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Nascimbene A, Bark D, Smadja DM. Hemocompatibility and biophysical interface of left ventricular assist devices and total artificial hearts. Blood 2024; 143:661-672. [PMID: 37890145 PMCID: PMC10900168 DOI: 10.1182/blood.2022018096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
ABSTRACT Over the past 2 decades, there has been a significant increase in the utilization of long-term mechanical circulatory support (MCS) for the treatment of cardiac failure. Left ventricular assist devices (LVADs) and total artificial hearts (TAHs) have been developed in parallel to serve as bridge-to-transplant and destination therapy solutions. Despite the distinct hemodynamic characteristics introduced by LVADs and TAHs, a comparative evaluation of these devices regarding potential complications in supported patients, has not been undertaken. Such a study could provide valuable insights into the complications associated with these devices. Although MCS has shown substantial clinical benefits, significant complications related to hemocompatibility persist, including thrombosis, recurrent bleeding, and cerebrovascular accidents. This review focuses on the current understanding of hemostasis, specifically thrombotic and bleeding complications, and explores the influence of different shear stress regimens in long-term MCS. Furthermore, the role of endothelial cells in protecting against hemocompatibility-related complications of MCS is discussed. We also compared the diverse mechanisms contributing to the occurrence of hemocompatibility-related complications in currently used LVADs and TAHs. By applying the existing knowledge, we present, for the first time, a comprehensive comparison between long-term MCS options.
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Affiliation(s)
- Angelo Nascimbene
- Advanced Cardiopulmonary Therapies and Transplantation, University of Texas, Houston, TX
| | - David Bark
- Division of Hematology and Oncology, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO
| | - David M. Smadja
- Université de Paris-Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France
- Hematology Department, Assistance Publique–Hôpitaux de Paris, Georges Pompidou European Hospital, Paris, France
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2
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Suehiro E, Shiomi N, Yatsushige H, Hirota S, Hasegawa S, Karibe H, Miyata A, Kawakita K, Haji K, Aihara H, Yokobori S, Inaji M, Maeda T, Onuki T, Oshio K, Komoribayashi N, Suzuki M. The current status of reversal therapy in Japan for elderly patients with head injury treated with antithrombotic agents: A prospective multicenter observational study. Heliyon 2024; 10:e25193. [PMID: 38318008 PMCID: PMC10839600 DOI: 10.1016/j.heliyon.2024.e25193] [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] [Received: 06/09/2023] [Revised: 12/18/2023] [Accepted: 01/22/2024] [Indexed: 02/07/2024] Open
Abstract
Background Acute exacerbation of head injury in elderly patients due to use of antithrombotic agents has become a concern in countries with aging populations. Reversal agents are recommended for treatment, but its usage is unclear. Therefore, we conducted a prospective observational study in this patient population to monitor usage of reversal therapy. Methods The subjects were 721 elderly patients aged ≥65 years old who were hospitalized in 15 centers from December 2019 to May 2021. Patients were divided into groups who did not receive antithrombotic agents (Group A), who received antithrombotic agents, but did not receive reversal therapy (Group B), and were treated with antithrombotic agents and reversal therapy (Group C). Age, gender, mechanism of injury, neurologic and imaging findings on admission, clinical course after admission and surgery, outcomes and complications were compared among these groups. Time from injury to reversal therapy was examined based on outcomes to investigate trends in the timing of administration of the reversal agent. Results Acute exacerbation during the clinical course occurred in 9.8 %, 15.8 % and 31.0 % of cases in Groups A, B and C, respectively, and differed significantly among the groups. On head CT, the incidences of hematoma were 35.7 %, 36.5 % and 60.4 %, respectively, with this incidence being significantly higher in Group C; and the respective rates of craniotomy were 18.8 %, 14.0 % and 50.9 %, again with this rate being significantly higher in Group C. The good outcome and mortality rates were 57.1 %, 52.5 % and 35.8 %, and 14.5 %, 18.0 % and 24.5 %, respectively, and both were poorest in Group C. Times from injury to treatment with a reversal agent were significantly shorter in patients without compared to those with acute exacerbation (405.9 vs. 880.8 min) and in patients with favorable outcomes compared to those with unfavorable outcomes (261.9 vs. 543.4 min). Conclusion Similarly to previous studies, the incidence of acute exacerbation was increased by use of antithrombotic agents. These results suggest that patients in Japan who require hematoma evacuation due to symptom exacerbation tend to be treated with reversal agents. Although it is difficult to assess the efficacy of reversal therapy from this study, earlier treatment with reversal agents before the occurrence of acute exacerbation may be useful to improve outcomes.
