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Deng Y, Tay HM, Zhou Y, Fei X, Tang X, Nishikawa M, Yatomi Y, Hou HW, Xiao TH, Goda K. Studying the efficacy of antiplatelet drugs on atherosclerosis by optofluidic imaging on a chip. LAB ON A CHIP 2023; 23:410-420. [PMID: 36511820 DOI: 10.1039/d2lc00895e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Vascular stenosis caused by atherosclerosis instigates activation and aggregation of platelets, eventually resulting in thrombus formation. Although antiplatelet drugs are commonly used to inhibit platelet activation and aggregation, they unfortunately cannot prevent recurrent thrombotic events in patients with atherosclerosis. This is partially due to the limited understanding of the efficacy of antiplatelet drugs in the complex hemodynamic environment of vascular stenosis. Conventional methods for evaluating the efficacy of antiplatelet drugs under stenosis either fail to simulate the hemodynamic environment of vascular stenosis characterized by high shear stress and recirculatory flow or lack spatial resolution in their analytical techniques to statistically identify and characterize platelet aggregates. Here we propose and experimentally demonstrate a method comprising an in vitro 3D stenosis microfluidic chip and an optical time-stretch quantitative phase imaging system for studying the efficacy of antiplatelet drugs under stenosis. Our method simulates the atherogenic flow environment of vascular stenosis while enabling high-resolution and statistical analysis of platelet aggregates. Using our method, we distinguished the efficacy of three antiplatelet drugs, acetylsalicylic acid (ASA), cangrelor, and eptifibatide, for inhibiting platelet aggregation induced by stenosis. Specifically, ASA failed to inhibit stenosis-induced platelet aggregation, while eptifibatide and cangrelor showed high and moderate efficacy, respectively. Furthermore, we demonstrated that the drugs tested also differed in their efficacy for inhibiting platelet aggregation synergistically induced by stenosis and agonists (e.g., adenosine diphosphate, and collagen). Taken together, our method is an effective tool for investigating the efficacy of antiplatelet drugs under vascular stenosis, which could assist the development of optimal pharmacologic strategies for patients with atherosclerosis.
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Affiliation(s)
- Yunjie Deng
- Department of Chemistry, University of Tokyo, Tokyo, 113-0033, Japan.
| | - Hui Min Tay
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore, 639798, Singapore
| | - Yuqi Zhou
- Department of Chemistry, University of Tokyo, Tokyo, 113-0033, Japan.
| | - Xueer Fei
- Department of Chemistry, University of Tokyo, Tokyo, 113-0033, Japan.
| | - Xuke Tang
- Department of Chemistry, University of Tokyo, Tokyo, 113-0033, Japan.
| | - Masako Nishikawa
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, 113-0033, Japan
| | - Yutaka Yatomi
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, 113-0033, Japan
| | - Han Wei Hou
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore, 639798, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 308232, Singapore
| | - Ting-Hui Xiao
- Department of Chemistry, University of Tokyo, Tokyo, 113-0033, Japan.
| | - Keisuke Goda
- Department of Chemistry, University of Tokyo, Tokyo, 113-0033, Japan.
- Institute of Technological Sciences, Wuhan University, Hubei, 430072, China
- Department of Bioengineering, University of California, Los Angeles, California, 90095, USA
- CYBO, Tokyo 101-0022, Japan
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Sheriff J, Malone LE, Avila C, Zigomalas A, Bluestein D, Bahou WF. Shear-Induced Platelet Activation is Sensitive to Age and Calcium Availability: A Comparison of Adult and Cord Blood. Cell Mol Bioeng 2020; 13:575-590. [PMID: 33281988 PMCID: PMC7704822 DOI: 10.1007/s12195-020-00628-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/16/2020] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Antiplatelet therapy for neonates and infants is often extrapolated from the adult experience, based on limited observation of agonist-induced neonatal platelet hypoactivity and poor understanding of flow shear-mediated platelet activation. Therefore, thrombotic events due to device-associated disturbed flow are inadequately mitigated in critically ill neonates with indwelling umbilical catheters and infants receiving cardiovascular implants. METHODS Whole blood (WB), platelet-rich plasma (PRP), and gel-filtered platelets (GFP) were prepared from umbilical cord and adult blood, and exposed to biochemical agonists or pathological shear stress of 70 dyne/cm2. We evaluated α-granule release, phosphatidylserine (PS) scrambling, and procoagulant response using P-selectin expression, Annexin V binding, and thrombin generation (PAS), respectively. Activation modulation due to depletion of intracellular and extracellular calcium, requisite second messengers, was also examined. RESULTS Similar P-selectin expression was observed for sheared adult and cord platelets, with concordant inhibition due to intracellular and extracellular calcium depletion. Sheared cord platelet Annexin V binding and PAS activity was similar to adult values in GFP, but lower in PRP and WB. Annexin V on sheared cord platelets was calcium-independent, with PAS slightly reduced by intracellular calcium depletion. CONCLUSIONS Increased PS activity on purified sheared cord platelets suggest that their intrinsic function under pathological flow conditions is suppressed by cell-cell or plasmatic components. Although secretory functions of adult and cord platelets retain comparable calcium-dependence, PS exposure in sheared cord platelets is uniquely calcium-independent and distinct from adults. Identification of calcium-regulated developmental disparities in shear-mediated platelet function may provide novel targets for age-specific antiplatelet therapy.
