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Kubicki R, Stiller B, Kroll J, Siepe M, Beyersdorf F, Benk C, Höhn R, Grohmann J, Fleck T, Zieger B. Acquired von Willebrand syndrome in paediatric patients during mechanical circulatory support. Eur J Cardiothorac Surg 2020; 55:1194-1201. [PMID: 30590475 DOI: 10.1093/ejcts/ezy408] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/15/2018] [Accepted: 11/01/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Bleeding signs can become life-threatening complications in patients on mechanical circulatory support (MCS). Clinical phenotyping and comprehensive analyses of the cause of bleeding are, therefore, essential, especially when risk-stratifying patients during MCS workup. We conducted coagulation analyses and determined von Willebrand factor (VWF) parameters in a paediatric cohort on temporary extracorporeal life support, extracorporeal membrane oxygenation or long-term ventricular assist device support. METHODS We carried out an observational single-centre study including 30 children with MCS (extracorporeal life support, n = 13; extracorporeal membrane oxygenation, n = 5; and ventricular assist device, n = 12). We also assessed the acquired von Willebrand parameters of each study participant: collagen binding capacity (VWF:CB), the ratio of collagen-binding capacity to VWF antigen (VWF:CB/VWF:Ag) and high-molecular-weight VWF multimers. We also documented bleeding events, transfusion requirement, haemolysis parameters and surgical interventions. RESULTS All children developed AVWS (acquired von Willebrand syndrome) during MCS, usually during the early postoperative course. They presented no AVWS after device explantation. We detected a loss of high-molecular-weight VWF multimers, decreased VWF:CB/VWF:Ag ratios and reduced VWF:CB levels. Twenty of the 30 patients experienced bleeding complications; approximately 53% of them required surgical revision. There were no deaths due to bleeding during support. CONCLUSIONS The AVWS prevalence in paediatric patients on MCS is 100% regardless of the types of devices tested in this study. The bleeding propensity of AVWS patients widely varies.
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Affiliation(s)
- Rouven Kubicki
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Kroll
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - René Höhn
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Grohmann
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thilo Fleck
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Flannery KM, Kamra K, Maeda K, Shuttleworth P, Almond C, Navaratnam M. Management of a Pediatric Patient With a Left Ventricular Assist Device and Symptomatic Acquired von Willebrand Syndrome Presenting for Orthotopic Heart Transplant. Semin Cardiothorac Vasc Anesth 2020; 24:355-359. [PMID: 32772894 DOI: 10.1177/1089253220949386] [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] [Indexed: 12/19/2022]
Abstract
We present the successful perioperative management of an 11-year-old patient presenting for heart transplant with a left ventricular assist device, symptomatic acquired von Willebrand syndrome, and recent preoperative intracranial hemorrhage. A brief review of the pathophysiology of acquired von Willebrand syndrome is included. As the number of pediatric patients supported with ventricular assist devices continues to increase, the management of symptomatic acquired von Willebrand syndrome during the perioperative period is an important consideration for anesthesiologists.
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Acquired von Willebrand Syndrome in Pediatric Extracorporeal Membrane Oxygenation: Sheared and Cleaved Everywhere, but What to Do About It? Pediatr Crit Care Med 2019; 20:998-999. [PMID: 31580279 DOI: 10.1097/pcc.0000000000002021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Horiuchi H, Doman T, Kokame K, Saiki Y, Matsumoto M. Acquired von Willebrand Syndrome Associated with Cardiovascular Diseases. J Atheroscler Thromb 2019; 26:303-314. [PMID: 30867356 PMCID: PMC6456452 DOI: 10.5551/jat.rv17031] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The blood glycoprotein von Willebrand factor (VWF) plays an important role in hemostasis and thrombosis. VWF is produced and secreted as large multimers by endothelial cells and megakaryocytes. It is then cleaved in a sheer-stress dependent manner by a specific protease, ADAMTS13, into multimers consisting of 2–80 subunits. Among VWF multimers, high molecular weight (HMW) multimers play important roles in platelet aggregation. Therefore, their loss induces a hemostatic disorder known as von Willebrand disease (VWD) type 2A. Various cardiovascular diseases, such as aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM), and several congenital structural diseases, as well as mechanical circulatory support systems, generate excessive high shear stress in the bloodstream. These cause excessive cleavage of VWF multimers resulting in a loss of HMW multimers, known as acquired von Willebrand syndrome (AVWS), a hemostatic disorder similar to VWD type 2A. Bleeding often occurs in the gastrointestinal tract since a fragile angiodysplasia develops associated with these diseases. Radical treatment for AVWS is to remove the pathological high shear causing AVWS.
