Global Outcome in Patients With Left Ventricular Assist Devices

Association of bleeding with serotonergic antidepressants in patients receiving left ventricular assist device support

STUDY OBJECTIVE

This study sought to determine whether SA use is associated with bleeding in patients receiving CF-LVAD support.

DESIGN

A retrospective cohort analysis was conducted of all adult patients who received CF-LVAD implantation at our institution.

SETTING

Barnes-Jewish Hospital between July 1, 2009, and October 1, 2018.

PATIENTS

Patients at least 18 years of age who received a HVAD™ (HeartWare Corp.), HeartMate II™ (St. Jude Medical), or HeartMate 3™ (St. Jude Medical) CF-LVAD and survived for at least 30 days postoperatively were included.

INTERVENTION

Patients who received SAs (n = 203) were compared to those who did not (n = 391) from 30 days to 18 months following implantation. The primary outcome was the incidence of first bleeding events including gastrointestinal bleed (GIB), epistaxis, or intracerebral hemorrhage (ICH).

MEASUREMENTS AND MAIN RESULTS

During follow-up, 219 patients had bleeding events: 93 of 203 (45.8%) in the SA group versus 126 of 391 (32.2%) in the control group (p = 0.001). After adjustment for age, angiotensin-converting enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) use, history of bleeding events, history of smoking, and CF-LVAD type, SA use remained associated with bleeding (adjusted odds ratio: 1.75, 95% confidence interval: 1.22-2.51, p = 0.002). HeartMate 3™ patients experienced less bleeding than HeartMate II™ patients (adjusted odds ratio 0.46, 95% confidence interval: 0.23-0.90, p = 0.024).

CONCLUSIONS

In this single-center, retrospective cohort of patients supported with CF-LVADs, SA use was associated with the incidence of first bleeding events, primarily driven by GIB. Further studies are needed to assess any differential risk of bleeding among SA agents and to assess the utility of altering antithrombotic strategies.

Evaluation of aspirin platelet inhibition in left ventricular assist device population

INTRODUCTION

Aspirin therapy is recommended in durable left ventricular assist device (LVAD) patients to prevent thromboembolic complications. Up to 30% of patients treated with aspirin may demonstrate aspirin resistance, which has been related to thrombotic complications. However, it is unknown whether individual patients exhibit temporal alterations in aspirin sensitivity during LVAD support. We hypothesized that aspirin platelet inhibition would wane after the initial postimplant period.

METHODS

This was a retrospective, observational, single center study conducted at an academic medical center. This study evaluated changes in aspirin platelet inhibition over the first 6 months of LVAD support. Patients who underwent placement of centrifugal LVAD with aspirin platelet sensitivity assays were included for analysis. Aspirin responsiveness was assessed postimplant after 5 days, 3 months, and 6 months.

RESULTS

A total of 28 patients were included for analysis of which 7% of patients were aspirin resistant initially. At 3 months, 32% (odds ratio [OR], 6.1, p = .03) of patients were aspirin resistant and 28% (OR, 4.1, p = .1) at 6 months. Over the first 3 months postimplant, the odds of aspirin resistance increased sixfold and remained relatively constant at 6 months. Patients who were aspirin resistant and received an increase in aspirin dose at 3 months subsequently had a sensitive ARU at 6 months.

CONCLUSION

Aspirin responsiveness not only varies between patients but can significantly wane within individual LVAD patients over time. Additional study is needed to determine if monitoring aspirin resistance may prevent thrombotic complications after LVAD implantation.

Novel Acoustic Biomarker of Quality of Life in Left Ventricular Assist Device Recipients

Background Although technological advances to pump design have improved survival, left ventricular assist device (LVAD) recipients experience variable improvements in quality of life. Methods for optimizing LVAD support to improve quality of life are needed. We investigated whether acoustic signatures obtained from digital stethoscopes can predict patient-centered outcomes in LVAD recipients. Methods and Results We followed precordial sounds over 6 months in 24 LVAD recipients (8 HeartWare HVAD™, 16 HeartMate 3 [HM3]). Subjects recorded their precordial sounds with a digital stethoscope and completed a Kansas City Cardiomyopathy Questionnaire weekly. We developed a novel algorithm to filter LVAD sounds from recordings. Unsupervised clustering of LVAD-mitigated sounds revealed distinct groups of acoustic features. Of 16 HM3 recipients, 6 (38%) had a unique acoustic feature that we have termed the pulse synchronized sound based on its temporal association with the artificial pulse of the HM3. HM3 recipients with the pulse synchronized sound had significantly better Kansas City Cardiomyopathy Questionnaire scores at baseline (median, 89.1 [interquartile range, 86.2-90.4] versus 66.1 [interquartile range, 31.1-73.7]; P=0.03) and over the 6-month study period (marginal mean, 77.6 [95% CI, 66.3-88.9] versus 59.9 [95% CI, 47.9-70.0]; P<0.001). Mechanistically, the pulse synchronized sound shares acoustic features with patient-derived intrinsic sounds. Finally, we developed a machine learning algorithm to automatically detect the pulse synchronized sound within precordial sounds (area under the curve, 0.95, leave-one-subject-out cross-validation). Conclusions We have identified a novel acoustic biomarker associated with better quality of life in HM3 LVAD recipients, which may provide a method for assaying optimized LVAD support.