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Affiliation(s)
- Jawaad Sheriff
- Department of Biomedical Engineering, T08-50 Health Sciences Center, Stony Brook University, Stony Brook, NY 11794-8084 USA
| | - Lisa E. Malone
- Division of Hematology and Oncology, Department of Medicine, Stony Brook University, Stony Brook, NY 11794 USA
| | - Cecilia Avila
- Department of Obstetrics, Gynecology and Reproductive Medicine, Stony Brook University, Stony Brook, NY 11794 USA
| | - Amanda Zigomalas
- Department of Biomedical Engineering, T08-50 Health Sciences Center, Stony Brook University, Stony Brook, NY 11794-8084 USA
| | - Danny Bluestein
- Department of Biomedical Engineering, T08-50 Health Sciences Center, Stony Brook University, Stony Brook, NY 11794-8084 USA
| | - Wadie F. Bahou
- Division of Hematology and Oncology, Department of Medicine, Stony Brook University, Stony Brook, NY 11794 USA
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Morici N, Varrenti M, Brunelli D, Perna E, Cipriani M, Ammirati E, Frigerio M, Cattaneo M, Oliva F. Antithrombotic therapy in ventricular assist device (VAD) management: From ancient beliefs to updated evidence. A narrative review. IJC HEART & VASCULATURE 2018; 20:20-26. [PMID: 30229131 PMCID: PMC6141382 DOI: 10.1016/j.ijcha.2018.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/17/2018] [Accepted: 06/21/2018] [Indexed: 12/23/2022]
Abstract
Platelets play a key role in the pathogenesis of ventricular assist device (VAD) thrombosis; therefore, antiplatelet drugs are essential, both in the acute phase and in the long-term follow-up in VAD management. Aspirin is the most used agent and still remains the first-choice drug for lifelong administration after VAD implantation. Anticoagulant drugs are usually recommended, but with a wide range of efficacy targets. Dual antiplatelet therapy, targeting more than one pathway of platelet activation, has been used for patients developing a thrombotic event, despite an increased risk of bleeding complications. Although different strategies have been attempted, bleeding and thrombotic events remain frequent and there are no uniform strategies adopted for pharmacological management in the short and mid- or long-term follow up. The aim of this article is to provide an overview of the evidence from randomized clinical trials and observational studies with a focus on the pathophysiologic mechanisms underlying bleeding and thrombosis in VAD patients and the best antithrombotic regimens available.
