Management and outcome of intracranial hemorrhage in patients with left ventricular assist devices

Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report

This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.

Secondary prevention after intracerebral haemorrhage

BACKGROUND

Intracerebral haemorrhage (ICH) has high mortality in the acute phase and poor functional outcome in the majority of survivors. ICH recurrence is a major determinant of long-term prognosis and is the most feared complication of antithrombotic treatment. On the other hand, ICH patients are at high risk of future ischaemic vascular events.

METHODS

This narrative review provides a critical analysis of the current knowledge on the topic. We performed a Pubmed search with the following terms 'intracerebral haemorrhage', 'stroke', 'outcome', 'secondary prevention', 'anticoagulation' and 'atrial fibrillation', including only English written studies with no time restrictions.

RESULTS

Blood pressure management is the cornerstone of secondary ICH prevention, regardless of ICH location or underlying cerebral small vessel disease. Resumption of antiplatelet and anticoagulation therapy is often challenging, with limited evidence from randomized trials. Clinical and imaging predictors can inform the stratification of ICH recurrence risk and might identify patients at very high probability of future haemorrhagic events. This narrative review provides a summary of the main diagnostic tools and therapeutic strategies available for secondary prevention in ICH survivors.

CONCLUSION

Appropriate recognition and treatment of modifiable risk factors for ICH recurrence might improve outcomes in ICH survivors. Ongoing randomized trials might provide novel insights and improve long-term management.

Middle meningeal artery embolization for pediatric chronic subdural hematoma under anticoagulant therapy with ventricular assist device: a case report

INTRODUCTION

Recently, the efficacy of middle meningeal artery (MMA) embolization for chronic subdural hematoma (cSDH) in the elderly has been reported. However, no previous reports of MMA embolization for cSDH in children with ventricular assist devices (VAD) have been published. Here, we report a case of MMA embolization for cSDH in a child with VAD.

CASE

A 15-month-old female was diagnosed with dilated cardiomyopathy at 7 months old. Soon, a VAD was inserted, and anticoagulant and antiplatelet therapy was started. Bilateral cSDH was observed at 15 months, and, 2 months later, an acute exacerbation of the right cSDH necessitated intracerebral hemorrhage removal. Afterwards, increased intracranial pressure occurred due to a contralateral subdural hematoma but, 4 months after intracerebral hemorrhage removal, CT showed new hemorrhaging in the left cSDH. MMA embolization was then conducted to prevent rebleeding in the hematoma. Selective angiography of the left MMA demonstrated stains of hematoma capsules from the frontal and parietal branches, which were embolized using liquid embolic material. During the procedure, the material migrated into the intracranial vessels via an undetected transdural anastomosis. Postoperatively, no new neurological abnormalities, including hemiparesis, were observed. Two months later, CT showed a decrease in hematoma size.

CONCLUSION

MMA embolization for cSDH in pediatric patients with VAD may be effective, if vigilance is maintained against transdural anastomoses.

Neurosurgical intervention in children with ventricular assist devices: A single-center case series review

BACKGROUND

The incidence of neurological complications related to ventricular assist devices (VAD) remains high and includes life-threatening conditions such as intracranial hemorrhage or ischemic stroke. Although no definitive management guidelines exist, operative interventions may be required for major neurological injuries.

AIMS

This case series describes the perioperative management of children at a single center who underwent neurosurgical procedures for major intracranial bleeds or ischemic strokes while on VAD support.

METHODS

A database review identified all pediatric VAD patients who underwent a neurosurgical procedure for an intracranial hemorrhage or ischemic stroke from April 2014 to January 2020. Data regarding patient characteristics, preoperative medical management, intraoperative anesthetic management, and postoperative outcomes were collected using retrospective chart review.

