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Li X, Kondray V, Tavri S, Ruhparwar A, Azeze S, Dey A, Partovi S, Rengier F. Role of imaging in diagnosis and management of left ventricular assist device complications. Int J Cardiovasc Imaging 2019; 35:1365-1377. [PMID: 30830527 DOI: 10.1007/s10554-019-01562-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/11/2019] [Indexed: 12/14/2022]
Abstract
Heart failure is a clinical condition that is associated with significant morbidity and mortality. With the advent of left ventricular assist device (LVAD), an increasing number of patients have received an artificial heart both as a bridge-to-therapy and as a destination therapy. Clinical trials have shown clear survival benefits of LVAD implantation. However, the increased survival benefits and improved quality of life come at the expense of an increased complication rate. Common complications include perioperative bleeding, infection, device thrombosis, gastrointestinal bleeding, right heart failure, and aortic hemodynamic changes. The LVAD-associated complications have unique pathophysiology. Multiple imaging modalities can be employed to investigate the complications, including computed tomography (CT), positron emission tomography-computed tomography (PET-CT), catheter angiography and echocardiography. Imaging studies not only help ascertain diagnosis and evaluate the severity of disease, but also help direct relevant clinical management and predict prognosis. In this article, we aim to review the common LVAD complications, present the associated imaging features and discuss the role of imaging in their management.
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Affiliation(s)
- Xin Li
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Victor Kondray
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sidhartha Tavri
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Samuel Azeze
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Aritra Dey
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sasan Partovi
- Department of Radiology, Section of Interventional Radiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Fabian Rengier
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
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Bleeding and thrombosis associated with ventricular assist device therapy. J Heart Lung Transplant 2017; 36:1164-1173. [DOI: 10.1016/j.healun.2017.05.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/03/2017] [Accepted: 05/09/2017] [Indexed: 01/03/2023] Open
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Ambient hemolysis and activation of coagulation is different between HeartMate II and HeartWare left ventricular assist devices. J Heart Lung Transplant 2013; 33:80-7. [PMID: 24418734 DOI: 10.1016/j.healun.2013.11.010] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 11/13/2013] [Accepted: 11/26/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Thromboembolic and bleeding events in patients with a left ventricular assist device (LVAD) are still a major cause of complications. Therefore, the balance between anti-coagulant and pro-coagulant factors needs to be tightly controlled. The principle hypothesis of this study is that different pump designs may have an effect on hemolysis and activation of the coagulation system. Referring to this, the HeartMate II (HMII; Thoratec Corp, Pleasanton, CA) and the HeartWare HVAD (HeartWare International Inc, Framingham, MA) were investigated. METHODS For 20 patients with LVAD support (n = 10 each), plasma coagulation, full blood count, and clinical chemistry parameters were measured. Platelet function was monitored using platelet aggregometry, platelet function analyzer-100 system ( Siemens, Marburg, Germany), vasodilator-stimulated phosphoprotein phosphorylation assay, immature platelet fraction, platelet-derived microparticles, and von Willebrand diagnostic. RESULTS Acquired von Willebrand syndrome could be detected in all patients. Signs of hemolysis, as measured by lactate dehydrogenase levels (mean, 470 U/liter HMII, 250 U/liter HVAD; p < 0.001), were more pronounced in the HMII patients. In contrast, D-dimer analysis indicated a significantly higher activation of the coagulation system in HVAD patients (mean, 0.94 mg/liter HMII, 2.01 mg/liter HVAD; p < 0.01). The efficacy of anti-platelet therapy using clopidogrel was not sufficient in more than 50% of the patients. CONCLUSIONS Our results support the finding that all patients with rotary blood pumps suffered from von Willebrand syndrome. In addition, a distinct footprint of effects on hemolysis and the coagulation system can be attributed to different devices. As a consequence, the individual status of the coagulation system needs to be controlled in long-term patients.