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Affiliation(s)
- Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Dept. of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Marisa Varrenti
- Health Science Department, Milano-Bicocca University, Milano, Italy
| | - Dario Brunelli
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Transplant Center and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Enrico Perna
- Transplant Center and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Manlio Cipriani
- Transplant Center and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Enrico Ammirati
- Transplant Center and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Frigerio
- Transplant Center and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Cattaneo
- Health Science Department, Università Degli Studi di Milano, Milan, Italy.,Unità di Medicina 3, ASST Santi Paolo e Carlo, Milan, Italy
| | - Fabrizio Oliva
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Sherwin J, Thompson E, Hill KD, Watt K, Lodge AJ, Gonzalez D, Hornik CP. Clinical pharmacology considerations for children supported with ventricular assist devices. Cardiol Young 2018; 28:1082-1090. [PMID: 29991374 PMCID: PMC6299825 DOI: 10.1017/s1047951118001075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The ventricular assist device is being increasingly used as a "bridge-to-transplant" option in children with heart failure who have failed medical management. Care for this medically complex population must be optimised, including through concomitant pharmacotherapy. Pharmacokinetic/pharmacodynamic alterations affecting pharmacotherapy are increasingly discovered in children supported with extracorporeal membrane oxygenation, another form of mechanical circulatory support. Similarities between extracorporeal membrane oxygenation and ventricular assist devices support the hypothesis that similar alterations may exist in ventricular assist device-supported patients. We conducted a literature review to assess the current data available on pharmacokinetics/pharmacodynamics in children with ventricular assist devices. We found two adult and no paediatric pharmacokinetic/pharmacodynamic studies in ventricular assist device-supported patients. While mechanisms may be partially extrapolated from children supported with extracorporeal membrane oxygenation, dedicated investigation of the paediatric ventricular assist device population is crucial given the inherent differences between the two forms of mechanical circulatory support, and pathophysiology that is unique to these patients. Commonly used drugs such as anticoagulants and antibiotics have narrow therapeutic windows with devastating consequences if under-dosed or over-dosed. Clinical studies are urgently needed to improve outcomes and maximise the potential of ventricular assist devices in this vulnerable population.
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Affiliation(s)
- Jennifer Sherwin
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Kevin D. Hill
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kevin Watt
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Andrew J. Lodge
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Nicholson JD, Kaakeh Y. Pharmacotherapy considerations for long-term management of patients with left ventricular assist devices. Am J Health Syst Pharm 2018; 75:755-766. [PMID: 29802111 DOI: 10.2146/ajhp170317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Yaman Kaakeh
- Purdue University College of Pharmacy, West Lafayette, IN
- Indiana University School of Medicine, West Lafayette, IN
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6
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Valerio L, Sheriff J, Tran PL, Brengle W, Redaelli A, Fiore GB, Pappalardo F, Bluestein D, Slepian MJ. Routine clinical anti-platelet agents have limited efficacy in modulating hypershear-mediated platelet activation associated with mechanical circulatory support. Thromb Res 2017; 163:162-171. [PMID: 29428715 DOI: 10.1016/j.thromres.2017.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/03/2017] [Accepted: 12/02/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Continuous flow ventricular assist devices (cfVADs) continue to be limited by thrombotic complications associated with disruptive flow patterns and supraphysiologic shear stresses. Patients are prescribed complex antiplatelet therapies, which do not fully prevent recurrent thromboembolic events. This is partially due to limited data on antiplatelet efficacy under cfVAD-associated shear conditions. MATERIALS AND METHODS We investigated the efficacy of antiplatelet drugs directly acting on three pathways: (1) cyclooxygenase (aspirin), (2) phosphodiesterase (dipyridamole, pentoxifylline, cilostazol), and (3) glycoprotein IIb-IIIa (eptifibatide). Gel-filtered platelets treated with these drugs were exposed for 10min to either constant shear stresses (30dyne/cm2 and 70dyne/cm2) or dynamic shear stress profiles extracted from simulated platelet trajectories through a cfVAD (Micromed DeBakey). Platelet activation state (PAS) was measured using a modified prothrombinase-based assay, with drug efficacy quantified based on PAS reduction compared to untreated controls. RESULTS AND CONCLUSIONS Significant PAS reduction was observed for all drugs after exposure to 30dyne/cm2 constant shear stress, and all drugs but dipyridamole after exposure to the 30th percentile shear stress waveform of the cfVAD. However, only cilostazol was significantly effective after 70dyne/cm2 constant shear stress exposure, though no significant reduction was observed upon exposure to median shear stress conditions in the cfVAD. These results, coupled with the persistence of reported clinical thrombotic complication, suggest the need for the development of new classes of drugs that are especially designed to mitigate thrombosis in cfVAD patients, while reducing or eliminating the risk of bleeding.
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Affiliation(s)
- Lorenzo Valerio
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy; Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Scientifico San Raffaele, Milan, Italy
| | - Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Phat L Tran
- Department of Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ, USA
| | - William Brengle
- Department of Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ, USA
| | - Alberto Redaelli
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Gianfranco B Fiore
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Federico Pappalardo
- Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Scientifico San Raffaele, Milan, Italy
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Marvin J Slepian
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA; Department of Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ, USA; Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, USA.
