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Gangwani MK, Aziz M, Nawras A, Priyanka F, Ahmed Z, Khan RS, Qamar MA, Haroon F, Aziz A, Smith WL, Kirshan Ravi SJ, Parikh V, Alyousif Z, Mahmood A, Tariq R, Rai D, Aronow WS. Predictors of gastrointestinal bleeding in patients following left ventricular assist device implantation: a systematic review and meta-analysis. Future Cardiol 2022; 18:957-967. [PMID: 36334072 DOI: 10.2217/fca-2022-0054] [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: 11/08/2022] Open
Abstract
Aim: Our study aims to provide a more holistic understanding of the available data and predictive risk factors for gastrointestinal bleed (GIB). Materials & methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Web of Science Core Collection and calculated relative risk and meta-regression was utilized to evaluate for risk factors in order to assess the effect of covariates. Results: Our meta-analysis reported a pooled prevalence rate of GIB of 24.4%. Meta-regression analysis did not yield a statistically significant association between GIB and risk factors, including age, gender, hypertension, chronic kidney disease and diabetes. Conclusion: Studies investigating larger sample sizes are required for conclusive findings.
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Affiliation(s)
| | - Muhammad Aziz
- Department of Gastroenetrology, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Ali Nawras
- Department of Gastroenetrology, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Fnu Priyanka
- Department of Medicine, Chandka Medical College, Larkana, Pakistan
| | - Zohaib Ahmed
- Department of Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Raja Samir Khan
- Department of Gastroenetrology, Baylor College of Medicine, Houston, TX 77030, USA
| | | | - Fawad Haroon
- Department of Internal Medicine, Mercy Hospital St. Louis, MO 63141, USA
| | - Abeer Aziz
- Department of Medicine, Aga Khan University, USA
| | - Wade Lee Smith
- Department of Toledo Libraries, University of Toledo, Toledo, OH 43614, USA
| | | | - Vishal Parikh
- Department of Cardiology, Sands Constellation Heart Institute, Rochester Regional Health, Rochester, NY 14621, USA
| | - Zakaria Alyousif
- Department of Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Asif Mahmood
- Department of Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA
| | - Raseen Tariq
- Department of Gastroenterology, Mayo Clinic, Rochester, MN 55902, USA
| | - Devesh Rai
- Department of Cardiology, Sands Constellation Heart Institute, Rochester Regional Health, Rochester, NY 14621, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA
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2
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Khedr A, Mahmoud EE, Attallah N, Mir M, Boike S, Rauf I, Jama AB, Mushtaq H, Surani S, Khan SA. Role of octreotide in small bowel bleeding. World J Clin Cases 2022; 10:9192-9206. [PMID: 36159407 PMCID: PMC9477697 DOI: 10.12998/wjcc.v10.i26.9192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/30/2022] [Accepted: 08/15/2022] [Indexed: 02/05/2023] Open
Abstract
Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients’ lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding. Small bowel bleeding is the least common cause of gastrointestinal bleeding. However, it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation. A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding. This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis. In this review article, we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.
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Affiliation(s)
- Anwar Khedr
- Department of Internal Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | | | - Noura Attallah
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Mikael Mir
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Sydney Boike
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Ibtisam Rauf
- Department of Medicine, St. George School of Medicine, Grenada, West Indies
| | - Abbas B Jama
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Hisham Mushtaq
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University Health Science Center, Bryan, TX 77807, United States
| | - Syed A Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
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3
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Abstract
Acquired von Willebrand syndrome can occur in the setting of myeloproliferative neoplasms; plasma cell dyscrasias and other lymphoproliferative disorders; autoimmune conditions; and causes of increased shear forces, such as aortic stenosis or other structural heart disease and mechanical circulatory support. The depletion of von Willebrand factor, especially high-molecular-weight multimers, can lead to mucocutaneous bleeding and the formation of arteriovenous malformations, particularly in the gastrointestinal tract. Management focuses on correction of the underlying cause when possible, but may include intravenous immunoglobulins, von Willebrand factor concentrate, rituximab, or antiangiogenic therapy depending on the clinical context.
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Affiliation(s)
- Arielle L Langer
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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4
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McNamara N, Narroway H, Williams M, Brookes J, Farag J, Cistulli D, Bannon P, Marasco S, Potapov E, Loforte A. Contemporary outcomes of continuous-flow left ventricular assist devices-a systematic review. Ann Cardiothorac Surg 2021; 10:186-208. [PMID: 33842214 DOI: 10.21037/acs-2021-cfmcs-35] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background End stage heart failure is a major cause of morbidity and mortality, and its prevalence is expected to rise with the ageing population. For suitable patients, orthotopic heart transplantation remains the gold standard therapy, however, a paucity of donor organs has led to the development of left ventricular assist devices (LVAD). These devices can be utilized as either a bridge-to-transplant (BTT) or as an alternative to heart transplantation. While these devices can prolong life and improve quality of life, they are associated with a significant number of adverse events. We aim to systematically review the literature to quantify survival and the incidence of adverse events following implantation of continuous-flow LVADs (cf-LVAD). Methods A systematic review was performed to determine outcomes following implantation of a cf-LVAD. Primary outcomes were survival and frequency of adverse events (such as bleeding, infection, thrombosis, stroke and right ventricular failure). Secondary outcomes included quality of life and assessment of functional status. Results Sixty-three studies reported clinical outcomes of 9,280 patients. Survival after cf-LVAD varied between studies. Industry-funded trials generally reported better overall survival than the single- and multi-center case series, which showed significant variation. The largest registry report documented twelve, twenty-four and forty-eight-month survival rates of 82%, 72% and 57% respectively. The most commonly reported adverse events were gastrointestinal bleeding (GIB), device-related infection, neurological events and right heart failure (RHF). Bleeding, RHF and infection were the most frequent complications experienced by those supported with cf-LVAD, occurring in up to 35%, 40% and 55% of patients, respectively. Quality of life as measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and functional status as measured with the 6-minute walk test (6MWT) improved after cf-LVAD implantation with no decline evident two years after implantation. Conclusions The paucity of donor hearts has led to the development of left-ventricular assist devices as a BTT or as a destination therapy (DT). Outcomes after cf-LVAD implantation are excellent, with short-term survival comparable to heart transplantation, but long-term survival remains limited due to the incidence of post-implantation adverse events. Despite these complications, quality of life and functional status improve significantly post-implantation and remain improved over the long-term. This study demonstrates the potential benefits of cf-LVAD therapy whilst also identifying adverse events as an area of increased morbidity and mortality.