RESULTS

Ninety VADs were implanted in 78 patients. Five neurosurgical interventions were performed: four for intracranial hemorrhages and one for an ischemic stroke. All four patients with hemorrhages were receiving anticoagulation at the time of their event and the three patients on warfarin received emergent reversal with prothrombin concentrate complex and vitamin K. Three patients also received pre-procedural platelet transfusions. Two of the five procedures were emergent bedside external ventricular drain placements, and three were surgical operations. All three patients who underwent operative procedures received invasive hemodynamic monitoring and were supported with a combination of inotropes and afterload reduction. One patient required a massive blood product transfusion. The two patients who underwent external ventricular drain placement had no further surgical interventions and died from the severity of their neurological injuries. All three patients who underwent operative procedures survived to transplantation and discharge home.

CONCLUSIONS

Perioperative concerns for the anesthesiologist include VAD hemodynamic management, bleeding, VAD thrombosis, and prevention of secondary brain injury. A systematic, multidisciplinary approach to management is paramount to attain favorable outcomes.

Medical and Surgical Management of Left Ventricular Assist Device-Associated Intracranial Hemorrhage

OBJECTIVES

Management of left ventricular assist device (LVAD)-associated intracranial hemorrhage (ICH) is complicated by the competing concerns of hematoma expansion and the risk of thrombosis. Strategies include reversal or withholding of anticoagulation (AC) and neurosurgical (NSG) interventions. The consequences of these decisions can significantly impact both short- and long-term survival. Currently no guidelines exist. We reviewed medical and NSG practices following LVAD-associated ICH and analyzed outcomes.

MATERIALS AND METHODS

Retrospective analysis of data collected between 2012-2018 was performed. Survival probability following ICH was calculated using the Kaplan-Meier method.

RESULTS

Out of 283 patients, 32 (11%) had 34 ICHs: 16 intraparenchymal (IPH, 47%), 4 subdural (SDH, 12%), and 14 subarachnoid (SAH, 41%). IPH tended to occur sooner (median 138 [IQR 48 - 258] days post-LVAD placement) and be more neurologically devastating (mean GCS 11.4 [4.4]). Antithrombotics were reversed in 27 (79%); 1 thrombotic event occurred while off AC. Following resumption, re-hemorrhage occurred in 7 (25%), a median of 13 days (IQR 8-30) post-ICH. Five underwent NSG intervention and 6 (18%) went on to receive heart transplant. Overall, 30-day mortality was 26% (38% in IPH, 0% in SDH, and 29% in SAH), but rose to 44% at 6 months.

CONCLUSION

ICH is a common post-LVAD complication with high short- and long-term mortality, though ICH subtypes may not be equally devastating. Despite this, some may benefit from neurosurgical intervention and do well following cardiac transplant. Anticoagulation is frequently reversed after ICH. Resumption however should be approached cautiously in patients with LVADs given their possible baseline coagulopathy.

Anticoagulation in Critically Ill Adults during Extracorporeal Circulation

Extracorporeal circuits including renal replacement therapy, extracorporeal membrane oxygenation, and ventricular assist devices are increasingly used in critically ill patients. The need for anticoagulation to provide circuit patency and avoid thrombosis remains a challenging task for treating physicians. In the presence of overall low scientific evidence concerning the optimal anticoagulants, monitoring tests, and therapeutic target ranges, recommendations are largely expert opinions and most centers use individual "in-house" anticoagulation protocols. This review gives a practical view on current concepts of anticoagulation strategies in patients with extracorporeal assist devices.

Prothrombin Complex Concentrate for Emergent Reversal of Intracranial Hemorrhage in Patients with Ventricular Assist Devices

BACKGROUND

Intracranial hemorrhage (ICH) is a devastating complication for patients with ventricular assist devices (VADs). The safety of emergent anticoagulation reversal with four-factor prothrombin complex concentrate (PCC) and optimal timing of anticoagulation resumption are not clear. In addition, lactate dehydrogenase (LDH) is used as a biomarker for thromboembolic risk, but its utility in guiding anticoagulation management after reversal with PCC has not be described.

METHODS

We retrospectively reviewed a consecutive series of patients with VADs presenting with ICH between 2014 and 2020 who received four-factor PCC for rapid anticoagulation reversal. We collected the timing of PCC administration, timing of resumption of anticoagulation, survival, occurrence of thromboembolic events, and LDH levels throughout hospitalization.