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Affiliation(s)
- Hisanori Horiuchi
- Department of Molecular and Cellular Biology, Institute of Development, Aging and Cancer, Tohoku University
| | - Tsuyoshi Doman
- Department of Molecular and Cellular Biology, Institute of Development, Aging and Cancer, Tohoku University
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
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Chan CHH, Diab S, Moody K, Frazier OH, Sampaio LC, Fraser CD, Teruya J, Adachi I. In Vitro Hemocompatibility Evaluation of Ventricular Assist Devices in Pediatric Flow Conditions: A Benchmark Study. Artif Organs 2018; 42:1028-1034. [DOI: 10.1111/aor.13165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/29/2018] [Accepted: 03/29/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Chris Hoi Houng Chan
- Cardiovascular Surgery Research Laboratories; Texas Heart Institute; Houston TX USA
| | - Sara Diab
- Cardiovascular Surgery Research Laboratories; Texas Heart Institute; Houston TX USA
- School of Medicine; University of Queensland; Brisbane QLD AUS
| | - Kayla Moody
- Cardiovascular Surgery Research Laboratories; Texas Heart Institute; Houston TX USA
| | - O Howard Frazier
- Cardiovascular Surgery Research Laboratories; Texas Heart Institute; Houston TX USA
| | - Luiz C. Sampaio
- Cardiovascular Surgery Research Laboratories; Texas Heart Institute; Houston TX USA
| | - Charles D. Fraser
- Division of Congenital Heart Surgery; Texas Children's Hospital; Houston TX USA
- Surgery and Pediatrics; Houston TX USA
| | - Jun Teruya
- Pathology & Immunology; Baylor College of Medicine; Houston TX USA
- Transfusion Medicine and Coagulation; Texas Children's Hospital; Houston TX USA
| | - Iki Adachi
- Division of Congenital Heart Surgery; Texas Children's Hospital; Houston TX USA
- Surgery and Pediatrics; Houston TX USA
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Weyand AC, Jesudas R, Pipe SW. Advantage of recombinant von Willebrand factor for peri-operative management in paediatric acquired von Willebrand syndrome. Haemophilia 2018; 24:e120-e121. [DOI: 10.1111/hae.13436] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- A. C. Weyand
- Department of paediatrics and Communicable Diseases; University of Michigan; Ann Arbor MI USA
| | - R. Jesudas
- Bleeding and Clotting Disorders Institute; Peoria IL USA
| | - S. W. Pipe
- Department of paediatrics and Communicable Diseases; University of Michigan; Ann Arbor MI USA
- Department of Pathology; University of Michigan; Ann Arbor MI USA
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Space and Time Resolved Detection of Platelet Activation and von Willebrand Factor Conformational Changes in Deep Suspensions. Int J Biomed Imaging 2017; 2017:8318906. [PMID: 29234351 PMCID: PMC5695078 DOI: 10.1155/2017/8318906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/30/2017] [Accepted: 09/27/2017] [Indexed: 11/26/2022] Open
Abstract
Tracking cells and proteins' phenotypic changes in deep suspensions is critical for the direct imaging of blood-related phenomena in in vitro replica of cardiovascular systems and blood-handling devices. This paper introduces fluorescence imaging techniques for space and time resolved detection of platelet activation, von Willebrand factor (VWF) conformational changes, and VWF-platelet interaction in deep suspensions. Labeled VWF, platelets, and VWF-platelet strands are suspended in deep cuvettes, illuminated, and imaged with a high-sensitivity EM-CCD camera, allowing detection using an exposure time of 1 ms. In-house postprocessing algorithms identify and track the moving signals. Recombinant VWF-eGFP (rVWF-eGFP) and VWF labeled with an FITC-conjugated polyclonal antibody are employed. Anti-P-Selectin FITC-conjugated antibodies and the calcium-sensitive probe Indo-1 are used to detect activated platelets. A positive correlation between the mean number of platelets detected per image and the percentage of activated platelets determined through flow cytometry is obtained, validating the technique. An increase in the number of rVWF-eGFP signals upon exposure to shear stress demonstrates the technique's ability to detect breakup of self-aggregates. VWF globular and unfolded conformations and self-aggregation are also observed. The ability to track the size and shape of VWF-platelet strands in space and time provides means to detect pro- and antithrombotic processes.