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Affiliation(s)
- Eiichi Suehiro
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Japan
| | - Naoto Shiomi
- Emergency Medical Care Center, Saiseikai Shiga Hospital, Ritto, Japan
| | - Hiroshi Yatsushige
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Japan
| | - Shin Hirota
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Shu Hasegawa
- Department of Neurosurgery, Kumamoto Red Cross Hospital, Kumamoto, Japan
| | - Hiroshi Karibe
- Department of Neurosurgery, Sendai City Hospital, Sendai, Japan
| | - Akihiro Miyata
- Department of Neurosurgery, Chiba Emergency Medical Center, Chiba, Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Kita-gun, Japan
| | - Kohei Haji
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan
| | - Hideo Aihara
- Department of Neurosurgery, Hyogo prefectual Kakogawa Medical Center, Kakogawa, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Nippon Medical School, Bunkyo-ku, Japan
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University, Bunkyo-ku, Japan
| | - Takeshi Maeda
- Department of Neurological Surgery, Nihon University School of Medicine, Itabashi-ku, Japan
| | - Takahiro Onuki
- Department of Emergency Medicine, Teikyo University School of Medicine, Itabashi-ku, Japan
| | - Kotaro Oshio
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Nobukazu Komoribayashi
- Iwate Prefectural Advanced Critical Care and Emergency Center, Iwate Medical University, Yahaba, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan
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3
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Sennhauser S, Sridharan L. Left Ventricular Assist Device Emergencies: Diagnosis and Management. Crit Care Clin 2024; 40:159-177. [PMID: 37973352 DOI: 10.1016/j.ccc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Durable left ventricular assist devices (LVADs) are a virtually limitless advanced therapy option for an increasingly growing population of patients with end-stage advanced heart failure. As of 2019, 30% to 40% of all patients diagnosed with heart failure were categorized as New York Heart Association class III or IV. In 2018 more than 3.2 million office visits and 1.4 million emergency department visits carried a primary diagnosis of heart failure. Given the rapid growth of the LVAD population, facility in the diagnosis and management of common perioperative and outpatient LVAD emergencies has become of paramount importance in a variety of clinical settings.
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Affiliation(s)
- Susie Sennhauser
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
| | - Lakshmi Sridharan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine.
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4
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Phan J, Elgendi K, Javeed M, Aranda JM, Ahmed MM, Vilaro J, Al-Ani M, Parker AM. Thrombotic and Hemorrhagic Complications Following Left Ventricular Assist Device Placement: An Emphasis on Gastrointestinal Bleeding, Stroke, and Pump Thrombosis. Cureus 2023; 15:e51160. [PMID: 38283491 PMCID: PMC10811971 DOI: 10.7759/cureus.51160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
The left ventricular assist device (LVAD) is a mechanical circulatory support device that supports the heart failure patient as a bridge to transplant (BTT) or as a destination therapy for those who have other medical comorbidities or complications that disqualify them from meeting transplant criteria. In patients with severe heart failure, LVAD use has extended survival and improved signs and symptoms of cardiac congestion and low cardiac output, such as dyspnea, fatigue, and exercise intolerance. However, these devices are associated with specific hematologic and thrombotic complications. In this manuscript, we review the common hematologic complications of LVADs.
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Affiliation(s)
- Joseph Phan
- Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Kareem Elgendi
- Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Masi Javeed
- Internal Medicine, HCA Healthcare/University of South Florida Morsani College of Medicine, Graduate Medical Education: Bayonet Point Hospital, Hudson, USA
| | - Juan M Aranda
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Mustafa M Ahmed
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Juan Vilaro
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Mohammad Al-Ani
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Alex M Parker
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
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Bae DJ, Willey JZ, Ibeh C, Yuzefpolskaya M, Colombo PC. Stroke and Mechanical Circulatory Support in Adults. Curr Cardiol Rep 2023; 25:1665-1675. [PMID: 37921947 DOI: 10.1007/s11886-023-01985-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 11/05/2023]
Abstract
PURPOSE OF THE REVIEW Short-term and durable mechanical circulatory support (MCS) devices represent life-saving interventions for patients with cardiogenic shock and end-stage heart failure. This review will cover the epidemiology, risk factors, and treatment of stroke in this patient population. RECENT FINDINGS Short-term devices such as intra-aortic balloon pump, Impella, TandemHeart, and Venoatrial Extracorporal Membrane Oxygenation, as well as durable continuous-flow left ventricular assist devices (LVADs), improve cardiac output and blood flow to the vital organs. However, MCS use is associated with high rates of complications, including ischemic and hemorrhagic strokes which carry a high risk for death and disability. Improvements in MCS technology have reduced but not eliminated the risk of stroke. Mitigation strategies focus on careful management of anti-thrombotic therapies. While data on therapeutic options for stroke are limited, several case series reported favorable outcomes with thrombectomy for ischemic stroke patients with large vessel occlusions, as well as with reversal of anticoagulation for those with hemorrhagic stroke. Stroke in patients treated with MCS is associated with high morbidity and mortality. Preventive strategies are targeted based on the specific form of MCS. Improvements in the design of the newest generation device have reduced the risk of ischemic stroke, though hemorrhagic stroke remains a serious complication.
