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Anticoagulation Strategies in Temporary Mechanical Circulatory Support. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023. [DOI: 10.1007/s11936-023-00978-5] [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: 02/19/2023]
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Goetz J, O'Brien M, Bream-Rouwenhorst H, Toyoda A, Hobbs R, Horwitz PA. Incidence and severity of thrombocytopenia associated with use of intravascular microaxial ventricular assist devices for treatment of cardiogenic shock. Catheter Cardiovasc Interv 2023; 101:318-323. [PMID: 36490219 DOI: 10.1002/ccd.30520] [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: 05/24/2022] [Revised: 10/31/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The use of temporary mechanical circulatory support (MCS) for patients with refractory cardiogenic shock has increased over the past decade. Impella devices (intravascular microaxial ventricular assist devices [VADs]) have become common MCS options but reportedly cause thrombocytopenia. Limited published data regarding the incidence or severity of microaxial VAD-associated thrombocytopenia exists. OBJECTIVES The goal of this study was to determine the incidence, timing, and severity of thrombocytopenia in a microaxial VAD population. METHODS A retrospective multicenter review of electronic medical records identified all patients implanted with microaxial VAD at three US academic teaching hospitals between June 2015 and August 2017. Patients were excluded for short-term procedural microaxial VAD use during percutaneous coronary intervention. RESULTS Sixty-four patients underwent microaxial VAD insertion (95% for left-sided support) during the observed time period. Support was in place for a median duration of 5.2 (interquartile range [IQR]: 2.4-10.0) days. Within 7 days postinsertion, 98.5% of patients developed thrombocytopenia (platelet count <150,000/μl) and 81.3% of patients experienced a >50% platelet decrease. Average platelet count nadir was 68,200/μl or 63.9% from baseline occurring on median day 3.8 (IQR: 2.4-5.4). Twenty-four patients (38.1%) were tested for heparin-induced thrombocytopenia by the heparin-dependent antibody (HDA) test. All HDAs were either negative or had serotonin release assay negative confirmation. Postdevice removal, platelet counts returned to baseline or >150,000/μl in 63% of patients by Day 5. CONCLUSION Microaxial VAD-associated thrombocytopenia is common. Practitioners should consider this when evaluating supported patients for other causes of thrombocytopenia. Platelet counts return to preimplantation levels within days of device removal.
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Affiliation(s)
- Jenna Goetz
- Department of Pharmacy, Barnes Jewish Hospital, St Louis, Missouri, USA
| | - Michael O'Brien
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Alexander Toyoda
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ryan Hobbs
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Phillip A Horwitz
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Bashline M, DiBridge J, Klass WJ, Morelli B, Kaczorowski D, Schmidhofer M, Horn ET, Gomez H, Ramanan R, Hickey GW, Rivosecchi RM. Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5. Artif Organs 2023; 47:361-369. [PMID: 36271639 DOI: 10.1111/aor.14428] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/09/2022] [Accepted: 10/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Impella 5.5 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation and sodium bicarbonate-dextrose purge solution (SBPS) in IMP5.5. METHODS This single center, retrospective study included 34 patients supported on IMP5.5 with BIV based AC and SBPS between December 1st 2020 to December 1st 2021.The efficacy and safety end points were incidence of development of HIT, Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure as well as clinically significant bleeding. RESULTS The median duration of IMP5.5 support was 9.8 days (IQR: 6-15). Most patients were bridged to HTX (58%) followed by recovery (27%) and LVAD implantation (15%). Patients were therapeutic on bivalirudin for 64% of their IMP5.5 support. One patient (2.9%) suffered from ischemic stroke and 26.5% (9) patients developed clinically significant bleeding. tPA was administered to 7(21%) patients. One patient in the entire cohort developed HIT. CONCLUSIONS Our experience supports the use of systemic BIV and SBPS as a method to avoid heparin exposure in a patient population predisposed to the development of HIT.
