:5690-5691. [PMID: 36183396 DOI: 10.1111/jocs.16989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/19/2022] [Indexed: 01/06/2023]
Affiliation(s)
| | - Satesh Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, Pakistan
| | - Mahima Khatri
- Dow University of Health Sciences, Karachi, Pakistan
| |
Collapse
|
8
|
He LM, Zhang A, Xiong B. Effectiveness of Amiodarone in Preventing the Occurrence of Reperfusion Ventricular Fibrillation After the Release of Aortic Cross-Clamp in Open-Heart Surgery Patients: A Meta-Analysis. Front Cardiovasc Med 2022; 9:821938. [PMID: 35187132 PMCID: PMC8854653 DOI: 10.3389/fcvm.2022.821938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/04/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate the efficiency of amiodarone in preventing the occurrence of reperfusion ventricular fibrillation (RVF) after aortic cross-clamp (ACC) release in patients undergoing open-heart surgery. Methods We searched the Web of Science, Cochrane Library, EMBASE, and PubMed databases through January 2021 for relevant studies addressing the efficacy of amiodarone in preventing RVF after ACC release in patients undergoing cardiac surgery. A complete statistical analysis was performed using RevMan 5.3. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated to express the results of dichotomous outcomes using random or fixed-effect models. The chi-square test and I2 test were used to calculate heterogeneity. Results Seven studies (856 enrolled patients; 311 in the amiodarone group, 268 in the lidocaine group, and 277 in the placebo group) were selected for the meta-analysis. The incidence of RVF was significantly decreased in the amiodarone group compared to the placebo group (RR = 0.69, 95%CI: 0.50–0.94, P = 0.02). However, amiodarone and lidocaine did not confer any significant difference (RR = 0.98, 95%CI: 0.61–1.59, P = 0.94). The percentage of patients requiring electric defibrillation counter shocks (DCSs) did not confer any significant difference between patients administered amiodarone and lidocaine or placebo (RR = 1.58, 95%CI: 0.29–8.74, P = 0.60; RR = 0.55, 95%CI: 0.27–1.10, P = 0.09; respectively). Conclusions Amiodarone is more effective than a placebo in preventing RVF after ACC release in cardiac surgery. However, the amiodarone group required the same number of electrical DCSs to terminate RVF as the lidocaine or placebo groups.
Collapse
Affiliation(s)
- Li-min He
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - An Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Bin Xiong
- Department of Critical Care Medicine, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
- *Correspondence: Bin Xiong
| |
Collapse
|
9
|
Moster M, Bolliger D. Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00511-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Purpose of Review
Multiple guidelines and recommendations have been written to address the perioperative management of antiplatelet and anticoagulant drugs. In this review, we evaluated the recent guidelines in non-cardiac, cardiac, and regional anesthesia. Furthermore, we focused on unresolved problems and novel approaches for optimized perioperative management.
Recent Findings
Vitamin K antagonists should be stopped 3 to 5 days before surgery. Preoperative laboratory testing is recommended. Bridging therapy does not decrease the perioperative thromboembolic risk and might increase perioperative bleeding risk. In patients on direct-acting oral anticoagulants (DOAC), a discontinuation interval of 24 and 48 h in those scheduled for surgery with low and high bleeding risk, respectively, has been shown to be saved. Several guidelines for regional anesthesia recommend a conservative interruption interval of 72 h for DOACs before neuraxial anesthesia. Finally, aspirin is commonly continued in the perioperative period, whereas potent P2Y12 receptor inhibitors should be stopped, drug-specifically, 3 to 7 days before surgery.
Summary
Many guidelines have been published from various societies. Their applicability is limited in emergent or urgent surgery, where novel approaches might be helpful. However, their evidence is commonly based on small series, case reports, or expert opinions.