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Affiliation(s)
- David J Bae
- Division of Medicine, Center for Advanced Cardiac Care, Columbia University, New York, NY, USA
| | - Joshua Z Willey
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Irving Medical Center, New York, NY, 10032, USA.
| | - Chinwe Ibeh
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Melana Yuzefpolskaya
- Division of Medicine, Center for Advanced Cardiac Care, Columbia University, New York, NY, USA
| | - Paolo C Colombo
- Division of Medicine, Center for Advanced Cardiac Care, Columbia University, New York, NY, USA
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Suehiro E, Ishihara H, Kogeichi Y, Ozawa T, Haraguchi K, Honda M, Honda Y, Inaba M, Kabeya R, Kanda N, Koketsu K, Murakami N, Nakamoto H, Oshio K, Saigusa K, Shuto T, Sugiyama S, Suzuyama K, Terashima T, Tsuura M, Nakada M, Kobata H, Higashi T, Sakai N, Suzuki M. Retrospective Observational Study of Patients With Subdural Hematoma Treated With Idarucizumab. Neurotrauma Rep 2023; 4:790-796. [PMID: 38028276 PMCID: PMC10659013 DOI: 10.1089/neur.2023.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Use of anticoagulants is increasing with the aging of societies. The safe first-line drug is likely to be a direct oral anticoagulant (DOAC), but outcomes of treatment of traumatic brain injury (TBI) with anticoagulants are uncertain. Therefore, we examined the clinical effect of idarucizumab as reversal therapy in elderly patients with TBI who were treated with dabigatran. A retrospective multi-center observational study was performed in patients ≥65 years of age who developed acute traumatic subdural hematoma during treatment with dabigatran and underwent reversal therapy with idarucizumab. The items examined included patient background, neurological and imaging findings at arrival, course after admission, complications, and outcomes. A total of 23 patients were enrolled in the study. The patients had a mean age of 78.9 years. Cause of TBI was fall in 60.9% of the subjects. Mean Glasgow Coma Scale score at arrival was 8.7; anisocoria was present in 31.8% of cases. Exacerbation of consciousness was found in 30.4%, but only in 13.3% of subjects treated with idarucizumab before consciousness and imaging findings worsened. Dabigatran was discontinued in 81.8% of cases after hematoma development, with a mean withdrawal period of 12.1 days. The favorable outcome rate was 21.7%, and mortality was 39.1%. In multi-variate analysis, timing of idarucizumab administration was associated with a favorable outcome. There were ischemic complications in 3 cases (13.1%), and all three events occurred ≥7 days after administration of idarucizumab. These findings suggest that in cases that develop hematoma during treatment with dabigatran, it is important to administer idarucizumab early and restart dabigatran after conditions stabilize.