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7
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Valerio L, Tran PL, Sheriff J, Brengle W, Ghosh R, Chiu WC, Redaelli A, Fiore GB, Pappalardo F, Bluestein D, Slepian MJ. Aspirin has limited ability to modulate shear-mediated platelet activation associated with elevated shear stress of ventricular assist devices. Thromb Res 2016; 140:110-117. [PMID: 26938158 DOI: 10.1016/j.thromres.2016.01.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 01/25/2016] [Accepted: 01/31/2016] [Indexed: 10/22/2022]
Abstract
Continuous flow ventricular assist devices (cfVADs) while effective in advanced heart failure, remain plagued by thrombosis related to abnormal flows and elevated shear stress. To limit cfVAD thrombosis, patients utilize complex anti-thrombotic regimens built upon a foundation of aspirin (ASA). While much data exists on ASA as a modulator of biochemically-mediated platelet activation, limited data exists as to the efficacy of ASA as a means of limiting shear-mediated platelet activation, particularly under elevated shear stress common within cfVADs. We investigated the ability of ASA (20, 25 and 125 μM) to limit shear-mediated platelet activation under conditions of: 1) constant shear stress (30 dynes/cm(2) and 70 dynes/cm(2)); 2) dynamic shear stress, and 3) initial high shear exposure (70 dynes/cm(2)) followed by low shear exposure - i.e. a platelet sensitization protocol, utilizing a hemodynamic shearing device providing uniform shear stress in vitro. The efficacy of ASA to limit platelet activation mediated via passage through a clinical cfVAD system (DeBakey Micromed) in vitro was also studied. ASA reduced platelet activation only under conditions of low shear stress (38% reduction compared to control, n=10, p<0.004), with minimal protection at higher shear stress and under dynamic conditions (n=10, p>0.5) with no limitation of platelet sensitization. ASA had limited ability (25.6% reduction in platelet activation rate) to modulate shear-mediated platelet activation induced via cfVAD passage. These findings, while performed under "deconstructed" non-clinical conditions by utilizing purified platelets alone in vitro, provide a potential contributory mechanistic explanation for the persistent thrombosis rates experienced clinically in cfVAD patients despite ASA therapy. An opportunity exists to develop enhanced pharmacologic strategies to limit shear-mediated platelet activation at elevated shear levels associated with mechanical circulatory support devices.
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Affiliation(s)
- Lorenzo Valerio
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy; Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Scientifico San Raffaele, Milan, Italy.
| | - Phat L Tran
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, USA
| | - Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - William Brengle
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, USA
| | - Ram Ghosh
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Wei-Che Chiu
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Alberto Redaelli
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Gianfranco B Fiore
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Federico Pappalardo
- Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Scientifico San Raffaele, Milan, Italy
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Marvin J Slepian
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, USA; Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, USA; Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
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Donahey EE, Polly DM, Vega JD, Lyon M, Butler J, Nguyen D, Pekarek A, Wittersheim K, Kilgo P, Paciullo CA. Multidrug-Resistant Organism Infections in Patients with Left Ventricular Assist Devices. Tex Heart Inst J 2015; 42:522-7. [PMID: 26664303 DOI: 10.14503/thij-14-4612] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Left ventricular assist devices improve survival prospects in patients with end-stage heart failure; however, infection complicates up to 59% of implantation cases. How many of these infections are caused by multidrug-resistant organisms is unknown. We sought to identify the incidence, risk factors, and outcomes of multidrug-resistant organism infection in patients who have left ventricular assist devices. We retrospectively evaluated the incidence of multidrug-resistant organisms and the independent risk factors associated with them in 57 patients who had permanent left ventricular assist devices implanted at our institution from May 2007 through October 2011. Outcomes included death, transplantation, device explantation, number of subsequent hospital admissions, and number of subsequent admissions related to infection. Infections were categorized in accordance with criteria from the Infectious Diseases Council of the International Society for Heart and Lung Transplantation. Multidrug-resistant organism infections developed in 18 of 57 patients (31.6%)-a high incidence. We found 3 independent risk factors: therapeutic goal (destination therapy vs bridging), P=0.01; body mass index, P=0.04; and exposed velour at driveline exit sites, P=0.004. We found no significant differences in mortality, transplantation, or device explantation rates; however, there was a statistically significant increase in postimplantation hospital admissions in patients with multidrug-resistant organism infection. To our knowledge, this is the first report in the medical literature concerning multidrug-resistant organism infection in patients who have permanent left ventricular assist devices.