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Affiliation(s)
- Nicholas McNamara
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Health and Medicine, University of Sydney, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - Harry Narroway
- Department of Vascular Surgery, Gosford Hospital, Gosford, Australia
| | - Michael Williams
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Health and Medicine, University of Sydney, Sydney, Australia
| | - John Brookes
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - James Farag
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - David Cistulli
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul Bannon
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, Australia.,Baird Institute of Applied Heart and Lung Research, Sydney, Australia
| | - Silvana Marasco
- Cardiothoracic Surgical Department, The Alfred, Melbourne, Australia.,Department of Medicine and Surgery, Monash University, Melbourne, Australia
| | - Evgenij Potapov
- Deutsches Zentrum für Herz Kreislauf Forschung (DZHK) - Standort Berlin/Charité, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin (DHZB), Berlin, Germany
| | - Antonio Loforte
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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5
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Givertz MM, DeFilippis EM, Colvin M, Darling CE, Elliott T, Hamad E, Hiestand BC, Martindale JL, Pinney SP, Shah KB, Vierecke J, Bonnell M. HFSA/SAEM/ISHLT clinical expert consensus document on the emergency management of patients with ventricular assist devices. J Heart Lung Transplant 2020; 38:677-698. [PMID: 31272557 DOI: 10.1016/j.healun.2019.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/01/2019] [Indexed: 01/21/2023] Open
Abstract
Mechanical circulatory support is now widely accepted as a viable long-term treatment option for patients with end-stage heart failure (HF). As the range of indications for the implantation of ventricular assist devices grows, so does the number of patients living in the community with durable support. Because of their underlying disease and comorbidities, in addition to the presence of mechanical support, these patients are at a high risk for medical urgencies and emergencies (Table 1). Thus, it is the responsibility of clinicians to understand the basics of their emergency care. This consensus document represents a collaborative effort by the Heart Failure Society of America, the Society for Academic Emergency Medicine, and the International Society for Heart and Lung Transplantation (ISHLT) to educate practicing clinicians about the emergency management of patients with ventricular assist devices. The target audience includes HF specialists and emergency medicine physicians, as well as general cardiologists and community-based providers.
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Affiliation(s)
- Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Ersilia M DeFilippis
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Monica Colvin
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Chad E Darling
- UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Tonya Elliott
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Eman Hamad
- Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian C Hiestand
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | | | - Keyur B Shah
- VCU Pauley Heart Center, Richmond, Virginia, USA
| | - Juliane Vierecke
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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6
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Prothrombin Complex Concentrate for Warfarin Reversal in Patients with Continuous-Flow Left Ventricular Assist Devices: A Narrative Review. ASAIO J 2020; 66:482-488. [PMID: 31192853 DOI: 10.1097/mat.0000000000001021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Durable left ventricular assist device (LVAD) recipients require long-term anticoagulation to prevent thromboembolic complications. Their management is complicated by the risk of bleeding, which may require rapid anticoagulation reversal. We conducted a narrative review of data published from January 2007 to September 2018, analyzing anticoagulation reversal strategies in patients with durable, continuous-flow LVADs. The aim of this review is to provide guidance for reversal strategies in patients with LVADs experiencing bleeding complications or needing urgent surgical procedures, incorporating four-factor prothrombin complex concentrate (4F-PCC). Most data were from small, retrospective studies. Data for 4F-PCC use were more robust for heart transplant than for other surgical procedures or bleeding management. In patients undergoing heart transplant, 4F-PCC reversed warfarin more rapidly and reduced total blood product use versus other reversal strategies. Most surgical procedures were conducted without excess bleeding when utilizing 4F-PCCs. Time to warfarin reversal was shorter when managing intracranial hemorrhage with 4F-PCC. No differences in thromboembolic rates between 4F-PCC and control groups were observed. Overall, the use of 4F-PCC resulted in more rapid and predictable warfarin reversal in LVAD patients with no apparent risk of thromboembolism. Well-designed, larger prospective trials are required to better define 4F-PCC use in patients with LVADs.