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Gossai N, Brown NM, Ameduri R, Zantek ND, Louis JS, Steiner ME. Pediatric Acquired von Willebrand Disease With Berlin Heart Excor Ventricular Assist Device Support. World J Pediatr Congenit Heart Surg 2017; 7:614-8. [PMID: 27587498 DOI: 10.1177/2150135116651836] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/05/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The balance of hemostasis and anticoagulation is a concern for patients dependent upon ventricular assist devices (VADs). Bleeding is a common complication with both short- and long-term use of these devices. A better understanding of the risk factors and etiologies of bleeding associated with these devices is needed and could improve the overall results. We sought to determine the relationship of mechanical circulatory assist device use with acquired von Willebrand disease (avWD) in children. METHODS Data were analyzed retrospectively via review of the medical record of 19 consecutive patients who were supported with the Berlin EXCOR VAD for greater than 24 hours. Laboratory testing for avWD was performed at the discretion of the clinical team, often in association with clinical bleeding. RESULTS Of 19 pediatric patients, 10 (52.6%) had laboratory testing consistent with avWD. Median time to detection of avWD was 35 days postimplantation of device (range 0-310 days). Both minor mucosal bleeding and bleeding requiring intervention were highly prevalent in patients in whom avWD was identified (10/10 [100%] and 7/10 [70%]). The mean age of all patients was 3.3 years, but patients found to have avWD tended to be older (mean 5.3 years) and supported with larger volume VADs. CONCLUSIONS This experience demonstrates a high prevalence of avWD following EXCOR implantation. Bleeding, older age, and larger VAD size may be associated with avWD. These results should stimulate critical evaluation of individualized anticoagulation regimens in pediatric VAD patients.
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Affiliation(s)
- Nathan Gossai
- Division of Pediatric Hematology and Oncology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Nicholas M Brown
- Division of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rebecca Ameduri
- Division of Pediatric Cardiology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - James St Louis
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Marie E Steiner
- Division of Pediatric Hematology and Oncology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
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Baumann Kreuziger L, Massicotte MP. Mechanical circulatory support: balancing bleeding and clotting in high-risk patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:61-68. [PMID: 26637702 DOI: 10.1182/asheducation-2015.1.61] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Mechanical circulatory support (MCS) provides a bridge to heart transplant in children and adults with life-threatening heart failure and sustains patients ineligible for transplant. Extracorporeal membrane oxygenation (ECMO) provides temporary support for patients in cardiac or pulmonary failure through external gas exchange and continuous flow of blood. Because the median time to heart transplant exceeds event-free time on ECMO, pulsatile left ventricular assist devices (LVADs) are used to support infants and children. Continuous flow LVADs are preferred in adolescents and adults due to increased pump durability and improved overall survival. The shear stress created by the mechanical pumps cause changes in the hematologic system; acquired von Willebrand syndrome occurs in almost all patients treated with MCS. Despite the improvements in survival, major bleeding occurs in one-third of patients with a LVAD and ischemic stroke and LVAD thrombosis can affect 12% of adults and 29% of children. An antithrombotic strategy to mitigate LVAD bleeding and thrombotic complications has been tested in a randomized trial in children, but intensity of antithrombotic therapy in adults varies widely. Consensus guidelines for antithrombotic therapy during ECMO were created due to significant differences in management across centers. Because of the high risk for both bleeding and thrombotic complications, experts in hemostasis can significantly impact care of patients requiring mechanical circulatory support and are a necessary part of the management team.
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Affiliation(s)
- Lisa Baumann Kreuziger
- BloodCenter of Wisconsin, Department of Medicine, Division of Hematology, Medical College of Wisconsin, Milwaukee, WI; and
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