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Affiliation(s)
- Michael Bashline
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Julie DiBridge
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Wyatt J Klass
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian Morelli
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark Schmidhofer
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Edward T Horn
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hernando Gomez
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gavin W Hickey
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Leick J, Grottke O, Oezkur M, Mangner N, Sanna T, Al Rashid F, Vandenbriele C. What is known in pre-, peri-, and post-procedural anticoagulation in micro-axial flow pump protected percutaneous coronary intervention? Eur Heart J Suppl 2022; 24:J17-J24. [PMCID: PMC9731207 DOI: 10.1093/eurheartjsupp/suac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Interest in the use of percutaneous left ventricular assist devices (p-LVADs) for patients undergoing high-risk percutaneous coronary intervention (PCI) is growing rapidly. The Impella™ (Abiomed Inc.) is a catheter-based continuous micro-axial flow pump that preserves haemodynamic support during high-risk PCI. Anticoagulation is required to counteract the activation of the coagulation system by the patient’s procoagulant state and the foreign-body surface of the pump. Excessive anticoagulation and the effect of dual antiplatelet therapy (DAPT) increase the risk of bleeding. Inadequate anticoagulation leads to thrombus formation and device dysfunction. The precarious balance between bleeding and thrombosis in patients with p-LVAD support is often the primary reason that patients’ outcomes are jeopardized. In this chapter, we will discuss anticoagulation strategies and anticoagulant management in the setting of protected PCI. This includes anticoagulant therapy with unfractionated heparin, direct thrombin inhibitors, DAPT, purge blockage prevention by bicarbonate-based purge solution, and monitoring by activated clotting time, partial thromboplastin time, as well as anti-factor Xa levels. Here, we provide a standardized approach to the management of peri-interventional anticoagulation in patients undergoing protected PCI.
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Affiliation(s)
- Jürgen Leick
- Corresponding author. Tel: +49 651208981911, Fax: 00496512082786,
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Mehmet Oezkur
- Department of Cardiovascular Surgery, University Hospital Mainz, 55131 Mainz, Germany
| | - Norman Mangner
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universitaet Dresden, Dresden, Germany
| | - Tommaso Sanna
- Institute of Cardiology, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fadi Al Rashid
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, 45147 Essen, Germany
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Evaluation of Thrombocytopenia in Patients Receiving Percutaneous Mechanical Circulatory Support With an Impella Device. Crit Care Explor 2022; 4:e0772. [PMID: 36248319 PMCID: PMC9553399 DOI: 10.1097/cce.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Evaluate the time course of thrombocytopenia in patients with Impella devices (Abiomed, Danvers, MA).
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Hess NR, Ziegler LA, Kaczorowski DJ. The 10 Commandments of Microaxial Temporary Left Ventricular Assist Devices. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:368-376. [PMID: 36524534 DOI: 10.1177/15569845221134514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, PA, USA
| | - Luke A Ziegler
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, PA, USA
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, PA, USA
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Balthazar T, Bennett J, Adriaenssens T. Hemolysis during short-term mechanical circulatory support: from pathophysiology to diagnosis and treatment. Expert Rev Med Devices 2022; 19:477-488. [PMID: 35912874 DOI: 10.1080/17434440.2022.2108319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Despite advances in heart failure therapies and percutaneous coronary interventions, survival for cardiogenic shock remains poor. Percutaneous ventricular assist devices (pVAD) are increasingly used, but current evidence remains conflicting. The Impella is an example of such a device, based on a catheter mounted micro-axial continuous flow pump, that has been rapidly adopted in routine practice. An important aspect in the post implantation care is the prevention of complications. Hemolysis is one of the more frequent complications seen with this device. AREAS COVERED In this review we discuss the pathophysiology, diagnosis and treatment of hemolysis in patients supported with a pVAD. A practical algorithm for rapid identification of hemolysis and the underlying cause is presented, allowing for early treatment and prevention of further complications. EXPERT OPINION Hemolysis remains a threat to patients supported with any mechanical circulatory support device. Prevention as well as treatment demands for sufficient knowledge about the device, the optimal position and hemodynamics. Future studies should try to clarify some of the elements that are still unclear such as optimal anticoagulation, the place of pentoxyfilline or extracorporeal removal of free hemoglobin. This could help to optimize outcomes in clinical practice as well as future studies.