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7
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Carlson LA, Maynes EJ, Choi JH, Hallett AM, Horan DP, Weber MP, Deb AK, Patel S, Samuels LE, Morris RJ, Entwistle JW, Massey H, Tchantchaleishvili V. Characteristics and outcomes of gastrointestinal bleeding in patients with continuous‐flow left ventricular assist devices: A systematic review. Artif Organs 2020; 44:1150-1161. [DOI: 10.1111/aor.13725] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/24/2020] [Accepted: 05/01/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Laura A. Carlson
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | | | - Jae Hwan Choi
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Andrew M. Hallett
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Dylan P. Horan
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Matthew P. Weber
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Avijit K. Deb
- Philadelphia College of Osteopathic Medicine Philadelphia PA USA
| | - Sinal Patel
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Louis E. Samuels
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - Rohinton J. Morris
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - John W. Entwistle
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
| | - H. Massey
- Division of Cardiac Surgery Thomas Jefferson University Philadelphia PA USA
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8
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Bartoli CR, Kang J, Motomura T. Decreased RPM reduces von Willebrand factor degradation with the EVAHEART LVAS: implications for device-specific LVAD management. J Card Surg 2020; 35:1477-1483. [PMID: 32652785 DOI: 10.1111/jocs.14620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 04/16/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (LVADs) produces supraphysiologic shear stress that causes von Willebrand factor (VWF) degradation and a bleeding diathesis. Reduction of revolutions per minute (RPM) with axial-flow LVADs does not decrease shear stress enough to reduce VWF degradation and bleeding. However, it is unknown if RPM reduction with centrifugal flow LVADs may minimize VWF degradation. We tested the hypothesis that RPM reduction preserves VWF multimers in the centrifugal-flow EVAHEART left ventricular assist system (LVAS), which is designed to minimize shear stress and blood trauma. METHODS Whole blood samples were collected from humans (n = 28). Blood was circulated in ex vivo mock circulatory loops for 6 hours with an EVAHEART LVAS at 2300 (n = 12), 2100 (n = 8), or 1800 RPM (n = 8). Immunoblotting was used to resolve and quantify VWF multimers and degradation fragments. RESULTS RPM reduction from 2300 to 2100 to 1800 RPM significantly decreased EVAHEART blood flow from 5.8 ± 0.4 to 4.3 ± 0.6 to 4.1 ± 0.5 L/min (analysis of variance [ANOVA], P = .03). RPM reduction protected VWF from pathologic degradation. At lower RPMs, significantly greater levels of VWF multimers were observed (ANOVA, P = .001). Similarly, at lower RPMs, significantly fewer VWF fragments, a product of VWF degradation, were observed (ANOVA, P = .007). CONCLUSIONS RPM reduction significantly reduced VWF degradation with the centrifugal-flow EVAHEART LVAS, an LVAD specifically designed with low shear stress. Different LVADs have unique hematologic footprints and should be managed with device-specific protocols. Adjustment of RPM to minimize blood trauma while still maintaining physiologic hemodynamics has the potential to decrease complications related to LVAD-associated von Willebrand's disease, such as gastrointestinal bleeding and hemorrhagic stroke.
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Affiliation(s)
- Carlo R Bartoli
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jooeun Kang
- MD-PhD Program, Vanderbilt University, Nashville, Tennessee
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9
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Wu T, Lin H, Zhu Y, Huang P, Lin F, Chen C, Hsu PL. Hemodynamic performance of a compact centrifugal left ventricular assist device with fully magnetic levitation under pulsatile operation: An in vitro study. Proc Inst Mech Eng H 2020; 234:1235-1242. [DOI: 10.1177/0954411920937919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Long-term using continuous flow ventricular assist devices could trigger complications associated with diminished pulsatility, such as valve insufficiency and gastrointestinal bleeding. One feasible solution is to produce pulsatile flow assist with speed regulation in continuous flow ventricular assist devices. A third-generation blood pump with pulsatile operation control algorithm was first characterized alone under pulsatile mode at various speeds, amplitudes, and waveforms. The pump was then incorporated in a Mock circulation system to evaluate in vitro hemodynamic effects when using continuous and different pulsatile operations. Pulsatility was evaluated by surplus hemodynamic energy. Results showed that pulsatile operations provided sufficient hemodynamic assistance and increased pulsatility of the circulatory system (53% increment), the mean aortic pressure (65% increment), and cardiac output (27% increment). The pulsatility of the system under pulsatile operation support was increased 147% compared with continuous operation support. The hemodynamic performance of pulsatile operations is susceptible to phase shifts, which could be a tacking angle for physiological control optimization. This study found third-generation blood pumps using different pulsatile operations for ventricular assistance promising.
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Affiliation(s)
- Tingting Wu
- Artificial Organ Technology Laboratory, Soochow University, Suzhou, China
| | - Hao Lin
- Artificial Organ Technology Laboratory, Soochow University, Suzhou, China
| | - Yuxin Zhu
- Artificial Organ Technology Laboratory, Soochow University, Suzhou, China
| | - Penghui Huang
- Artificial Organ Technology Laboratory, Soochow University, Suzhou, China
| | | | - Chen Chen
- Artificial Organ Technology Laboratory, Soochow University, Suzhou, China
- CH Biomedical, Inc., Suzhou, China
| | - Po-Lin Hsu
- Artificial Organ Technology Laboratory, Soochow University, Suzhou, China
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10
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Darling CE, Martindale JL, Hiestand BC, Bonnell M, Colvin M, DeFilippis EM, Elliott T, Hamad E, Pinney SP, Shah KB, Vierecke J, Givertz MM. An Emergency Medicine-focused Summary of the HFSA/SAEM/ISHLT Clinical Consensus Document on the Emergency Management of Patients With Ventricular Assist Devices. Acad Emerg Med 2020; 27:618-629. [PMID: 32176420 DOI: 10.1111/acem.13964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/24/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
Mechanical circulatory support is increasingly used as a long-term treatment option for patients with end-stage heart failure. Patients with implanted ventricular assist devices are at high risk for a range of diverse medical urgencies and emergencies. Given the increasing prevalence of mechanical circulatory support devices, this expert clinical consensus document seeks to help inform emergency medicine and prehospital providers regarding the approach to acute medical and surgical conditions encountered in these complex patients.