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Affiliation(s)
- Eiichi Suehiro
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan
| | - Yohei Kogeichi
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | | | - Koichi Haraguchi
- Department of Neurosurgery, Hakodate Shintoshi Hospital, Hakodate, Japan
| | - Masaru Honda
- Department of Neurosurgery, Shunan Memorial Hospital, Kudamatsu, Japan
| | - Yumie Honda
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Japan
| | - Makoto Inaba
- Department of Neurosurgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Ryusuke Kabeya
- Department of Neurosurgery, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Naoaki Kanda
- Department of Neurology, Imamura General Hospital, Kagoshima, Japan
| | - Kenta Koketsu
- Department of Neurological Surgery, Chiba Hokuso Hospital, Nippon Medical School, Inzai, Japan
| | - Nobukuni Murakami
- Department of Neurosurgery, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
| | | | - Kotaro Oshio
- Department of Neurosurgery, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
| | - Kuniyasu Saigusa
- Department of Neurosurgery, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Takashi Shuto
- Department of Neurosurgery, Yokohama Rosai Hospital, Yokohama, Japan
| | - Shuichi Sugiyama
- Department of Neurosurgery, Yamaguchi Rosai Hospital, Sanyoonoda, Japan
| | - Kenji Suzuyama
- Department of Neurosurgery, Karatsu Red Cross Hospital, Karatsu, Japan
| | - Tsuguaki Terashima
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Mitsuharu Tsuura
- Department of Neurosurgery, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Hitoshi Kobata
- Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Toshio Higashi
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Michiyasu Suzuki
- Department of Advanced ThermoNeuroBiology, Yamaguchi Graduate School of Medicine, Ube, Japan
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Jung IH, Yun JH, Kim SJ, Chung J, Lee SK. Anticoagulation and Antiplatelet Agent Resumption Timing following Traumatic Brain Injury. Korean J Neurotrauma 2023; 19:298-306. [PMID: 37840609 PMCID: PMC10567523 DOI: 10.13004/kjnt.2023.19.e42] [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] [Received: 05/09/2023] [Revised: 06/30/2023] [Accepted: 07/29/2023] [Indexed: 10/17/2023] Open
Abstract
Traumatic brain injury (TBI) is a major global health concern. Due to the increase in TBI incidence and the aging population, an increasing number of patients with TBI are taking antithrombotic agents for their underlying disease. When TBI occurs in patients with these diseases, there is a conflict between the disease, which requires an antithrombotic effect, and the neurosurgeon, who must minimize intracranial hemorrhage. Nevertheless, there are no clear guidelines for the reversal or resumption of antithrombotic agents when TBI occurs in patients taking antithrombotic agents. In this review article, we intend to classify antithrombotic agents and provide information on them. We also share previous studies on the reversal and resumption of antithrombotic agents in patients with TBI to help neurosurgeons in this dilemma.
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Affiliation(s)
- In-Ho Jung
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Jung-Ho Yun
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Sung Jin Kim
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Jaewoo Chung
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Sang Koo Lee
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
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Li Y, Liu X, Chen S, Wang J, Pan C, Li G, Tang Z. Effect of antiplatelet therapy on the incidence, prognosis, and rebleeding of intracerebral hemorrhage. CNS Neurosci Ther 2023; 29:1484-1496. [PMID: 36942509 PMCID: PMC10173719 DOI: 10.1111/cns.14175] [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: 02/02/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVE Antiplatelet medications are increasingly being used for primary and secondary prevention of ischemic attacks owing to the increasing prevalence of ischemic stroke occurrences. Currently, many patients receive antiplatelet therapy (APT) to prevent thromboembolic events. However, long-term use of APT might also lead to an increased occurrence of intracerebral hemorrhage (ICH) and affect the prognosis of patients with ICH. Furthermore, some research suggest that restarting APT for patients who have previously experienced ICH may result in rebleeding events. The precise relationship between APT and ICH remains unknown. METHODS We searched PubMed for the most recent related literature and summarized the findings from various studies. The search terms included "antiplatelet," "intracerebral hemorrhage," "cerebral microbleeds," "hematoma expansion," "recurrent," and "reinitiate." Clinical studies involving human subjects were ultimately included and interpreted in this review, and animal studies were not discussed. RESULTS When individuals are administered APT, the risk of thrombotic events should be weighted against the risk of bleeding. In general, for some patients' concomitant with risk factors of thrombotic events, the advantages of antiplatelet medication may outweigh the inherent risk of rebleeding. However, the use of antiplatelet medications for other patients with a higher risk of bleeding should be carefully evaluated and closely monitored. In the future, a quantifiable system for assessing thrombotic risk and bleeding risk will be necessary. After evaluation, the appropriate time to restart APT for ICH patients should be determined to prevent underlying ischemic stroke events. According to the present study results and expert experience, most patients now restart APT at around 1 week following the onset of ICH. Nevertheless, the precise time to restart APT should be chosen on a case-by-case basis as per the patient's risk of embolic events and recurrent bleeding. More compelling evidence-based medicine evidence is needed in the future. CONCLUSION This review thoroughly discusses the relationship between APT and the development of ICH, the impact of APT on the course and prognosis of ICH patients, and the factors influencing the decision to restart APT after ICH. However, different studies' conclusions are inconsistent due to the differences in quality control. To support future clinical decisions, more large-scale randomized controlled trials are required.