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Affiliation(s)
- Tim Balthazar
- University Hospitals Brussel, Department of Cardiology, Jette, Belgium
| | - Johan Bennett
- University Hospitals Leuven, Department of Cardiovascular Medicine, Leuven, Belgium.,Katholieke Universiteit Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
| | - Tom Adriaenssens
- University Hospitals Leuven, Department of Cardiovascular Medicine, Leuven, Belgium.,Katholieke Universiteit Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
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Al-Ayoubi AM, Bhavsar K, Hobbs RA, Smith KL, Lee LY, Ikegami H, Singhal AK. Use of Sodium Bicarbonate Purge Solution in Impella Devices for Heparin-Induced Thrombocytopenia. J Pharm Pract 2022:8971900221089078. [PMID: 35388725 DOI: 10.1177/08971900221089078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Heparin purge solution is recommended to be used in Impella devices to prevent biomaterial buildup and subsequent device dysfunction. The use of sodium bicarbonate purge solution in an Impella device is described in two patients with heparin-induced thrombocytopenia (HIT). The first case details a patient with severe mitral regurgitation and cardiogenic shock who had an Impella CP placed who developed HIT. Heparin purge solution was replaced by sodium bicarbonate purge solution in addition to systemic direct thrombin inhibitor (DTI) initiation. There was no significant change in Impella purge pressure or flow over the 13 days of Impella use. The second case describes a patient who developed an acute myocardial infarction and subsequent cardiogenic shock for which an Impella CP was placed who also developed HIT. Heparin purge solution was replaced by sodium bicarbonate purge solution. There was no significant change in purge pressure, flow, or motor current spikes over 11 days of use. In conclusion, we describe the successful use of a novel sodium bicarbonate purge solution utilized in patients with HIT for Impella management alone and in combination with systemic direct thrombin inhibitor therapy. This resulted in no protein deposition in the device gaps or device dysfunction.
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Affiliation(s)
- Adnan M Al-Ayoubi
- Division of Cardiothoracic Surgery, 21782University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Kinnari Bhavsar
- Division of Cardiothoracic Surgery, 25044Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Ryan A Hobbs
- Department of Pharmaceutical Care, 21782University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Katharyn L Smith
- Department of Pharmaceutical Care, 21782University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Leonard Y Lee
- Division of Cardiothoracic Surgery, 25044Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Hirohisa Ikegami
- Division of Cardiothoracic Surgery, 25044Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Arun K Singhal
- Division of Cardiothoracic Surgery, 21782University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Zein R, Patel C, Mercado-Alamo A, Schreiber T, Kaki A. A Review of the Impella Devices. Interv Cardiol 2022; 17:e05. [PMID: 35474971 PMCID: PMC9026144 DOI: 10.15420/icr.2021.11] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 12/01/2021] [Indexed: 01/14/2023] Open
Abstract
The use of mechanical circulatory support (MCS) to provide acute haemodynamic support for cardiogenic shock or to support high-risk percutaneous coronary intervention (HRPCI) has grown over the past decade. There is currently no consensus on best practice regarding its use in these two distinct indications. Impella heart pumps (Abiomed) are intravascular microaxial blood pumps that provide temporary MCS during HRPCI or in the treatment of cardiogenic shock. The authors outline technical specifications of the individual Impella heart pumps and their accompanying technology, the Automated Impella Controller and SmartAssist, their indications for use and patient selection, implantation techniques, device weaning and escalation, closure strategies, anticoagulation regimens, complications, future directions and upcoming trials.
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Affiliation(s)
- Rami Zein
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
| | - Chirdeep Patel
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
| | - Adrian Mercado-Alamo
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
| | - Theodore Schreiber
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
| | - Amir Kaki
- Interventional Cardiology Department, Ascension St John Hospital and Medical Center Detroit, MI, US
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Sugimura Y, Bauer S, Immohr MB, Hermsen DF, Westenfeld R, Boeken U, Aubin H, Tudorache I, Lichtenberg A, Akhyari P. Heparin-Induced Thrombocytopenia under Mechanical Circulatory Support by Large Impella for Acute Cardiogenic Shock. J Cardiovasc Dev Dis 2021; 8:jcdd8120161. [PMID: 34940516 PMCID: PMC8709300 DOI: 10.3390/jcdd8120161] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 12/02/2022] Open
Abstract
Despite the critical feature of heparin-induced thrombocytopenia (HIT) for patients on mechanical circulatory support, reports on its incidence and outcome are still scarce. Thus, we report on clinical features of HIT in patients under Impella 5.0 or 5.5 (Abiomed Inc., Danvers, MA, USA) (Impella 5+) support for acute cardiogenic shock (CS) by focusing on observed thrombotic events. Between November 2018 and December 2020, a total of 56 consecutive patients were enrolled in a single-center retrospective study. A total of 21 patients (37.5%) were tested for HIT, and 6 (10.7%) proved positive for HIT at 10.5 ± 2.89 days after the first heparin administration during current admission. Interestingly, thrombocyte counts dropped under Impella support in all groups (all cases, no HIT test, and HIT negative group: p < 0.001, HIT-positive group: p = 0.001). All HIT-positive patients were switched from heparin to argatroban. HIT-associated thrombotic events were observed in two cases resulting in Impella dysfunction due to pump thrombosis (n = 1) and left ventricular (LV) thrombus formation (n = 1). Under large Impella support, the prevalence of HIT was relatively high. Further, thrombocytopenia does not deliver a high specificity in the setting of Impella 5+ support. Considering HIT manifestation, a routine HIT test may be considered to avoid critical thrombotic adverse events.