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9
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Sheriff J, Girdhar G, Chiu WC, Jesty J, Slepian MJ, Bluestein D. Comparative efficacy of in vitro and in vivo metabolized aspirin in the DeBakey ventricular assist device. J Thromb Thrombolysis 2015; 37:499-506. [PMID: 24043375 DOI: 10.1007/s11239-013-0997-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Ventricular assist devices (VADs) are implanted in patients with end-stage heart failure to provide both short- and long-term hemodynamic support. Unfortunately, bleeding and thromboembolic complications due to the severely disturbed, dynamic flow conditions generated within these devices require complex, long-term antiplatelet and anticoagulant therapy. While several studies have examined the effectiveness of one such agent, aspirin, under flow conditions, data comparing the efficacy of in vitro and in vivo metabolized aspirin is lacking. Two sets of studies were conducted in vitro with purified human platelets circulating for 30 min in a flow loop containing the DeBakey VAD (MicroMed Cardiovascular, Houston, TX, USA): (a) 20 μM aspirin was added exogenously in vitro to platelets isolated from aspirin-free subjects, and (b) platelets were obtained from donors 2 h (n = 14) and 20 h (n = 13) after ingestion of 1,000 mg aspirin. Near real-time platelet activation state (PAS) was measured with a modified prothrombinase-based assay. Platelets exposed to aspirin in vitro and in vivo (metabolized) showed 28.2 and 25.3 % reduction in platelet activation rate, respectively, compared to untreated controls. Our results demonstrate that in vitro treatment with antiplatelet drugs such as aspirin is as effective as in vivo metabolized aspirin in testing the effect of reducing shear-induced platelet activation in the VAD. Using the PAS assay provides a practical in vitro alternative to in vivo testing of antiplatelet efficacy, as well as for testing the thrombogenic performance of devices during their research and development.
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Affiliation(s)
- Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, T15-090 Health Sciences Center, Stony Brook, NY, 11794-8151, USA
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10
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Mazzeffi M, Paciullo C, Vega JD, Nguyen D, Connor M. Moderate-to-large increases in perioperative serum sodium concentration associated with adverse neurologic events after continuous flow left ventricular assist device implantation. J Cardiothorac Vasc Anesth 2014; 29:360-6. [PMID: 25499669 DOI: 10.1053/j.jvca.2014.07.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE It was hypothesized that preoperative hyponatremia is associated with increased 30-day mortality after left ventricular assist device placement, and that large increases in sodium concentration are associated with adverse neurologic events and 30-day mortality. DESIGN Data were collected retrospectively on all patients having continuous flow left ventricular assist device implantation between January 1, 2009 and March 31, 2013. Preoperative variables, operative variables, and perioperative sodium concentrations were recorded. Both 30-day mortality and 72-hour adverse neurologic events (stroke or seizure) were recorded as primary outcome variables. Preoperative sodium and Δ sodium (postoperative sodium-preoperative sodium) were analyzed as tests for 30-day mortality and adverse neurologic events using receiver operating characteristic curves. Both crude and adjusted logistic regression analyses were used to estimate odds ratios for the outcome variables. SETTING Tertiary care academic medical center. PARTICIPANTS Patients having durable continuous flow left ventricular assist device placement. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 88 patients, 30-day mortality was 14% (12 of 88) and the rate of perioperative stroke or seizure was 9% (8 of 88). There were 3 strokes and 5 tonic-clonic seizures. Preoperative sodium was a poor discriminative test for 30-day mortality and stroke or seizure (AUC=0.47 and 0.57, respectively). Δ sodium was a poor discriminative test for 30-day mortality, but a fair discriminative test for stroke or seizure (AUC=0.55 and 0.78, respectively). Δ sodium was a good discriminative test for seizure alone (AUC=0.82) and a fair discriminative test for stroke alone (AUC=0.70). It also increased the odds of stroke or seizure significantly, even when adjusting for possible confounders. CONCLUSIONS Moderate-to-large increases in sodium concentration during left ventricular assist device placement appear to be associated with adverse postoperative neurologic events. Preoperative hyponatremia has no relationship with 30-day mortality or adverse perioperative neurologic events.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland, Baltimore, MD
| | | | - J David Vega
- Department of Surgery-Division of Cardiothoracic Surgery, Emory University, Atlanta, GA
| | - Duc Nguyen
- Department of Surgery-Division of Cardiothoracic Surgery, Emory University, Atlanta, GA
| | - Michael Connor
- Emory Center for Critical Care & Division of Pulmonary, Allergy, and Critical Care Medicine, Emory University, Atlanta, GA.