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Affiliation(s)
- Chad E. Darling
- UMass Memorial Medical Center UMass Medical School Worcester MA
| | | | | | | | | | | | | | - Eman Hamad
- Temple University Hospital Philadelphia PA
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11
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Ahsan I, Faraz A, Mehmood A, Ullah W, Ghani AR. Clinical Approach to Manage Gastrointestinal Bleeding with a Left Ventricular Assist Device (LVAD). Cureus 2019; 11:e6341. [PMID: 31938629 PMCID: PMC6952049 DOI: 10.7759/cureus.6341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Left ventricular assist devices (LVADs) are an exceedingly important form of mechanical support for patients with end-stage heart failure. LVADs can be utilized both as a bridge to cardiac transplant and also as a definitive treatment. However, a few complications are associated with LVAD placement, the most common and cumbersome of which is gastrointestinal (GI) bleeding with an incidence of about 30%. These bleeding events often require transfusion therapy, but they are rarely fatal. The etiologies of GI bleeding following LVAD are multifactorial and include unstable hemodynamics, an acquired von Willebrand factor (vWf) deficiency, impaired platelet aggregation, and activation of fibrinolytic systems. The treatment of choice in LVAD implantation-associated GI bleeding is endoscopy, which plays a vital role in both its diagnosis and management. Even so, its effectiveness in controlling post-LVAD implantation GI bleeding is still poorly ascertained. In this article, we will review the use of medication and alterations in the LVAD setting to prevent the occurrence of GI bleeding, as well as the findings of previously reported literature on LVAD implantation-associated GI bleeding.
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Affiliation(s)
- Irfan Ahsan
- Internal Medicine, Geisinger Health System, Danville, USA
| | - Aniqa Faraz
- Internal Medicine, University of Buffalo, Buffalo, USA
| | - Asif Mehmood
- Internal Medicine, Geisinger Medical Center, Danville, USA
| | - Waqas Ullah
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, USA
| | - Ali R Ghani
- Cardiovascular Medicine, Saint Louis University, Saint Louis, USA
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12
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Hilal T, Mudd J, DeLoughery TG. Hemostatic complications associated with ventricular assist devices. Res Pract Thromb Haemost 2019; 3:589-598. [PMID: 31624778 PMCID: PMC6781923 DOI: 10.1002/rth2.12226] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/08/2019] [Indexed: 01/03/2023] Open
Abstract
Hemostatic complications are common in patients with ventricular assist devices. The pathophysiologic mechanisms that lead to dysregulated hemostasis involve complex interactions between device surface, sheer stress, and blood flow. These factors lead to various manifestations that require a thorough understanding of the interplay among platelets, coagulation factors, and red cells. In this article, we review the pathophysiology of hematologic complications (bleeding, acquired von Willebrand disease, heparin-induced thrombocytopenia, hemolysis, stroke and pump thrombosis), the clinical manifestations, and the management of each. We summarize the evidence available for management of these entities and provide a pragmatic clinical review.
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Affiliation(s)
- Talal Hilal
- Division of Hematology/OncologyMayo Clinic Cancer CenterMayo ClinicPhoenixArizona
| | - James Mudd
- Center for Advanced Heart Disease and TransplantationProvidence Sacred Heart Medical CenterSpokaneWashington
| | - Thomas G. DeLoughery
- Division of Hematology/Medical OncologyKnight Cancer CenterOregon Health & Science UniversityPortlandOregon
- Division of Laboratory MedicineDepartment of PathologyOregon Health & Science UniversityPortlandOregon
- Division of Hematology/OncologyDepartment of PediatricsOregon Health & Science UniversityPortlandOregon
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13
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Givertz MM, DeFilippis EM, Colvin M, Darling CE, Elliott T, Hamad E, Hiestand BC, Martindale JL, Pinney SP, Shah KB, Vierecke J, Bonnell M. HFSA/SAEM/ISHLT Clinical Expert Consensus Document on the Emergency Management of Patients with Ventricular Assist Devices. J Card Fail 2019; 25:494-515. [DOI: 10.1016/j.cardfail.2019.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/17/2022]
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14
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Gastrointestinal Bleeding in Left Ventricular Assist Device: Octreotide and Other Treatment Modalities. ASAIO J 2019; 64:433-439. [PMID: 29406356 DOI: 10.1097/mat.0000000000000758] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Left ventricular assist devices (LVADs) offer a therapeutic strategy for patients with end-stage heart failure. Increased device utilization has also increased the incidence of device-related complications including gastrointestinal bleeding (GIB). Multiple mechanisms have been proposed in the pathophysiology of continuous-flow LVAD-associated GIB including physiologic changes associated with high shear and nonpulsatile flow such as gastrointestinal arteriovenous malformations and acquired von Willebrand syndrome. Strategies to minimize the morbidity and mortality of LVAD-associated GIB are needed. Octreotide, a somatostatin analogue, has been described as an adjunct to current therapies and interventions. Factors that contribute to LVAD-associated GIB may be targeted by the pharmacologic effects of octreotide, including improved platelet aggregation, increased vascular resistance, and decreased splanchnic circulation. Octreotide has demonstrated clinical benefit in several case series and clinical trials for the treatment of LVAD-associated GIB. The focus of this article will be to review the pathophysiology of LVAD-associated GIB, discuss pharmacologic and nonpharmacologic treatment modalities, and review available literature on the role of octreotide in the management of LVAD-associated GIB.