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Affiliation(s)
- Peter M. Eckman
- From the Department of Medicine, Division of Cardiovascular Medicine (P.M.E.) and Department of Surgery, Division of Cardiovascular and Thoracic Surgery (R.J.), University of Minnesota, Minneapolis
| | - Ranjit John
- From the Department of Medicine, Division of Cardiovascular Medicine (P.M.E.) and Department of Surgery, Division of Cardiovascular and Thoracic Surgery (R.J.), University of Minnesota, Minneapolis
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Abstract
There have been numerous publications on the coagulopathy of cardiopulmonary bypass (CPB). This review provides an introduction to the history and main components of current CPB circuits and summarizes the current knowledge of pathogenesis, prevention, and treatment of the CPB coagulopathy. It encompasses an overview of intra- and postoperative monitoring of coagulation with special emphasis on the near-patient testing, its main complications, and the transfusion support, while taking into account the major changes in the technology used and supportive care provided since its inception.
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Affiliation(s)
- Martin W Besser
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
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Reece MJ, Klein AA, Salviz EA, Hastings A, Ashworth A, Freeman C, Luddington RJ, Nair S, Besser MW. Near-patient platelet function testing in patients undergoing coronary artery surgery: a pilot study*. Anaesthesia 2011; 66:97-103. [DOI: 10.1111/j.1365-2044.2010.06608.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Steinlechner B, Dworschak M, Birkenberg B, Duris M, Zeidler P, Fischer H, Milosevic L, Wieselthaler G, Wolner E, Quehenberger P, Jilma B. Platelet dysfunction in outpatients with left ventricular assist devices. Ann Thorac Surg 2009; 87:131-7. [PMID: 19101285 DOI: 10.1016/j.athoracsur.2008.10.027] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Revised: 10/13/2008] [Accepted: 10/14/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND Thromboembolic and bleeding complications in outpatients with a left ventricular assist device are common and can be detrimental. A meticulous balance between anticoagulant and procoagulant factors is therefore crucial. However, in contrast to routinely performed plasmatic coagulation tests, platelet function is hardly ever monitored although recent reports indicated platelet dysfunction. We therefore differentially evaluated platelet function with four commonly used point-of-care devices. METHODS In a cross-sectional design platelet function was assessed in 12 outpatients and 12 healthy matched volunteers using thrombelastography platelet mapping, thromboelastometry, platelet function analyzer, and a new whole blood aggregometer (Multiplate). RESULTS Phenprocoumon produced an international normalized ratio of 3.5. It was associated with a twofold prolongation in the thromboelastometry clotting time (p < 0.001). Platelet function under high shear was severely compromised: collagen adenosine diphosphate closure times were 2.5-fold longer in patients than in volunteers (p < 0.001), and 50% of patients had maximal collagen adenosine diphosphate closure time values. Although antigen levels of von Willebrand factor were 80% higher in patients (p < 0.001), von Willebrand factor-ristocetin was subnormal in 5 of 12 patients. Ristocetin-induced aggregation was also threefold higher in volunteers (p < 0.001), indicating an additional functional defect of platelets affecting the glycoprotein Ib-von Willebrand factor axis. The von Willebrand factor multimer pattern in patients also appeared abnormal. CONCLUSIONS Multimodal antiplatelet monitoring showed markedly impaired platelet function in patients with a left ventricular assist device. Platelet dysfunction under high shear rates and abnormal ristocetin-induced aggregation is only partly attributable to low von Willebrand factor activity. These findings resemble the acquired von Willebrand syndrome that is associated with microaggregate formation and enhanced bleeding.
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Affiliation(s)
- Barbara Steinlechner
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria.