Collapse
|
10
|
Shahanavaz S, Qureshi AM, Petit CJ, Goldstein BH, Glatz AC, Bauser-Heaton HD, McCracken CE, Kelleman MS, Law MA, Nicholson GT, Zampi JD, Pettus J, Meadows J. Factors Influencing Reintervention Following Ductal Artery Stent Implantation for Ductal-Dependent Pulmonary Blood Flow: Results From the Congenital Cardiac Research Collaborative. Circ Cardiovasc Interv 2021; 14:e010086. [PMID: 34789017 DOI: 10.1161/circinterventions.120.010086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Stenting of the patent ductus arteriosus (PDA) is an established palliative option for infants with ductal-dependent pulmonary blood flow. Following initial palliation, reintervention on the PDA stent is common, but risk factors have not been characterized. METHODS Infants with ductal-dependent pulmonary blood flow palliated with PDA stent between 2008 and 2015 were reviewed within the Congenital Cardiac Research Collaborative. Rates and risk factors for reintervention were analyzed. RESULTS Among 105 infants who underwent successful PDA stenting, 41 patients (39%) underwent a total of 53 reinterventions on the PDA stent, with all but one occurring within 6 months of the initial intervention. Stent redilation constituted the majority of reintervention (n=35; 66%) followed by additional stent placement (n=11; 21%) and surgical shunt placement (n=7; 13%). The majority of reintervention was nonurgent, and there were no deaths during the reintervention procedure. All but one reintervention occurred within 6 months of the initial procedure. On univariate analysis, risk factors for reintervention included anticipated single-ventricle physiology, lack of prior balloon pulmonary valvuloplasty, use of drug-eluting stent, and increased ductal tortuosity. CONCLUSIONS In infants with ductal-dependent pulmonary blood flow palliated with PDA stent implantation, reintervention is common, can be performed safely, and is associated with both anatomic/procedural factors and anticipated final physiology.
Collapse
Affiliation(s)
- Shabana Shahanavaz
- Division of Cardiology, Department of Pediatrics, Washington University in St. Louis School of Medicine, MO (S.S.).,The Heart Institute, Cincinnati Children's Hospital Medical Center, OH (S.S., B.H.G.)
| | - Athar M Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston (A.M.Q.)
| | - Christopher J Petit
- Emory University School of Medicine, Children's Healthcare of Atlanta, GA (C.J.P., H.D.B.-H., J.P.).,Division of Pediatric Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York Presbyterian Hospital (C.J.P.)
| | - Bryan H Goldstein
- The Heart Institute, Cincinnati Children's Hospital Medical Center, OH (S.S., B.H.G.).,Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, PA (B.H.G.)
| | - Andrew C Glatz
- Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia (A.C.G.)
| | - Holly D Bauser-Heaton
- Emory University School of Medicine, Children's Healthcare of Atlanta, GA (C.J.P., H.D.B.-H., J.P.)
| | - Courtney E McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (C.E.M., M.S.K.)
| | - Michael S Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (C.E.M., M.S.K.)
| | - Mark A Law
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alabama at Birmingham (M.A.L.)
| | - George T Nicholson
- Division of Pediatric Cardiology, Department of Pediatrics at the Ann and Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN (G.T.N.)
| | - Jeffrey D Zampi
- Department of Pediatrics, Division of Cardiology, University of Michigan, Ann Arbor (J.D.Z.)
| | - Joelle Pettus
- Emory University School of Medicine, Children's Healthcare of Atlanta, GA (C.J.P., H.D.B.-H., J.P.)
| | - Jeffery Meadows
- Division of Pediatric Cardiology, University of California, San Francisco (J.M.)