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15
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Risk Factors of Gastrointestinal Bleeding After Continuous Flow Left Ventricular Assist Device. ASAIO J 2019; 64:458-461. [PMID: 28957820 DOI: 10.1097/mat.0000000000000678] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
This study aimed to compare von Willebrand factor (vWF) levels, ristocetin cofactor levels, platelet counts, aortic valve movements, and right heart failure (RHF) as risk factors of gastrointestinal (GI) bleeding in patients with continuous flow left ventricular assist device (cf-LVAD). In a single centre, 90 patients (mean age 52.0 ± 10.5 years), of which 59 were male and 31 were female, had cf-LVAD implantation from October 2010 to November 2012. Seventy-six (84.4%) patients had HeartWare (Medtronic, Mounds View, MN) and 14 (15.5%) had Heartmate II (Thoratec, Pleasanton, CA) implanted. vWF level, ristocetin cofactor level, and platelet count were measured before and after implantation to determine the presence of acquired von Willebrand Syndrome; aortic valve movement and postoperative RHF were evaluated to compare the difference in bleeding and nonbleeding patient groups. Fifteen patients (16.6%) suffered GI bleeding after cf-LVAD implantation. A statistically significant decrease was found in vWF and ristocetin cofactor levels from preoperative period to postoperative period in both bleeding and nonbleeding patient groups (p < 0.05). There was no significant difference in bleeding and nonbleeding groups regarding aortic valve movements (p ≥ 0.05). Postoperative RHF incidence was significantly high in the bleeding patient group compared with the nonbleeding group (p < 0.05). Therefore, depending on the findings of this study, acquired von Willebrand Syndrome was seen in all cf-LVAD patients, and postoperative RHF was an important risk factor for GI bleeding.
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16
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Rauch A, Susen S, Zieger B. Acquired von Willebrand Syndrome in Patients With Ventricular Assist Device. Front Med (Lausanne) 2019; 6:7. [PMID: 30805339 PMCID: PMC6371037 DOI: 10.3389/fmed.2019.00007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/11/2019] [Indexed: 01/27/2023] Open
Abstract
During the last decade the use of ventricular assist devices (VADs) for patients with severe heart failure has increased tremendously. However, flow disturbances, mainly high shear induced by the device is associated with bleeding complications. Shear stress-induced changes in VWF conformation are associated with a loss of high molecular weight multimers (HMW) of VWF and an increased risk of bleeding. This phenomenon and its cause will be elaborated and reviewed in the following.
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Affiliation(s)
- Antoine Rauch
- INSERM, U1011, Univ. Lille, U1011-EGID, Institut Pasteur de Lille, Lille, France.,CHU Lille, Hematology and Transfusion, Lille, France
| | - Sophie Susen
- INSERM, U1011, Univ. Lille, U1011-EGID, Institut Pasteur de Lille, Lille, France.,CHU Lille, Hematology and Transfusion, Lille, France
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
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17
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Eisen HJ. Left Ventricular Assist Devices (LVADS): History, Clinical Application and Complications. Korean Circ J 2019; 49:568-585. [PMID: 31243930 PMCID: PMC6597447 DOI: 10.4070/kcj.2019.0161] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 12/17/2022] Open
Abstract
Congestive heart failure is a major cause of morbidity and mortality as well as a major health care cost in the developed world. Despite the introduction of highly effective heart failure medical therapies and simple devices such as cardiac resynchronization therapy that reduce mortality, improve cardiac function and quality of life, there remains a large number of patients who do not respond to these therapies or whose heart failure progresses despite optimal therapy. For these patients, cardiac transplantation is an option but is limited by donor availability as well as co-morbidities which may limit survival post-transplant. For these patients, left ventricular assist devices (LVADs) offer an alternative that can improve survival as well as exercise tolerance and quality of life. These devices have continued to improve as technology has improved with substantially improved durability of the devices and fewer post-implant complications. Pump thrombosis, stroke, gastrointestinal bleeding and arrhythmias post-implant have become less common with the newest devices, making destination therapy where ventricular assist device are implanted permanently in patients with advanced heart failure, a reality and an appropriate option for many patients. This may offer an opportunity for long term survival in many patients. As the first of the totally implantable devices are introduced and go to clinical trials, LVADs may be introduced that may truly be alternatives to cardiac transplantation in selected patients. Post-implant right ventricular failure remains a significant complication and better ways to identify patients at risk as well as to manage this complication must be developed.
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Affiliation(s)
- Howard J Eisen
- Heart and Vascular Institute, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA.
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Kim JH, Brophy DF, Shah KB. Continuous-Flow Left Ventricular Assist Device–Related Gastrointestinal Bleeding. Cardiol Clin 2018; 36:519-529. [DOI: 10.1016/j.ccl.2018.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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19
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Vukelic S, Vlismas PP, Patel SR, Xue X, Shitole SG, Saeed O, Sims DB, Chinnadurai T, Shin JJ, Forest SJ, Goldstein DJ, Jorde UP. Digoxin Is Associated With a Decreased Incidence of Angiodysplasia-Related Gastrointestinal Bleeding in Patients With Continuous-Flow Left Ventricular Assist Devices. Circ Heart Fail 2018; 11:e004899. [DOI: 10.1161/circheartfailure.118.004899] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Sasa Vukelic
- Division of Cardiology, Department of Medicine (S.V., P.P.V., S.R.P., S.G.S., O.S., D.B.S., T.C., J.J.S., U.P.J.)
| | - Peter P. Vlismas
- Division of Cardiology, Department of Medicine (S.V., P.P.V., S.R.P., S.G.S., O.S., D.B.S., T.C., J.J.S., U.P.J.)
| | - Snehal R. Patel
- Division of Cardiology, Department of Medicine (S.V., P.P.V., S.R.P., S.G.S., O.S., D.B.S., T.C., J.J.S., U.P.J.)
| | - Xiaonan Xue
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (X.X.)