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11
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Koene RJ, Win S, Naksuk N, Adatya SN, Rosenbaum AN, John R, Eckman PM. HAS-BLED and CHA2DS2-VASc Scores as Predictors of Bleeding and Thrombotic Risk After Continuous-Flow Ventricular Assist Device Implantation. J Card Fail 2014; 20:800-7. [DOI: 10.1016/j.cardfail.2014.08.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 08/16/2014] [Accepted: 08/19/2014] [Indexed: 01/12/2023]
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12
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Jennings DL, Weeks PA. Thrombosis in continuous-flow left ventricular assist devices: pathophysiology, prevention, and pharmacologic management. Pharmacotherapy 2014; 35:79-98. [PMID: 25329333 DOI: 10.1002/phar.1501] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Continuous-flow left ventricular assist devices reduce short-term mortality and improve quality of life in patients with end-stage heart failure. Unfortunately, device-related complications remain common, with many patients experiencing adverse events within the first year. New literature suggests that rates of device-related thrombosis may be increasing since 2011, which is particularly troublesome given that this pathology can result in a disabling stroke, organ damage, and death. In 2013, a group of practitioners in the field of mechanical circulatory support published a treatment algorithm based on their expert opinion. However, a comprehensive review of the pharmacotherapy of this condition is lacking. A search of the literature revealed 20 separate publications of case reports or case series describing outcomes associated with the use of drug therapy for suspected pump thrombosis. Each of these experiences was limited by small sample size, nonrandomized treatment allocation, and nonstandardized medication dosing. Data describing the outcomes of surgical versus medical management of device thrombosis are also sparse, with only three published reports identified. Based on the review of this limited literature, surgical management appears to be the preferred treatment modality, especially in those with organ hypoperfusion or hemodynamic instability. In patients ineligible for surgery, pharmacotherapy options remain limited. Use of all drug classes described in the literature for the HeartMate II device-fibrinolytics, glycoprotein IIb/IIIa inhibitors, and direct thrombin inhibitors-was hindered by either marginal efficacy or bleeding. Based on historical experience with unfractionated heparin in patients under HeartMate II support, we recommend this agent as a possible option for those with suspected pump thrombosis in lieu of surgical device exchange. For the HeartWare HVAD, limited data suggest that direct intraventricular administration of alteplase may be an acceptable treatment alternative. Additional research is clearly needed to further delineate the role of pharmacotherapy and to identify the optimal agent for managing this potentially life-threatening condition.
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Affiliation(s)
- Douglas L Jennings
- Nova Southeastern University, Ft. Lauderdale, Florida; Jackson Memorial Hospital/Miami Transplant Institute, Miami, Florida
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Nakahara S, Chien C, Gelow J, Dalouk K, Henrikson CA, Mudd J, Stecker EC. Ventricular arrhythmias after left ventricular assist device. Circ Arrhythm Electrophysiol 2013; 6:648-54. [PMID: 23778248 DOI: 10.1161/circep.113.000113] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shashima Nakahara
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Lip GYH, Ponikowski P, Andreotti F, Anker SD, Filippatos G, Homma S, Morais J, Pullicino P, Rasmussen LH, Marin F, Lane DA. Thrombo-embolism and antithrombotic therapy for heart failure in sinus rhythm. A joint consensus document from the ESC Heart Failure Association and the ESC Working Group on Thrombosis. Eur J Heart Fail 2012; 14:681-95. [PMID: 22611046 DOI: 10.1093/eurjhf/hfs073] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Chronic heart failure (HF) with either reduced or preserved ejection fraction is common and remains an extremely serious disorder with a high mortality and morbidity. Many complications related to HF can be related to thrombosis. Epidemiological and pathophysiological data also link HF to an increased risk of thrombosis, leading to the clinical consequences of sudden death, stroke, systemic thrombo-embolism, and/or venous thrombo-embolism. This consensus document of the Heart Failure Association (EHFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Thrombosis reviews the published evidence and summarizes 'best practice', and puts forward consensus statements that may help to define evidence gaps and assist management decisions in everyday clinical practice. In HF patients with atrial fibrillation, oral anticoagulation is recommended, and the CHA(2)DS(2)-VASc and HAS-BLED scores should be used to determine the likely risk-benefit ratio (thrombo-embolism prevention vs. risk of bleeding) of oral anticoagulation. In HF patients with reduced left ventricular ejection fraction who are in sinus rhythm there is no evidence of an overall benefit of vitamin K antagonists (e.g. warfarin) on mortality, with risk of major bleeding. Despite the potential for a reduction in ischaemic stroke, there is currently no compelling reason to use warfarin routinely for these patients. Risk factors associated with increased risk of thrombo-embolic events should be identified and decisions regarding use of anticoagulation individualized. Patient values and preferences are important determinants when balancing the risk of thrombo-embolism against bleeding risk. New oral anticoagulants that offer a different risk-benefit profile compared with warfarin may appear as an attractive therapeutic option, but this would need to be confirmed in clinical trials.