| |
Collapse
|
11
|
Kann SH, Thomassen SA, Abromaitiene V, Jakobsen CJ. ICU Nurses-An Impact Factor on Patient Turnover in Cardiac Surgery in Western Denmark? J Cardiothorac Vasc Anesth 2021; 36:1967-1974. [PMID: 34736863 DOI: 10.1053/j.jvca.2021.09.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to describe changes in performance indicators such as length of stay [LOS] in the intensive care unit [ICU] and ventilation time, during the last six years in an attempt to identify associations between patient and systemic performance indicators, including the impact of nurse turnover. DESIGN A retrospective study of prospectively registered data (2013-2018). Propensity- score matching was performed to establish comparable groups. SETTING Three Danish university hospitals. PARTICIPANTS The study included a total of 12,404 adult cardiac surgical patients registered in the Western Denmark Heart Registry. The cohort was divided into an "early" group (2013-2016) and a "late" group (2017-2018). INTERVENTIONS An analysis of dynamics in patient indicators and systemic performance indicators, including the impact from selected performance parameters and nurse turnover. MEASUREMENTS AND MAIN RESULTS Comorbidity, calculated from the European System for Cardiac Operative Risk Evaluation, and the mean age were stable in the study period. Strong predictors of long LOS in the ICU included postoperative use of inotropes, re-exploration surgery, high postoperative drainage, and the "late" time group. Time parameters (relative risks) were all significantly longer in the "late" time group": ventilation time 1.21 (1.05-1.39), length of stay ICU 1.28 (1.11-1.48), and in-hospital time 1.36 (1.19-1.57). ICU nurse turnover increased from four (2013-2014) to 52 (2017-2018). CONCLUSION No single patient factor, such as age or comorbidity, could explain the decrease in patient turnover in the ICU. In the same period, the turnover of ICU nurses increased. Patient turnover is complex and affected by a mix of patient and systemic performance factors.
Collapse
Affiliation(s)
- Sigrun Høegholm Kann
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
| | - Sisse Anette Thomassen
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Vijoleta Abromaitiene
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Carl-Johan Jakobsen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
12
|
Rogers AL, Allman RD, Fang X, Kindell LC, Nifong LW, Degner BC, Akhter SA. Thromboelastography-Platelet Mapping Allows Safe and Earlier Urgent Coronary Artery Bypass Grafting. Ann Thorac Surg 2021; 113:1119-1125. [PMID: 34437860 DOI: 10.1016/j.athoracsur.2021.07.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/01/2021] [Accepted: 07/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current STS guidelines recommend delaying CABG for several days or performing platelet function testing in stable patients who received P2Y12 inhibitors. Our program routinely uses thromboelastography-platelet mapping (TEG-PM) to expedite CABG in P2Y12 non-responders (NR). We hypothesize that P2Y12 NR had no difference in LOS to surgery and blood product transfusion compared to patients undergoing urgent inpatient CABG not treated with a P2Y12 inhibitor. METHODS A total of 221 patients from 2015-2019 were P2Y12 NR based on TEG-PM result of < 50% ADP inhibition. The control group was 232 consecutive patients who also had urgent inpatient CABG but were not treated pre-operatively with a P2Y12 inhibitor. Exclusion criteria were identical between groups. RESULTS Sixty-seven percent of inpatient CABG patients who were treated pre-operatively with a P2Y12 inhibitor were NR. The mean number of days from cardiac surgical consultation to CABG in the TEG-PM NR group was 1.6 ± 0.1 versus 2.1 ± 0.1 in the control group (p<0.01). The mean total number of blood product units transfused was 1.6 ± 0.2 in the TEG-PM NR group versus 1.6 ± 0.4 in controls (p=0.91). CONCLUSIONS Our results demonstrate a very high incidence of P2Y12 non-responders in patients undergoing urgent CABG at our program. These patients underwent surgery at least 3 days earlier than STS recommendations and common practice with no difference in transfusion requirement. Routine use of TEG-PM to identify P2Y12 NR can safely decrease pre-operative hospital LOS and associated cost and improve resource utilization and patient satisfaction.