| | - Sanyog G. Shitole
- Division of Cardiology, Department of Medicine (S.V., P.P.V., S.R.P., S.G.S., O.S., D.B.S., T.C., J.J.S., U.P.J.)
| | - Omar Saeed
- Division of Cardiology, Department of Medicine (S.V., P.P.V., S.R.P., S.G.S., O.S., D.B.S., T.C., J.J.S., U.P.J.)
| | - Daniel B. Sims
- Division of Cardiology, Department of Medicine (S.V., P.P.V., S.R.P., S.G.S., O.S., D.B.S., T.C., J.J.S., U.P.J.)
| | - Thiru Chinnadurai
- Division of Cardiology, Department of Medicine (S.V., P.P.V., S.R.P., S.G.S., O.S., D.B.S., T.C., J.J.S., U.P.J.)
| | - Julia J. Shin
- Division of Cardiology, Department of Medicine (S.V., P.P.V., S.R.P., S.G.S., O.S., D.B.S., T.C., J.J.S., U.P.J.)
| | | | | | - Ulrich P. Jorde
- Division of Cardiology, Department of Medicine (S.V., P.P.V., S.R.P., S.G.S., O.S., D.B.S., T.C., J.J.S., U.P.J.)
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Association of Pulsatility with Gastrointestinal Bleeding in a Cohort of HeartMate II Recipients. ASAIO J 2018; 64:472-479. [PMID: 29489463 DOI: 10.1097/mat.0000000000000766] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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21
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Juricek C, Imamura T, Nguyen A, Chung B, Rodgers D, Sarswat N, Kim G, Raikhelkar J, Ota T, Song T, Burkhoff D, Sayer G, Jeevanandam V, Uriel N. Long-Acting Octreotide Reduces the Recurrence of Gastrointestinal Bleeding in Patients With a Continuous-Flow Left Ventricular Assist Device. J Card Fail 2018; 24:249-254. [PMID: 29427603 DOI: 10.1016/j.cardfail.2018.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/20/2017] [Accepted: 01/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recurrent gastrointestinal bleeding is one of the most significant adverse events in patients with left ventricular assist devices (LVADs). METHODS We enrolled LVAD patients who had received an intramuscular injection of 20 mg octreotide every 4 weeks as secondary prevention for recurrent gastrointestinal bleeding despite conventional medical therapies and repeated transfusions. The frequency of gastrointestinal bleeding and other associated clinical outcomes before and during octreotide therapy were compared. RESULTS Thirty LVAD patients (66.4 ± 8.8 years old, 16 men [53%]) received octreotide therapy for 498.8 ± 356.0 days without any octreotide-associated adverse events. The frequency of gastrointestinal bleeding was decreased significantly during octreotide therapy (from 3.4 ± 3.1 to 0.7 ± 1.3 events/year; P < .001), accompanied by significant reductions in red blood cell and flesh frozen plasma transfusions, days in hospital, and need for endoscopic procedures (P < .05 for all). CONCLUSIONS Octreotide therapy reduced the frequency of recurrent gastrointestinal bleeding and may be considered for secondary prevention.
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Affiliation(s)
- Colleen Juricek
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Teruhiko Imamura
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Ann Nguyen
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Ben Chung
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Nitasha Sarswat
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Jayant Raikhelkar
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, Columbia University Medical Center, New York, New York
| | - Gabriel Sayer
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | | | - Nir Uriel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
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Gurvits GE, Fradkov E. Bleeding with the artificial heart: Gastrointestinal hemorrhage in CF-LVAD patients. World J Gastroenterol 2017; 23:3945-3953. [PMID: 28652649 PMCID: PMC5473115 DOI: 10.3748/wjg.v23.i22.3945] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/10/2017] [Accepted: 05/09/2017] [Indexed: 02/06/2023] Open
Abstract
Continuous-flow left ventricular assist devices (CF-LVADs) have significantly improved outcomes for patients with end-stage heart failure when used as a bridge to cardiac transplantation or, more recently, as destination therapy. However, its implantations carries a risk of complications including infection, device malfunction, arrhythmias, right ventricular failure, thromboembolic disease, postoperative and nonsurgical bleeding. A significant number of left ventricular assist devices (LVAD) recipients may experience recurrent gastrointestinal hemorrhage, mainly due to combination of antiplatelet and vitamin K antagonist therapy, activation of fibrinolytic pathway, acquired von Willebrand factor deficiency, and tendency to develop small intestinal angiodysplasias due to increased rotary speed of the pump. Gastrointestinal bleeding in LVAD patients remains a source of increased morbidity including the need for blood transfusions, extended hospital stays, multiple readmissions, and overall mortality. Management of gastrointestinal bleeding in LVAD patients involves multidisciplinary approach in stabilizing the patients, addressing risk factors and performing structured endoluminal evaluation with focus on upper gastrointestinal tract including jejunum to find and eradicate culprit lesion. Medical and procedural intervention is largely successful and universal bleeding cessation occurs in transplanted patients.
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23
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Proudfoot AG, Davidson SJ, Strueber M. von Willebrand factor disruption and continuous-flow circulatory devices. J Heart Lung Transplant 2017; 36:1155-1163. [PMID: 28756118 DOI: 10.1016/j.healun.2017.06.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 06/05/2017] [Accepted: 06/07/2017] [Indexed: 01/12/2023] Open
Abstract
Bleeding events remain a significant and frequent complication of continuous-flow left ventricular assist devices (VADs). von Willebrand factor (VWF) is critical to hemostasis by acting as a bridging molecule at sites of vascular injury for normal platelet adhesion as well as promoting platelet aggregation under conditions of high shear. Clinical and experimental data support a role for acquired von Willebrand disease in VAD bleeding episodes caused by shear-induced qualitative defects in VWF. Pathologic shear induces VWF unfolding and proteolysis of large multimers into smaller less hemostatic multimers via ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13). This review outlines the pathobiology of VWF disruption in the context of VADs as well as current diagnostic and management strategies of the associated acquired von Willebrand disease.