RESULTS

We identified 16 ICH events in 14 patients with VADs treated with rapid anticoagulation reversal using four-factor PCC (11 intraparenchymal, 4 subdural, 1 subarachnoid hemorrhage). PCC was administered at a mean of 3.3 ± 0.3 h after imaging diagnosis of ICH. Overall mortality was 63%. Survivors had higher presenting Glasgow Coma Scale (median 15, interquartile range [IQR] 15-15 versus 14, IQR 8-14.7, P = 0.041). In all six instances where the patient survived, anticoagulation was resumed on average 9.16 ± 1.62 days after reversal. There were no thromboembolic events prior to resumption of anticoagulation. Three events occurred after anticoagulation resumption and within 3 months of reversal: VAD thrombosis in a patient with thrombosis at the time of reversal, ischemic stroke, and readmission for elevated LDH in the setting of subtherapeutic international normalized ratio.

CONCLUSIONS

Our limited series found no thromboembolic complications immediately following anticoagulation reversal with PCC prior to resumption of anticoagulation. LDH trends may be useful to monitor thromboembolic risk after reversal.

Antiplatelet and anticoagulation strategies for left ventricular assist devices

Left ventricular assist devices (LVAD) have revolutionized the management of advanced heart failure. However, complications rates remain high, among which hemorrhagic and thrombotic complications are the most important. Antiplatelet and anticoagulation strategies form a cornerstone of LVAD management and may directly affect LVAD complications. Concurrently, LVAD complications influence anticoagulation and anticoagulation management. A thorough understanding of device, patient, and management, including anticoagulation and antiplatelet therapies, are important in optimizing LVAD outcomes. This article provides a comprehensive state of the art review of issues related to antiplatelet and anticoagulation management in LVADs. We start with a historical overview, the epidemiology and pathophysiology of bleeding and thrombotic complications in LVADs. We then discuss platelet and anticoagulation biology followed by considerations prior to, during, and after LVAD implantation. This is followed by discussion of anticoagulation and the management of thrombotic and hemorrhagic complications. Specific problems, including management of heparin-induced thrombocytopenia, anticoagulant reversal, novel oral anticoagulants, artificial heart valves, and noncardiac surgeries are covered in detail.

Bionic women and men - Part 1: Cardiovascular lessons from heart failure patients implanted with left ventricular assist devices

NEW FINDINGS

What is the topic of this review? Patients with advanced heart failure who are implanted with left ventricular assist devices (LVADs) present an opportunity to understand the human circulation under extreme conditions. What advances does it highlight? LVAD patients have a unique circulation that is characterized by a reduced or even absent arterial pulse. The remarkable survival of these patients is accompanied by circulatory complications, including stroke, gastrointestinal bleeding and right-heart failure. Understanding the mechanisms related to the complications in LVAD patients will help the patients and also advance our fundamental understanding of the human circulation in general.

ABSTRACT

Some humans with chronic, advanced heart failure are surgically implanted with a left ventricular assist device (LVAD). Because the LVAD produces a continuous flow, a palpable pulse is often absent in these patients. This allows for a unique investigation of the human circulation and has created a controversy around the 'need' for a pulse. The medical debate has also generated a more generic, fundamental discussion into what is 'normal' arterial physiology and health. The comprehensive study and understanding of the arterial responses to drastically altered haemodynamics due to continuous-flow LVADs, at rest and during activity, presents an opportunity to significantly increase our current understanding of the fundamental components of arterial regulation (flow, blood pressure, sympathetic activity, endothelial function, pulsatility) in a way that could never have been studied previously. In a series of four articles, we summarize the talks presented at the symposium entitled 'Bionic women and men - Physiology lessons from implantable cardiac devices' presented at the 2019 Annual Meeting of The Physiological Society in Aberdeen, UK. The articles highlight the novel questions generated by physiological phenomena observed in LVAD patients and propose future areas of interest within the field of cardiovascular physiology.