Collapse
Affiliation(s)
- Austin L Rogers
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Robert D Allman
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Xiangming Fang
- Department of Biostatistics, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina
| | - Linda C Kindell
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Leslie W Nifong
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Benjamin C Degner
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Shahab A Akhter
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina.
| |
Collapse
|
13
|
Vernamonti J, Gadepalli SK. Non-cardiac surgical considerations in pediatric patients with congenital heart disease. Semin Pediatr Surg 2021; 30:151036. [PMID: 33992307 DOI: 10.1016/j.sempedsurg.2021.151036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Jack Vernamonti
- Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA.
| |
Collapse
|
14
|
Bartoszko J, Karkouti K. Managing the coagulopathy associated with cardiopulmonary bypass. J Thromb Haemost 2021; 19:617-632. [PMID: 33251719 DOI: 10.1111/jth.15195] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/29/2022]
Abstract
Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB-associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre-procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point-of-care viscoelastic and functional platelet testing. Common pitfalls in the management of post-CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near-normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB-associated coagulopathy can significantly improve patient outcomes.
Collapse
Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
15
|
Chandrasekar T, Boorjian SA, Capitanio U, Gershman B, Mir MC, Kutikov A. Collaborative Review: Factors Influencing Treatment Decisions for Patients with a Localized Solid Renal Mass. Eur Urol 2021; 80:575-588. [PMID: 33558091 DOI: 10.1016/j.eururo.2021.01.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
CONTEXT With the addition of active surveillance and thermal ablation (TA) to the urologist's established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced. OBJECTIVE To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process. EVIDENCE ACQUISITION A collaborative critical review of the medical literature was conducted. EVIDENCE SYNTHESIS We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making. CONCLUSIONS Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care. PATIENT SUMMARY With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.
Collapse
Affiliation(s)
- Thenappan Chandrasekar
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA.
| | | | - Umberto Capitanio
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Milan, Italy
| | - Boris Gershman
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Maria Carmen Mir
- Department of Urology, Fundación Instituto Valenciano Oncologia, Valencia, Spain
| | - Alexander Kutikov
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| |
Collapse
|
16
|
Ghbeis MB, Vander Pluym CJ, Thiagarajan RR. Hemostatic Challenges in Pediatric Critical Care Medicine-Hemostatic Balance in VAD. Front Pediatr 2021; 9:625632. [PMID: 33732668 PMCID: PMC7959853 DOI: 10.3389/fped.2021.625632] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/06/2021] [Indexed: 01/19/2023] Open
Abstract
Ventricular assist devices (VAD) are used more in children. Safe and effective anticoagulation is required for successful management of children supported with ventricular assist devices. Developmental hemostasis, device hemocompatibility, plastic to body ratio, surgical variable techniques, lack of knowledge on pharmacokinetics of anticoagulants, and wide variability in anticoagulation protocols have all contributed to increased incidence of bleeding and thromboembolic complications. New collaborative learning networks, such as the ACTION network, provide opportunities to define best practices, optimize, and reduce anticoagulation related adverse events. ACTION was established Dec 2017. It consists of expert clinicians in heart failure, as well as researchers, parents, and patients, with goals to improve outcomes, share data, improve education and standard practice for children with heart failure (, n.d). Changes in pediatric VAD anticoagulation strategy from using mainly heparin to DTI such as bivalirudin have helped reduce bleeding and clotting complications.
Collapse
Affiliation(s)
- Muhammad Bakr Ghbeis
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Christina J Vander Pluym
- Division of Advanced Cardiac Therapies, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ravi Ram Thiagarajan
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
17
|
Hosokawa T, Shibuki S, Tanami Y, Sato Y, Ko Y, Nomura K, Oguma E. Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography. J Pediatr Intensive Care 2020; 10:85-105. [PMID: 33884209 DOI: 10.1055/s-0040-1715483] [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: 06/03/2020] [Accepted: 06/24/2020] [Indexed: 12/24/2022] Open
Abstract
Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.