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Affiliation(s)
- Alastair G Proudfoot
- Frederick Meijer Heart & Vascular Institute, Spectrum Health, Grand Rapids, Michigan; Department of Perioperative Medicine, St Bartholomew's Hospital, London, United Kingdom
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24
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Nadziakiewicz P, Pacholewicz J, Zakliczynski M, Niklewski T, Borkowski J, Hrapkowicz T, Zembala M. Comparison of Mechanical Circulatory Support by the Use of Pulsatile Left Ventricular Assist Devices Polvad MEV and Continuous Flow Heart Ware and Heart Mate II in a Single-Center Experience. Transplant Proc 2017; 48:1770-4. [PMID: 27496489 DOI: 10.1016/j.transproceed.2016.01.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 01/21/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mechanical circulatory support is increasingly used in patients with heart failure as a bridge to transplant or recovery. Results of use the Polish POLVAD MEV pulsatile circulatory support system and its comparison with novel devices never was done. We compared the course of patients with left ventricular circulatory support (left ventricular assist device [LVAD]) supported by POLVAD MEV or continuous flow devices Heart Mate II (HM II) and Heart Ware (HW) in single-center cohort. METHODS We retrospectively reviewed 44 patients who underwent Polvad Mev (group P; n = 24 [21M/3F]) or HW or HM II (group C; n = 20 [20M/0F]) implantation between April 2007 and February 2014. Patients were in INTERMACS 1 (6 in group P and 1 in group C) or 2. Preimplant demographics, and perioperative and postoperative clinical outcomes were reviewed between groups. We analyzed baseline signs of heart failure, comorbidities, complications, and the 30- and 90-day results. RESULTS Among the groups, age, gender, weight, and cause of heart failure were comparable. Patients in group C suffered more frequently from hypercholesterolemia preoperatively. Patients in group P had more pulmonary complications (7 vs 0) after LVAD implantation and stay longer on intensive care unit than patients in group C (17.61 ± 16.96 vs 9.56 ± 9.42; P = .047). After exclusion, INTERMACS 1 patients it was not significant (14.8 ± 10.8 vs 9.8 ± 9.6 days; P = .065), the 30- and 90-day mortality was comparable. CONCLUSIONS Implantation of pulsatile POLVAD MEV and continuous flow devices as LVAD support provides comparable results. A greater number of complications in group P can cause increased mortality over a longer observation period.
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Affiliation(s)
- P Nadziakiewicz
- Department of Cardiac Anaesthesia and Intensive Care, Silesian Centre for Heart Diseases, Zabrze, Poland.
| | - J Pacholewicz
- Department of Cardiac Surgery and Transplantation SUM, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - M Zakliczynski
- Department of Cardiac Surgery and Transplantation SUM, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - T Niklewski
- Department of Cardiac Surgery and Transplantation SUM, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - J Borkowski
- Department of Cardiac Anaesthesia and Intensive Care, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - T Hrapkowicz
- Department of Cardiac Surgery and Transplantation SUM, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - M Zembala
- Department of Cardiac Surgery and Transplantation SUM, Silesian Centre for Heart Diseases, Zabrze, Poland
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25
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Bozkurt S, van Tuijl S, van de Vosse FN, Rutten MCM. Arterial pulsatility under phasic left ventricular assist device support. Biomed Mater Eng 2016; 27:451-460. [PMID: 27885993 DOI: 10.3233/bme-161599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study is to understand whether the phasic Continuous Flow Left Ventricular Assist Device (CF-LVAD) support would increase the arterial pulsatility. A Micromed DeBakey CF-LVAD was used to apply phasic support in an ex-vivo experimental platform. CF-LVAD was operated over a cardiac cycle by phase-shifting the pulsatile pump control with respect to the heart cycle, in 0.05 s increments in each experiment. The pump flow rate was selected as the control variable and a reference model was used to operate the CF-LVAD at a pulsatile speed. Arterial pulse pressure was the highest (9 mmHg) when the peak pump flow is applied at the peak systole under varying speed CF-LVAD support over a cardiac cycle while it was the lowest (2 mmHg) when the peak pump flow was applied in the diastolic phase. The mean arterial pressure and mean CF-LVAD output were the same in each experiment while arterial pulse pressure and pulsatility index varied depending on the phase of reference pump flow rate signal. CF-LVAD speed should be synchronized considering the timing of peak systole over a cardiac cycle to increase the arterial pulsatility. Moreover, it is possible to decrease the arterial pulsatility under counter-pulsating CF-LVAD support.