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Affiliation(s)
- Yunjie Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jingyi Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gaigai Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Trachtenberg B, Cowger J. HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support. J Card Fail 2023; 29:479-502. [PMID: 36828256 DOI: 10.1016/j.cardfail.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/24/2023]
Abstract
The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacologic therapies administered in the preoperative, intraoperative, postoperative and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable MCS, focusing on pharmacological therapies administered to patients on continuous flow LVADs. While quality data in the LVAD population are few, the utilization of guideline directed heart failure medical therapies (GDMT) and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacologic regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications are addressed. Finally, this document touches on important potential pharmacological interactions from anti-depressants, herbal and nutritional supplements of relevance to providers of patients on LVAD support.
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Affiliation(s)
- Barry Trachtenberg
- Houston Methodist Heart and Vascular Center, Methodist J.C. Walter Transplant Center.
| | - Jennifer Cowger
- Medical Director, Mechanical Circulatory Support Program, Codirector, Cardiac Critical Care, Henry Ford Advanced Heart Failure Program.
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10
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Neurologic Complications in Patients With Left Ventricular Assist Devices. Can J Cardiol 2023; 39:210-221. [PMID: 36400374 PMCID: PMC9905352 DOI: 10.1016/j.cjca.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Left ventricular assist device (LVAD) use has revolutionised the care of patients with advanced heart failure, allowing more patients to survive until heart transplantation and providing improved quality for patients unable to undergo transplantation. Despite these benefits, improvements in device technology, and better clinical care and experience, LVADs are associated with neurologic complications. This review provides information on the incidence, risk factors, and management of neurologic complications among LVAD patients. Although scant guidelines exist for the evaluation and management of neurologic complications in LVAD patients, a high index of suspicion can prompt early detection of neurologic complications which may improve overall neurologic outcomes. A better understanding of the implications of continuous circulatory flow on systemic and cerebral vasculature is necessary to reduce the common occurrence of neurologic complications in this population.
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11
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Toffali M, Carbone F, Fainardi E, Morotti A, Montecucco F, Liberale L, Padovani A. Secondary prevention after intracerebral haemorrhage. Eur J Clin Invest 2023; 53:e13962. [PMID: 36721900 DOI: 10.1111/eci.13962] [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: 12/21/2022] [Revised: 01/22/2023] [Accepted: 01/28/2023] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Maddalena Toffali
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Andrea Morotti
- Department of Neurological Sciences and Vision, Neurology Unit, ASST Spedali Civili, Brescia, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Department of Neurological Sciences and Vision, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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12
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 326] [Impact Index Per Article: 163.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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13
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Hayward C, Adachi I, Baudart S, Davis E, Feller ED, Kinugawa K, Klein L, Li S, Lorts A, Mahr C, Mathew J, Morshuis M, Müller M, Ono M, Pagani FD, Pappalardo F, Rich J, Robson D, Rosenthal DN, Saeed D, Salerno C, Sauer AJ, Schlöglhofer T, Tops L, VanderPluym C. Global Best Practices Consensus: Long-term Management of HeartWare Ventricular Assist Device Patients. J Thorac Cardiovasc Surg 2022; 164:1120-1137.e2. [DOI: 10.1016/j.jtcvs.2022.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/24/2022] [Accepted: 03/24/2022] [Indexed: 11/15/2022]
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14
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Cho SM, Floden D, Wallace K, Hiivala N, Joseph S, Teuteberg J, Rogers JG, Pagani FD, Mokadam N, Tirschwell D, Li S, Starling RC, Mahr C, Uchino K. Long-Term Neurocognitive Outcome in Patients With Continuous Flow Left Ventricular Assist Device. JACC-HEART FAILURE 2021; 9:839-851. [PMID: 34509403 DOI: 10.1016/j.jchf.2021.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The authors sought to examine the long-term cognitive outcome of patients with continuous flow left ventricular assist device (CF-LVAD). BACKGROUND Data on long-term neurocognitive outcome in LVAD are limited. We examined the neurocognitive outcome of patients who received a CF-LVAD as destination therapy. METHODS Patients with HeartWare (HVAD) and HeartMate II who were enrolled in the ENDURANCE and ENDURANCE Supplemental trials were eligible. Cognition was evaluated with neuropsychological testing preoperatively and at 6, 12, and 24 months after implantation. General linear models identified demographic, disease, and treatment factors that predicted decline on each neurocognitive measure. RESULTS Of 668 patients who completed baseline testing and at least 1 follow-up evaluation, 552 were impaired at baseline on at least 1 cognitive measure. At each follow-up, approximately 23% of tested patients declined and 20% improved relative to baseline on at least 1 cognitive measure. Of those who were intact at baseline, only 10%-12% declined in delayed memory and 11%-16% declined in executive function at all 3 follow-ups. For patients impaired at baseline, delayed memory decline was associated with the HVAD device and male sex, whereas executive function decline was associated with the HVAD device and stroke during CF-LVAD support. For patients intact at baseline, male sex and history of hypertension were associated with decline in immediate memory and executive function, respectively. CONCLUSIONS Neurocognitive function remained stable or improved for most patients (∼80%) with CF-LVAD at 6, 12, and 24 months after implantation. Male sex, hypertension, HVAD, and stroke were associated with cognitive decline.