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Smith K, Lerman M. Thrombocytopenia in a Patient on Continuous Renal Replacement Therapy. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.1998.tb00211.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
The natural lung is the organ responsible for oxygen and carbon dioxide exchange between the blood and the outside environment. This function is accomplished by the large surface area and high permeability of the gas exchange interface, the alveolar-capillary membrane. These same features are fundamental to the design of an artificial lung, or oxygenator. Additional lung-like features essential to the design of an ideal oxygenator include the ability to achieve balanced oxygen and carbon dioxide exchange with minimal blood damage and blood activation. The purpose of this review is to present the past and current developments of the oxygenator designs in terms of the structural and functional features of the natural lung as well as the limitations in the ability to mimic the features of the lung because of the lack of appropriate technology.
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Affiliation(s)
- J A Wegner
- University Medical Center, Tucson, AZ 85724, USA
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Boehrer JD, Kereiakes DJ, Navetta FI, Califf RM, Topol EJ. Effects of profound platelet inhibition with c7E3 before coronary angioplasty on complications of coronary bypass surgery. EPIC Investigators. Evaluation Prevention of Ischemic Complications. Am J Cardiol 1994; 74:1166-70. [PMID: 7977081 DOI: 10.1016/0002-9149(94)90474-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- J D Boehrer
- Department of Cardiology, Cleveland Clinic Foundation, Ohio
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Affiliation(s)
- F W Campbell
- Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia 19104-4283
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van Oeveren W, Wildevuur CR, Kazatchkine MD. Biocompatibility of extracorporeal circuits in heart surgery. TRANSFUSION SCIENCE 1989; 11:5-33. [PMID: 10171165 DOI: 10.1016/0955-3886(90)90004-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- W van Oeveren
- Department of Cardiopulmonary Surgery, University Hospital Groningen, The Netherlands
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Utoh J, Yamamoto T, Kambara T, Goto H, Miyauchi Y. Complement conversion and leukocyte kinetics in open heart surgery. THE JAPANESE JOURNAL OF SURGERY 1988; 18:259-67. [PMID: 3261363 DOI: 10.1007/bf02471442] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Complement conversions and a pulmonary leukocyte sequestration were observed during cardiopulmonary bypass (CPB) in all of twenty patients who received open heart surgery. A systemic neutropenia was initially observed in the early phase of CPB, and it subsequently turned into a systemic neutrocytosis during the late phase of it. A significant leukocyte sequestration was found in the pulmonary circulation during CPB coincidently with the systemic neutropenia. The contribution of the transpulmonary sequestration to the leukopenia was major, being as high as 80 per cent. Plasma C3, C4, and CH50 levels rapidly decreased following the commencement of CPB. Alterations of the C3 molecule in the patients' plasma were demonstrated using the immunoblotting method. The appearances of C3a and C3b with the apparent molecular weights of 10,000 and 170,000 respectively, might be evidence of the complement activation during CPB. Another type of alteration in the C3 molecule was observed in the generation of a new fragment with the apparent molecular weight of 14,000. The appearance of this fragment, which did not share common epitopes with C3a, might suggest the consumption of complement components during CPB, unrelated to the activation of the complement systems.
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Affiliation(s)
- J Utoh
- First Department of Surgery, Kumamoto University Medical School, Japan
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Ryhänen P, Ilonen J, Surcel HM, Nurmi T, Poikonen K, Järvenpää K, Salmi A. Characterization of in vivo activated lymphocytes found in the peripheral blood of patients undergoing cardiac operation. J Thorac Cardiovasc Surg 1987. [DOI: 10.1016/s0022-5223(19)36482-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kirklin JK, Westaby S, Blackstone EH, Kirklin JW, Chenoweth DE, Pacifico AD. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983. [DOI: 10.1016/s0022-5223(19)39061-0] [Citation(s) in RCA: 778] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Extensive contact between blood and the synthetic surfaces of an extra-corporeal circuit causes thrombocytopenia, release of platelet granular contents, initiation of thromboxane synthesis, disruption of subcellular architecture and loss of platelet sensitivity to standard platelet agonists. All too frequently, these adverse platelet alterations are reflected in a prolongation of the post-operative bleeding time and excessive blood loss which precludes implementation of long-term circulatory assist devices. Unfortunately, a truly biocompatible material does not exist and efficiency of gas transport demands haemodynamic designs which actually promote platelet injury. Although manipulation of surface properties and mechanical improvements in circuitry have managed to reduce platelet-surface interactions, the ultimate potential of these manoeuvres may be limited. Synthetic surfaces and soluble agonists, however, appear to modulate similar pathways suggesting that temporary platelet inhibition might provide significant protection by preserving the morphological and functional integrity of circulating platelets during contact with extracorporeal circuits.