Collapse
Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Saki Shibuki
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshihiro Ko
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| |
Collapse
|
18
|
Fahnhorst SE, Beasley G, Goldberg JF, Martinez HR, Ryan KA, Towbin JA, Boston U, Absi M. Novel use of cangrelor in pediatrics: A pilot cohort study demonstrating use in ventricular assist devices. Artif Organs 2020; 45:38-45. [PMID: 33180355 DOI: 10.1111/aor.13782] [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: 05/13/2020] [Revised: 06/19/2020] [Accepted: 07/14/2020] [Indexed: 01/02/2023]
Abstract
Thromboembolic events and bleeding are major sources of morbidity among pediatric patients supported on a ventricular assist device (VAD). Pharmacokinetics and pharmacodynamics of enteral antiplatelet agents are affected and variable due to erratic enteral absorption in end-stage heart failure and VAD circulation. Additionally, 20%-40% of the population are poor metabolizers of clopidogrel, a prodrug, making cangrelor an alternative when antiplatelet therapy is crucial. Cangrelor has been used effectively and safely for short durations in adults during percutaneous coronary interventions, but the use of cangrelor is still under investigation in pediatrics. This case series utilized cangrelor, a novel short-acting, reversible, intravenous P2Y12 platelet inhibitor in managing pediatric patients supported with a VAD. We performed a retrospective, single-center review of patients admitted to a tertiary medical center with end-stage heart failure requiring mechanical circulatory support and concomitant cangrelor administration between January 2019 and March 2020. Platelet function testing, cangrelor dose, bleeding complications, thromboembolic events, and frequency of circuit interventions during the use of cangrelor were recorded. Optimal platelet reactivity, defined as P2Y12 < 180 platelet reaction units (PRU), was measured with serial point-of-care testing (VerifyNow). Seven patients, median age of 4.9 years, met the above criteria. Three patients had a diagnosis of complex congenital heart disease. Four patients had dilated or restrictive cardiomyopathy. All patients were on continuous flow VADs. The median VAD duration was 84.5 days (IQR 61.5-103). The median duration on cangrelor was 43 days (IQR 8-70). The median cangrelor dose to reach the therapeutic threshold was 0.75 μg/kg/min with the mean P2Y12 , while on cangrelor of 164.75 PRU. Bleeding complications included mild gastrointestinal bleeding and hematuria. There was one patient with pump thrombosis requiring intervention. There were no cerebrovascular events while on cangrelor. We report the first successful long-term use of cangrelor in pediatric patients. The reversibility and short half-life of cangrelor make it a feasible antiplatelet agent in selected patients. This data supports the use of cangrelor in children as a viable antiplatelet option; with minimal bleeding complications and no cerebrovascular events demonstrated in this cohort.
Collapse
Affiliation(s)
- Sarah E Fahnhorst
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Gary Beasley
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Jason F Goldberg
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Hugo R Martinez
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Kaitlin A Ryan
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Jeffrey A Towbin
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Umar Boston
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mohammed Absi
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Memphis, TN, USA
| |
Collapse
|
19
|
Vedachalam S, Balasubramanian G, Haas GJ, Krishna SG. Treatment of gastrointestinal bleeding in left ventricular assist devices: A comprehensive review. World J Gastroenterol 2020; 26:2550-2558. [PMID: 32523310 PMCID: PMC7265145 DOI: 10.3748/wjg.v26.i20.2550] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/02/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Left ventricular assist devices (LVAD) are increasingly become common as life prolonging therapy in patients with advanced heart failure. Current devices are now used as definitive treatment in some patients given the improved durability of continuous flow pumps. Unfortunately, continuous flow LVADs are fraught with complications such as gastrointestinal (GI) bleeding that are primarily attributed to the formation of arteriovenous malformations. With frequent GI bleeding, antiplatelet and anticoagulation therapies are usually discontinued increasing the risk of life-threatening events. Small bowel bleeds account for 15% as the source and patients often undergo multiple endoscopic procedures. Treatment strategies include resuscitative measures and endoscopic therapies. Medical treatment is with octreotide. Novel treatment options include thalidomide, angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, estrogen-based hormonal therapies, doxycycline, desmopressin and bevacizumab. Current research has explored the mechanism of frequent GI bleeds in this population, including destruction of von Willebrand factor, upregulation of tissue factor, vascular endothelial growth factor, tumor necrosis factor-α, tumor growth factor-β, and angiopoetin-2, and downregulation of angiopoetin-1. In addition, healthcare resource utilization is only increasing in this patient population with higher admissions, readmissions, blood product utilization, and endoscopy. While some of the novel endoscopic and medical therapies for LVAD bleeds are still in their development stages, these tools will yet be crucial as the number of LVAD placements will likely only increase in the coming years.