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Affiliation(s)
- Sung-Min Cho
- Neurocritical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Darlene Floden
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Susan Joseph
- Department of Cardiology, Baylor Scott & White Heart and Vascular Hospital, Dallas, Texas, USA
| | - Jeffrey Teuteberg
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Joseph G Rogers
- Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Nahush Mokadam
- Department of Cardiac Surgery, The Ohio State University, Columbus, Ohio, USA
| | - David Tirschwell
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Song Li
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Randall C Starling
- Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Claudius Mahr
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Ken Uchino
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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15
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Ibeh C, Tirschwell DL, Mahr C, Creutzfeldt CJ. Medical and Surgical Management of Left Ventricular Assist Device-Associated Intracranial Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106053. [PMID: 34418673 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106053] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/02/2021] [Accepted: 08/05/2021] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Chinwe Ibeh
- Department of Neurology, Columbia University Irving Medical Center, 710 W 168th St, New York, NY 10032, United States.
| | - David L Tirschwell
- Department of Neurology, University of Washington, Seattle, WA, United States.
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States.
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16
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Strobel AM, Alblaihed L. Cardiac Emergencies in Kids. Emerg Med Clin North Am 2021; 39:605-625. [PMID: 34215405 DOI: 10.1016/j.emc.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Encountering a child with congenital heart disease after surgical palliation in the emergency department, specifically the single-ventricle or ventricular assist device, without a basic familiarity of these surgeries can be extremely anxiety provoking. Knowing what common conditions or complications may cause these children to visit the emergency department and how to stabilize will improve the chance for survival and is the premise for this article, regardless of practice setting.
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Affiliation(s)
- Ashley M Strobel
- Department of Emergency Medicine, University of Minnesota Medical School, Hennepin County Medical Center, University of Minnesota Masonic Children's Hospital, 701 South Park Avenue R2.123, Minneapolis, MN 55414, USA.
| | - Leen Alblaihed
- Department of Emergency Medicine, University of Maryland School of Medicine, University of Maryland Upper Chesapeake Medical System, 500 Upper Chesapeake Drive, Bel Air, MD 21014, USA
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17
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Chiarini G, Cho SM, Whitman G, Rasulo F, Lorusso R. Brain Injury in Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach. Semin Neurol 2021; 41:422-436. [PMID: 33851392 DOI: 10.1055/s-0041-1726284] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) represents an established technique to provide temporary cardiac and/or pulmonary support. ECMO, in veno-venous, veno-arterial or in extracorporeal carbon dioxide removal modality, is associated with a high rate of brain injuries. These complications have been reported in 7 to 15% of adults and 20% of neonates, and are associated with poor survival. Thromboembolic events, loss of cerebral autoregulation, alteration of the blood-brain barrier, and hemorrhage related to anticoagulation represent the main causes of severe brain injury during ECMO. The most frequent forms of acute neurological injuries in ECMO patients are intracranial hemorrhage (2-21%), ischemic stroke (2-10%), seizures (2-6%), and hypoxic-ischemic brain injury; brain death may also occur in this population. Other frequent complications are infarction (1-8%) and cerebral edema (2-10%), as well as neuropsychological and psychiatric sequelae, including posttraumatic stress disorder.