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Functional activity of platelets in the early period after artificial heart implantation. Bull Exp Biol Med 1981. [DOI: 10.1007/bf00837690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hope A, duP. Heyns A, Lötter M, van Reenen O, de Kock F, Badenhorst P, Pieters H, Kotze H, Meyer J, Minnaar P. Kinetics and sites of sequestration of indium 111-labeled human platelets during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1981. [DOI: 10.1016/s0022-5223(19)39423-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ryhünen P, Herva E, Hollmen A, Nuutinen L, Pihlajaniemi R, Saarela E. Changes in peripheral blood leukocyte counts, lymphocyte subpopulations, and in vitro transformation after heart valve replacement. J Thorac Cardiovasc Surg 1979. [DOI: 10.1016/s0022-5223(19)40967-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Young JA, Kisker CT, Doty DB. Adequate anticoagulation during cardiopulmonary bypass determined by activated clotting time and the appearance of fibrin monomer. Ann Thorac Surg 1978; 26:231-40. [PMID: 110273 DOI: 10.1016/s0003-4975(10)63676-4] [Citation(s) in RCA: 165] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The adequacy of anticoagulation during 2 hours of cardiopulmonary bypass at 30 degrees C in 9 rhesus monkeys was determined by measuring the whole-blood activated clotting time (ACT) and by noting the appearance of thrombin-altered fibrin (fibrin monomer) and the relative consumption of clotting factors. Factor V and VIII, the heparin cofactor, antithrombin III, prothrombin time, partial thromboplastin time, ACT, platelets, hematocrit, fibrinogen, and fibrin monomer were determined prior to heparinization and after protamine. In 6 of 9 experiments, fibrin monomer became positive in the plasma during cardiopulmonary bypass (CPB), indicating that active coagulation was occurring. In 5 of the 6 animals, initial ACT was less than 400 seconds, and fibrin monomer appeared within the first 30 minutes of bypass. In 1 animal with an initial ACT of 439 seconds, fibrin monomer appeared after 60 minutes of bypass, at which time the ACT was less than 400 seconds. An abnormal level of fibrin monomer was not detected in 5 pediatric patients with an ACT greater than 450 seconds during CPB. Our experimental study and clinical data suggest that the lower limit, as measured by the ACT, for anticoagulant effect to provide coagulation-free CPB is at least 400 seconds.
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Nuutinen LS, Pihlajaniemi R, Saarela E, Kärkölä P, Hollmén A. The effect of dipyridamole on the thrombocyte count and bleeding tendency in open-heart surgery. J Thorac Cardiovasc Surg 1977. [DOI: 10.1016/s0022-5223(19)41390-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Newland PE. Extracorporeal membrane oxygenation in the treatment of respiratory failure--a review. Anaesth Intensive Care 1977; 5:99-112. [PMID: 405883 DOI: 10.1177/0310057x7700500202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) can be used for the treatment of acute respiratory failure. Based on recent experience in establishing such a method of treatment, this paper reviews those aspects of ECMO that need careful consideration before it can be undertaken. Methods of patient selection for ECMO and the physiological changes associated with it are also discussed.
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Leichtman DA, Friedman BA. The hemorrhagic complications of open-heart surgery. CRC CRITICAL REVIEWS IN CLINICAL LABORATORY SCIENCES 1977; 7:239-54. [PMID: 324709 DOI: 10.3109/10408367709151580] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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