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Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK.
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Current World Literature. Curr Opin Cardiol 2012; 27:318-26. [DOI: 10.1097/hco.0b013e328352dfaf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Simpson E, Lin Y, Stanworth S, Birchall J, Doree C, Hyde C. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2012:CD005011. [PMID: 22419303 DOI: 10.1002/14651858.cd005011.pub4] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is licensed for use in patients with haemophilia and inhibitory allo-antibodies and for prophylaxis and treatment of patients with congenital factor VII deficiency. It is also used for off-license indications to prevent bleeding in operations where blood loss is likely to be high, and/or to stop bleeding that is proving difficult to control by other means. This is the third version of the 2007 Cochrane review on the use of recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia, and has been updated to incorporate recent trial data. OBJECTIVES To assess the effectiveness of rFVIIa when used therapeutically to control active bleeding or prophylactically to prevent (excessive) bleeding in patients without haemophilia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and other medical databases up to 23 March 2011. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing rFVIIa with placebo, or one dose of rFVIIa with another, in any patient population (except haemophilia). Outcomes were mortality, blood loss or control of bleeding, red cell transfusion requirements, number of patients transfused and thromboembolic adverse events. DATA COLLECTION AND ANALYSIS Two authors independently assessed potentially relevant studies for inclusion, extracted data and examined risk of bias. We considered prophylactic and therapeutic rFVIIa studies separately. MAIN RESULTS Twenty-nine RCTs were included: 28 were placebo-controlled, double-blind RCTs and one compared different doses of rFVIIa. In the 'Risk of bias' assessment, most studies were found to have some threats to validity although therapeutic RCTs were found to be less prone to bias than prophylactic RCTs.Sixteen trials involving 1361 participants examined the prophylactic use of rFVIIa; 729 received rFVIIa. There was no evidence of mortality benefit (risk ratio (RR) 1.04; 95% confidence interval (CI) 0.55 to 1.97). There was decreased blood loss (mean difference (MD) -297 mL; 95% CI -416 to -178) and decreased red cell transfusion requirements (MD -261 mL; 95% CI -367 to -154) with rFVIIa treatment; however, these values were likely overestimated due to the inability to incorporate data from trials (four RCTs in the outcome of blood loss and three RCTs in the outcome of transfusion requirements) showing no difference of rFVIIa treatment compared to placebo. There was a trend in favour of rFVIIa in the number of participants transfused (RR 0.85; 95% CI 0.72 to 1.01). However, there was a trend against rFVIIa with respect to thromboembolic adverse events (RR 1.35; 95% CI 0.82 to 2.25).Thirteen trials involving 2929 participants examined the therapeutic use of rFVIIa; 1878 received rFVIIa. There were no outcomes where any observed advantage or disadvantage of rFVIIa over placebo could not have been observed by chance alone. There was a trend in favour of rFVIIa for reducing mortality (RR 0.91; 95% CI 0.78 to 1.06). However, there was a trend against rFVIIa for increased thromboembolic adverse events (RR 1.14; 95% CI 0.89 to 1.47).When all trials were pooled together to examine the risk of thromboembolic events, a significant increase in total arterial events was observed (RR 1.45; 95% CI 1.02 to 2.05). AUTHORS' CONCLUSIONS The effectiveness of rFVIIa as a more general haemostatic drug, either prophylactically or therapeutically, remains unproven. The results indicate increased risk of arterial events in patients receiving rFVIIa. The use of rFVIIa outside its current licensed indications should be restricted to clinical trials.
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Affiliation(s)
- Ewurabena Simpson
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.
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Current world literature. Curr Opin Cardiol 2011; 27:62-5. [PMID: 22146379 DOI: 10.1097/hco.0b013e32834f4ed9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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