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Affiliation(s)
- Giovanni Chiarini
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frank Rasulo
- Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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18
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Cho SM, Tahsili-Fahadan P, Kilic A, Choi CW, Starling RC, Uchino K. A Comprehensive Review of Risk Factor, Mechanism, and Management of Left Ventricular Assist Device-Associated Stroke. Semin Neurol 2021; 41:411-421. [PMID: 33851393 DOI: 10.1055/s-0041-1726328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The use of left ventricular assist devices (LVADs) has been increasing in the last decade, along with the number of patients with advanced heart failure refractory to medical therapy. Ischemic stroke and intracranial hemorrhage remain the leading causes of morbidity and mortality in LVAD patients. Despite the common occurrence and the significant outcome impact, underlying mechanisms and management strategies of stroke in LVAD patients are controversial. In this article, we review our current knowledge on pathophysiology and risk factors of LVAD-associated stroke, outline the diagnostic approach, and discuss treatment strategies.
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Affiliation(s)
- Sung-Min Cho
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pouya Tahsili-Fahadan
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Neuroscience Intensive Care Unit, Department of Medicine, Virginia Commonwealth University, Inova Fairfax Medical Campus, Falls Church, Virginia.,Neuroscience Research, Neuroscience and Spine Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Ahmet Kilic
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun Woo Choi
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ken Uchino
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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19
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Lai GY, Maas MB, Leong CR, Liotta EM, Rich JD, Pham DT, Vorovich EE, Naidech AM, Jahromi BS, Potts MB. Prothrombin Complex Concentrate for Emergent Reversal of Intracranial Hemorrhage in Patients with Ventricular Assist Devices. Neurocrit Care 2021; 35:506-517. [PMID: 33821403 DOI: 10.1007/s12028-021-01210-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/18/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Grace Y Lai
- Department of Neurological Surgery, Northwestern Memorial Hospital, 676 N. St. Clair St., Suite 2210, Chicago, IL, USA
| | - Matthew B Maas
- Department of Neurology (Stroke and Neurocritical Care), Northwestern Memorial Hospital, Chicago, IL, USA
| | | | - Eric M Liotta
- Department of Neurology (Stroke and Neurocritical Care), Northwestern Memorial Hospital, Chicago, IL, USA
| | - Jonathan D Rich
- Division of Cardiology, Department of Medicine, Northwestern Memorial Hospital, Chicago, IL, USA.,Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Duc T Pham
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, USA.,Department of Cardiac Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Esther E Vorovich
- Division of Cardiology, Department of Medicine, Northwestern Memorial Hospital, Chicago, IL, USA.,Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Andrew M Naidech
- Department of Neurology (Stroke and Neurocritical Care), Northwestern Memorial Hospital, Chicago, IL, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern Memorial Hospital, 676 N. St. Clair St., Suite 2210, Chicago, IL, USA.,Department of Radiology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern Memorial Hospital, 676 N. St. Clair St., Suite 2210, Chicago, IL, USA. .,Department of Radiology, Northwestern Memorial Hospital, Chicago, IL, USA.
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20
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Shoskes A, Whitman G, Cho SM. Neurocritical Care of Mechanical Circulatory Support Devices. Curr Neurol Neurosci Rep 2021; 21:20. [PMID: 33694065 DOI: 10.1007/s11910-021-01107-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) devices have demonstrated improved survival outcomes in otherwise refractory cardiopulmonary failure but are associated with significant neurologic morbidity and mortality. This review aims to characterize MCS-associated brain injury and discuss the neurocritical care of this population. RECENT FINDINGS We found no practice guidelines or specific management strategies for the neurocritical care of patients with MCS devices. Acute brain injury was commonly observed in short-term and durable MCS devices. There is emerging evidence that a standardized neurological monitoring and management algorithm for MCS device-associated brain injury is feasible and potentially improves neurological outcomes. While MCS devices are associated with significant neurologic morbidity and mortality, there is scant evidence regarding optimal neuromonitoring and neurocritical care. With the increase in use of MCS devices for both short-term and durable applications, improved outcomes will depend on early identification and intervention of neurologic complications and further research into their pathophysiology.