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Affiliation(s)
- Yukiharu Sugimura
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany; (Y.S.); (S.B.); (M.B.I.); (U.B.); (H.A.); (I.T.); (P.A.)
| | - Sebastian Bauer
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany; (Y.S.); (S.B.); (M.B.I.); (U.B.); (H.A.); (I.T.); (P.A.)
| | - Moritz Benjamin Immohr
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany; (Y.S.); (S.B.); (M.B.I.); (U.B.); (H.A.); (I.T.); (P.A.)
| | - Derik Franz Hermsen
- Institute of Clinical Chemistry and Laboratory Diagnostics, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany;
| | - Ralf Westenfeld
- Department of Cardiology, Angiology and Pulmonology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany;
| | - Udo Boeken
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany; (Y.S.); (S.B.); (M.B.I.); (U.B.); (H.A.); (I.T.); (P.A.)
| | - Hug Aubin
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany; (Y.S.); (S.B.); (M.B.I.); (U.B.); (H.A.); (I.T.); (P.A.)
| | - Igor Tudorache
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany; (Y.S.); (S.B.); (M.B.I.); (U.B.); (H.A.); (I.T.); (P.A.)
| | - Artur Lichtenberg
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany; (Y.S.); (S.B.); (M.B.I.); (U.B.); (H.A.); (I.T.); (P.A.)
- Correspondence: ; Tel.: +49-211-81-18331
| | - Payam Akhyari
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, 40225 Düsseldorf, Germany; (Y.S.); (S.B.); (M.B.I.); (U.B.); (H.A.); (I.T.); (P.A.)
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11
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Beavers CJ, DiDomenico RJ, Dunn SP, Cox J, To L, Weeks P, Trujillo TC, Jennings DL. Optimizing anticoagulation for patients receiving Impella support. Pharmacotherapy 2021; 41:932-942. [PMID: 34597429 DOI: 10.1002/phar.2629] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 01/12/2023]
Abstract
Anticoagulation of patients treated with the Impella percutaneous mechanical circulatory support (MCS) devices is complex and lacks consistency across centers, potentially increasing the risk of complications. In order to optimize safety and efficacy, an expert committee synthesized all available evidence evaluating anticoagulation for patients receiving Impella support in order to provide consensus recommendations for the management of anticoagulation with these devices. The evidence synthesis led to the creation of 42 recommendations to improve anticoagulation management related to the use of the Impella devices. Recommendations address purge solution management, intravenous anticoagulation, monitoring, evaluation and management of heparin-induced thrombocytopenia (HIT), and management during combination MCS support. The use of a heparinized, dextrose-containing purge solution is critical for optimal device function, and a bicarbonate-based purge solution may be an alternative in certain situations. Likewise, intravenous (ie, systemic) anticoagulation with heparin is often necessary, although evidence supporting the optimal assay and target range for monitoring the level of anticoagulation is generally lacking. Patients treated with an Impella MCS device may develop HIT, which is more difficult to evaluate and treat in this setting. Lastly, the use of Impella with extracorporeal membrane oxygenation or for biventricular support creates additional anticoagulation challenges.