Ventricular Assist Devices and Their Usage as a Bridge to Recovery in Patients With Acute Cardiotoxicity and Cardiomyopathy

Cardiotoxicity can reduce the heart's function temporarily and is most commonly caused by radiation, immune reactions, and certain medications. Using a left ventricular assist device (LVAD) as a bridging therapy while waiting for cardiac recovery has been popular lately in patients who have a reduced ejection fraction after significant cardiac injury. Here we analyze the use of LVAD as a bridging therapy in three cases with chemotherapy-induced cardiotoxicity, acute myocarditis, and postpartum cardiac failure. Although LVADs are infamous for their device-related complications, the ejection fraction can increase up to 50% within days to months of usage without any complications in acute cardiotoxic patients that have no underlying significant risk factors or co-morbidities. Hence LVADs are excellent supportive devices while waiting for cardiac recovery, both in maintaining cardiac function and improving the associated organ failures.

A Rising Hope of an Artificial Heart: Left Ventricular Assisted Device - Outcome, Convenience, and Quality of Life

With the introduction of mechanical circulatory support, mainly continuous-flow left ventricular assisted devices (CF-LVAD), prolonging survival in end-stage heart failure patients can be seen in a new light. We also anticipate its use as a definitive therapy to overcome the limited donor organ resources for cardiac transplant. However, LVADs also have undesirable device-related complications and questionable improvement in the quality of life. In this review, we searched published articles using PubMed and Google Scholar to identify the complications and outcome of post-LVAD patients from 2014 to 2019. The studies we used included all study design types and a wide range of demographic variables focusing on age, sex, choice of LVAD as a bridge to cardiac transplant, or definitive therapy. For patients with New York Heart Association (NYHA) Class III B or IV or heart failure with reduced ejection fraction (HFrEF) with maximal medication therapy, there is a significant increase in mean ejection fraction from 4% to 6%. For patients with drug-induced cardiac toxicity or other causes of cardiac toxicity, with no significant risk factors, the ejection fraction increased to nearly 50% within 10-25 days of LVAD usage. There is also a substantial improvement in the quality of life in this literature review comparing to the pre-LVAD stage, as long as complications are taken into account. Data is limited for making an accurate judgment on the quality of life and functional capacity of LVADs. We found that the use of LVADs is not fully cost-effective, but still less financially burdening than a cardiac transplant. Although data from worldwide is limited and restricted to studies having a range of one to two years of follow-up, we conclude that LVADs are promising in improving cardiac function and the best bridging therapy available for patients waiting on a transplant.

Timing of Gastrointestinal Bleeding After Implantation of Left Ventricular Assist Devices Associates With Anatomic Location, Presentation, and Management

BACKGROUND & AIMS

Continuous-flow left ventricular assist devices (LVADs) for advanced heart failure have been associated with gastrointestinal bleeding (GIB). We examined the association between time of GIB after LVAD implantation and bleeding location (determined by endoscopy), etiology, and patient outcomes.

METHODS

We performed a retrospective study of consecutive patients who underwent implantation of continuous-flow LVADs from 2008 through 2015. We analyzed data on anatomic location of GIB, etiology, length of hospital stay, transfusion requirement, time to endoscopy, and readmission to the hospital within 30 days (30-day readmission).

RESULTS

GIB developed in 59 of the 271 patients (22%). Higher proportions of patients with GIB during their index hospitalization for LVAD implantation had upper or lower GIB (86.7%) than patients with GIB during a subsequent hospitalization (50.0%; P = .013). Patients with GIB during their index hospitalization also had lower rates of middle GIB (0 vs 20.5%; P = .052), higher rates of overt GIB (100% vs 63.6%; P = .006), longer hospital stays (24 days vs 11 days; P < .001), and more transfusions before endoscopy (7 units vs 4 units; P = .021) than patients with GIB during a subsequent hospitalization. There were no significant differences between groups in time to endoscopy (2 days vs 2.5 days) or 30-day readmission (6.7% vs 9.3%). Angiodysplasias were identified in 100% of patients with middle GIB compared to 48.5% of patients with upper or lower GIB (P < .001) in whom a bleeding lesion was identified.

CONCLUSION

In a retrospective study of patients who underwent implantation of continuous-flow LVADs, we found that timing of GIB associates with the location and severity of bleeding. Although patients with LVADs have an overall increase in risk of middle GIB, patients with GIB during their index LVAD hospitalization should undergo initial evaluation by upper endoscopy and colonoscopy, due to insufficient time for development of small bowel angiodysplasias. Patients who later develop GIB should be evaluated early for middle GI bleeding.

Quality of life with an LVAD: A misunderstood concept

The present study aims to synthesize current evidence on the impact of LVAD implantation on quality of life. Current evidence was systematically reviewed to obtain relevant quantitative and qualitative articles published after 2007. Sandelowski's recommended steps for meta-summary were used to analyze the 19 studies that met the inclusion criteria. LVADs can improve HF symptoms and some aspects of QoL. Emotional and physical adaptation involves many changes and learning to manage the device takes time. Functional limitations still exist and patients still lack independence. LVAD-related complications significantly impact QoL. Psychological distress remains high after implantation. LVADs significantly impact the caregiver as well and their perspective is not well heard in the existing evidence. It is important for providers to have ongoing, in-depth discussions with patients and their caregivers regarding treatment options, goals of care, anticipated end-of-life trajectories with an LVAD, possible LVAD-complications, and the caregiver burden associated with an LVAD.