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Affiliation(s)
- Aaron Shoskes
- Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Sung-Min Cho
- Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Division of Neuroscience Critical Care, Johns Hopkins University, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
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21
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Loyaga-Rendon RY, Kazui T, Acharya D. Antiplatelet and anticoagulation strategies for left ventricular assist devices. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:521. [PMID: 33850918 PMCID: PMC8039667 DOI: 10.21037/atm-20-4849] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
| | - Toshinobu Kazui
- Division of Cardiothoracic Surgery, University of Arizona, Tucson, AZ, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, USA
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22
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Carroll AH, Ramirez MP, Dowlati E, Mueller KB, Borazjani A, Chang JJ, Felbaum DR. Management of Intracranial Hemorrhage in Patients with a Left Ventricular Assist Device: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2020; 30:105501. [PMID: 33271486 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intracranial hemorrhage (ICH) has been reported to occur in up to 23% of patients with left ventricular assist devices (LVADs). Currently, limited data exists to guide neurosurgical management strategies to optimize outcomes in patients with an LVAD who develop ICH. METHODS A systematic review and meta-analysis of the literature was performed to evaluate the mortality rate in these patients following medical and/or surgical management and to evaluate antithrombotic reversal and resumption strategies after hemorrhage. RESULTS 17 studies reporting on 3869 LVAD patients and 545 intracranial hemorrhages spanning investigative periods from 1996 to 2019 were included. The rate of ICH in LVAD patients was 10.6% (411/3869) with 58.6% (231/394) being intraparenchymal hemorrhage (IPH), 23.6% (93/394) subarachnoid hemorrhage (SAH), and 15.5% (61/394) subdural hemorrhage (SDH). Total mortality rates for surgical management 65.6% (40/61) differed from medical management at 45.2% (109/241). There was an increased relative risk of mortality (RR=1.45, 95% CI: 1.10-1.91, p = 0.01) for ICH patients undergoing surgical intervention. The hemorrhage subtype most frequently managed with anticoagulation reversal was IPH 81.8% (63/77), followed by SDH 52.2% (12/23), and SAH 39.1% (18/46). Mean number of days until antithrombotic resumption ranged from 6 to 10.5 days. CONCLUSION Outcomes remain poor, specifically for those undergoing surgery. As experience with this population increases, prospective studies are warranted to contribute to management and prognostication .
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Affiliation(s)
| | | | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA.
| | - Kyle B Mueller
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School at Brown University, Providence, R.I., USA
| | - Ali Borazjani
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington D.C., USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, D.C., USA; Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, D.C., USA
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23
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Zima LA, Fotso CM, Parikh V, Sheinberg D, Monterey M, Choi HA, Kitagawa R. Cerebral hemorrhage in the LVAD patient: A case series and literature review. Clin Neurol Neurosurg 2020; 197:106094. [DOI: 10.1016/j.clineuro.2020.106094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
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24
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Melmed KR, Mondellini G, Roh D, Boehme A, Park S, Yuzefpolkya M, Naka Y, Uriel N, Agarwal S, Connolly ES, Claassen J, Colombo PC, Willey JZ. Clinical Impact of Hematoma Expansion in Left Ventricular Assist Device Patients. World Neurosurg 2020; 143:e384-e390. [PMID: 32745643 DOI: 10.1016/j.wneu.2020.07.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hematoma expansion (HE) is associated with poor outcome in patients with intracerebral hemorrhage (ICH), but the impact on patients with an left ventricular assist device (LVAD) is unknown. We aimed to define the occurrence of HE in the LVAD population and to determine the association between HE and mortality. METHODS We performed a retrospective cohort study of LVAD patients and intentionally matched anticoagulated controls without LVAD admitted to Columbia University Irving Medical Center with ICH between 2008 and 2019. We compared HE occurrence between patients with an LVAD and those without an LVAD using regression modeling, adjusting for factors known to influence HE. We evaluated pump thrombosis following anticoagulation reversal. We examined the association between HE and hospital mortality using Poisson regression modeling adjusting for factors associated with poor outcome. RESULTS Among 605 patients with an LVAD, we identified 28 patients with ICH meeting the study's inclusion criteria. Our LVAD ICH cohort was predominantly male (71%), with a mean age of 56 ± 10 years. The median baseline hematoma size was 20.1 mL3 (interquartile range [IQR], 8.6-46.9 mL3), and the median ICH score was 1 (IQR, 1-2). There was no significant difference in occurrence of HE in LVAD patients and matched non-LVAD patients (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.4-4.2). There was an association between HE and in-hospital mortality in LVAD patients (adjusted OR, 4.8; 95% CI, 1.4-6.2). CONCLUSIONS HE occurrence appears to be similar in LVAD and non-LVAD patients. HE has a significant impact on LVAD ICH mortality, underscoring the importance of adequate coagulopathy reversal and blood pressure management in these patients.
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Affiliation(s)
- Kara R Melmed
- Departments of Neurology and Neurosurgery, New York University School of Medicine, New York, New York, USA; Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.
| | - Giulio Mondellini
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - David Roh
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Amelia Boehme
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Melana Yuzefpolkya
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Sachin Agarwal
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - E Sander Connolly
- Department of Neurosurgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Jan Claassen
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Joshua Z Willey
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
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25
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