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Affiliation(s)
- Craig J Beavers
- University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Robert J DiDomenico
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Steven P Dunn
- Department of Pharmacy, University of Virginia Heart and Vascular Center, Charlottesville, Virginia, USA
| | - Jenna Cox
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, South Carolina, USA
| | - Long To
- Department of Pharmacy, Henry Ford Health System, Detroit, Michigan, USA
| | - Phillip Weeks
- Department of Pharmacy, Memorial Hermann Health System, Houston, Texas, USA
| | - Toby C Trujillo
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences/University of Colorado Hospital, Denver, Colorado, USA
| | - Douglas L Jennings
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, New York, USA.,Department of Pharmacy, New York-Presbyterian Hospital Columbia University Medical Center, New York, New York, USA
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12
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Shtoyko AN, Feldman EA, Cwikla GM, Darko W, Green GR, Seabury RW. Use of an argatroban systemic infusion and purge solution in a patient with a percutaneous ventricular assist device with suspected heparin-induced thrombocytopenia. Am J Health Syst Pharm 2021; 79:e8-e13. [PMID: 34390237 DOI: 10.1093/ajhp/zxab331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Thrombocytopenia can occur when using an Impella percutaneous ventricular assist device (pVAD), and heparin-induced thrombocytopenia (HIT) is often suspected. Data on heparin- and anticoagulant-free purge solutions in these devices are limited. Previous case reports have described argatroban-based purge solutions, both with and without systemic argatroban, at varying concentrations in patients with known or suspected HIT. SUMMARY A 33-year-old male was transferred to our institution and emergently initiated on life support with venoarterial extracorporeal membrane oxygenation (ECMO), an Impella pVAD, and continuous venovenous hemofiltration to receive an urgent aortic valve replacement. Over the next several days, the patient's platelet count declined with a nadir of 17 × 10 3/µL on hospital day 13. The patient's 4T score for probability of HIT was calculated as 4. All heparin products were discontinued on hospital day 15, and the patient was initiated on systemic infusion with argatroban 1,000 µg/mL at a rate of 0.2 µg/kg/min with a purge solution of argatroban 0.05 mg/mL. The systemic infusion remained at a rate of 0.2 µg/kg/min, and the total argatroban dose was, on average, less than 0.25 µg/kg/min. On hospital day 21, the patient was transferred to another institution. CONCLUSION Systemic infusion and a purge solution with argatroban were used in a patient with an Impella pVAD with multisystem organ dysfunction and suspected HIT. The patient achieved therapeutic activated partial thromboplastin times without adjustment of the systemic argatroban infusion and did not experience bleeding or thrombosis. Further studies concerning the safety and effectiveness of argatroban-based purge solutions in patients with pVADs are needed.
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Affiliation(s)
- Ashley N Shtoyko
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY, USA
| | - Elizabeth A Feldman
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY, and Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
| | - Gregory M Cwikla
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY, and Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, USA
| | - William Darko
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY, Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, and Department of Medicine, Upstate Medical University, Syracuse, NY, USA
| | - G Randall Green
- Department of Surgery, Upstate Medical University, Syracuse, NY, USA
| | - Robert W Seabury
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY, Upstate Pharmacy Services Translational Research Team (UPSTART), Syracuse, NY, and Department of Medicine, Upstate Medical University, Syracuse, NY, USA
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13
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Fabrizio C, Levito MN, Rivosecchi R, Bashline M, Slocum B, Kilic A, Toma C, Murray H, Ramanan R, Fowler J, Hickey GW, Horn ET. Outcomes of systemic anticoagulation with bivalirudin for Impella 5.0. Int J Artif Organs 2021; 44:681-686. [PMID: 34250827 DOI: 10.1177/03913988211032238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Temporary mechanical circulatory support (tMCS) devices are used for the management of cardiogenic shock. The Impella 5.0 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation in IMP5. This single center, retrospective study included patients supported on IMP5 with BIV based AC. The efficacy and safety end points were recovery, bridge to left ventricular assist device (LVAD), cardiac transplant (HTX), or death as well as clinically significant bleeding, incidence of Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure. There were 31 patients included, and 26 (84%) received BIV purge solutions. The median duration of IMP5 was 6 (IQR 4-10) days. Most patients were bridged to LVAD (39%, 12); 16% (5) were bridged to HTX, 16% (5) recovered, and 29% (9) died. One patient (3%) suffered from ischemic stroke and 12% (4) patients developed clinically significant bleeding. tPA was administered to 8 (26%) patients. Logistic regression analysis demonstrated that duration of IMP5 was a significant predictor of tPA use (OR 1.28; 95% Confidence Interval 1.04-1.56). There were no cases of pump failure. Our experience highlights the feasibility of utilizing BIV for routine AC use in IMP5.
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Affiliation(s)
- Carly Fabrizio
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Marissa N Levito
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryan Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Bashline
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brittany Slocum
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arman Kilic
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Holt Murray
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey Fowler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gavin W Hickey
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Edward T Horn
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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