Collapse
Affiliation(s)
- Srikanth Vedachalam
- Department of Internal Medicine, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| | - Garrie J Haas
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center; Columbus, OH 43210, United States
| |
Collapse
|
20
|
Martins ILF, Scaramello CBV. Is Bovine Heparin, an Old Fellow, a Safe Anticoagulation Approach during Extracorporeal Circulation Inside the Cardiac Operating Room? INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
21
|
Greenhawt M, Oppenheimer J, Shaker M. Fearing the Bark That Has No Bite: Parsing Practical From Theoretical Risk. Ann Allergy Asthma Immunol 2020; 123:327-328. [PMID: 31586537 DOI: 10.1016/j.anai.2019.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/20/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.
| | | | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| |
Collapse
|
22
|
Rizk J, Mehra MR. Anticoagulation management strategies in heart transplantation. Prog Cardiovasc Dis 2020; 63:210-218. [PMID: 32035125 DOI: 10.1016/j.pcad.2020.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/03/2020] [Indexed: 12/19/2022]
Abstract
Anticoagulation before, during, and after heart transplantation (HT) presents unique challenges to clinicians. Bleeding and thrombotic morbidity continues to affect this patient population throughout all phases of the HT journey. Reversal is commonly required since patients are commonly bridged to HT with left ventricular assist devices, which require chronic anti platelet and anticoagulation. Caution must be exercised in patients requiring cardiopulmonary bypass during surgery who are at risk of complications from heparin induced thrombocytopenia. The reported incidence of venous thromboembolism following HT is high, particularly during the first post-HT year, most likely due to surgery, biopsies, specific immunosuppression (mTOR inhibitors) and immobilization. It is crucial to maintain long-term oral anticoagulation after the first venous thromboembolism event, especially when risk factors exist. A major issue, and one for which there remains considerable debate, is the optimal treatment of such complications, particularly upper extremity venous thrombosis. For both warfarin and the thrombin inhibitors or Factor Xa inhibitors, the clinician must determine potential drug interactions based on the HT drug regimen, and then develop a patient-specific management strategy.
Collapse
Affiliation(s)
- John Rizk
- Arizona State University, Edson College, Phoenix, AZ, United States of America
| | - Mandeep R Mehra
- Brigham and Women's Heart & Vascular Center and Harvard Medical School, Boston, MA, United States of America.
| |
Collapse
|
23
|
Rizk J, Mehra MR. WITHDRAWN: Anticoagulation management strategies in heart transplantation. Prog Cardiovasc Dis 2020:S0033-0620(20)30026-8. [PMID: 32014513 DOI: 10.1016/j.pcad.2020.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/29/2020] [Indexed: 11/22/2022]
Affiliation(s)
- John Rizk
- Arizona State University, Edson College, Phoenix, AZ, United States of America
| | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States of America.
| |
Collapse
|
24
|
Ho LTS, Lenihan M, McVey MJ, Karkouti K, Wijeysundera DN, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC, Achen B, Brar S, Morrison D, Wong D, Bussières JS, Waal T, Harle C, Médicis É, McAdams C, Syed S, Tran D, Waters T. The association between platelet dysfunction and adverse outcomes in cardiac surgical patients. Anaesthesia 2019; 74:1130-1137. [PMID: 30932171 DOI: 10.1111/anae.14631] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypass-associated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.
Collapse
Affiliation(s)
- L T S Ho
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M Lenihan
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M J McVey
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, ON, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada.,Toronto General Research Institute and the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|