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Affiliation(s)
- Selim Bozkurt
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | | | - Frans N van de Vosse
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Marcel C M Rutten
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
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26
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Gastrointestinal Bleeding during Continuous-Flow Left Ventricular Assist Device Support is Associated with Lower Rates of Cardiac Transplantation. ASAIO J 2016; 61:635-9. [PMID: 26366686 DOI: 10.1097/mat.0000000000000279] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Gastrointestinal bleeding (GIB) remains a significant problem after continuous-flow left ventricular assist device (CF-LVAD) implantation. We hypothesized that the subsequent need for blood transfusions in patients with GIB may reduce rates of cardiac transplantation. We performed a retrospective review of 232 patients implanted with the HeartMate II (HM II) CF-LVAD from June 2005 through May 2013 at our center to determine risk factors for GIB and assess its effect on cardiac transplantation. Over a total LVAD follow-up time of 364 person-years, 62 GIB episodes occurred in 49 patients (27%), for an event rate of 0.45 gastrointestinal bleeds/patient-year of LVAD support. Women made up 15% of our cohort, yet contributed 29% of the GIB (p = 0.06). Survival at 6 month, 1 year, and 2 years was not statistically different in patients who developed GIB and those who did not (77% vs 78%, 74% vs 71%, and 61% vs 54%, respectively). In transplant-eligible patients, GIB was associated with a 27% lower rate of cardiac transplantation (rate ratio 0.73, p < 0.05). Although the mechanism behind this finding is unclear, GIB appears to be linked to higher transfusion rates, which may cause the development of subsequent allosensitization.
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27
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Kang J, Zhang DM, Restle DJ, Kallel F, Acker MA, Atluri P, Bartoli CR. Reduced continuous-flow left ventricular assist device speed does not decrease von Willebrand factor degradation. J Thorac Cardiovasc Surg 2016; 151:1747-1754.e1. [DOI: 10.1016/j.jtcvs.2016.01.031] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 01/09/2016] [Accepted: 01/15/2016] [Indexed: 02/07/2023]
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28
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Gastrointestinal Bleeding Following LVAD Placement from Top to Bottom. Dig Dis Sci 2016; 61:1440-7. [PMID: 27017225 PMCID: PMC4875872 DOI: 10.1007/s10620-016-4123-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 03/06/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are an increasingly prevalent form of mechanical support for patients with end-stage heart failure. These devices can be implanted both as a bridge to transplant and as definitive/destination therapy. Gastrointestinal (GI) bleeding is one of the most common and recalcitrant long-term complications following LVAD implantation, with an incidence approaching 30 %. AIMS This review will discuss what is known about the pathophysiology of GI bleeding in LVADs and the currently available options for medical and/or endoscopic management. RESULTS The pathophysiology of bleeding is multifactorial, with hemodynamic alterations, acquired von Willebrand factor deficiency, and coagulopathy being most often implicated. The majority of bleeding events in this population result from angioectasias and gastroduodenal erosive disease. While these bleeding events are significant and often require transfusion therapy, they are rarely life threatening. Endoscopy remains the standard of care with upper endoscopy offering the highest diagnostic yield in these patients. However, the effectiveness of endoscopic hemostasis in this population is not well established. A small number of studies have evaluated medical therapy and alterations in LVAD settings as a means of preventing or treating bleeding with variable results. CONCLUSIONS In summary, GI bleeding with LVADs is a common occurrence and will continue to be as more LVADs are being performed for destination therapy.
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29
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Gastrointestinal Bleeding Following Left Ventricular Assist Device (LVAD) Implantation: Taking the Pulse of the Problem. Dig Dis Sci 2015. [PMID: 26204975 DOI: 10.1007/s10620-015-3810-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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30
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Susen S, Rauch A, Van Belle E, Vincentelli A, Lenting PJ. Circulatory support devices: fundamental aspects and clinical management of bleeding and thrombosis. J Thromb Haemost 2015; 13:1757-67. [PMID: 26302994 DOI: 10.1111/jth.13120] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/02/2015] [Indexed: 12/01/2022]
Abstract
Circulatory support devices are increasingly being used to overcome cardiac or respiratory failure. Long-term devices are used either as a 'bridge to transplant' to support patients who are unable to wait any longer for a heart transplant, or, more recently, as 'destination therapy' for older patients suffering from end-stage heart failure and who have contraindications to heart transplantation. Short-term support devices for high-risk percutaneous coronary intervention, or as a 'bridge for decision' for patients suffering from refractory cardiogenic shock, have also been developed. The clinical benefit of such assist devices has been demonstrated in several important studies, but, unfortunately, thrombotic and bleeding complications are two major clinical issues in patients requiring these devices. Overcoming these issues is of major importance to allow the safe and broad use of these devices, and to consider them as true alternatives to heart transplantation. The present review focuses on thrombotic and bleeding complications, and describes how the risk of thrombosis and bleeding may vary according to the clinical indication, but also according to the type of device. We describe the current knowledge of the mechanisms underlying the occurrence of these complications, provide some guidance for choosing the most appropriate anticoagulation regimen to prevent their occurrence for each type of device and indication, and provide some recommendations for the management of patients when the complication occurs.
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Affiliation(s)
- S Susen
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
| | - A Rauch
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
| | - E Van Belle
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
- Department of Cardiology, Lille University Hospital, Lille, France
| | - A Vincentelli
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
- Department of Cardiology, Lille University Hospital, Lille, France
- Department of Cardiac Surgery, Lille University Hospital, Lille, France
| | - P J Lenting
- Inserm U1176 & UMR_S 1176, University Paris-Sud, Le Kremlin Bicêtre, France
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31
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Baumann Kreuziger LM, Kim B, Wieselthaler GM. Antithrombotic therapy for left ventricular assist devices in adults: a systematic review. J Thromb Haemost 2015; 13:946-55. [PMID: 25845489 DOI: 10.1111/jth.12948] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) have dramatically increased the survival of adults with end-stage systolic heart failure. However, rates of bleeding and thromboembolism remain high. OBJECTIVES We completed a systematic review to evaluate outcomes of adults with LVADs treated with various anticoagulant and antiplatelet strategies. METHODS Databases were searched using the terms 'assist device', 'thrombosis', and 'anticoagulant' or 'platelet aggregation inhibitor' with appropriate synonyms, device names and manufacturers. RESULTS AND CONCLUSIONS Of 977 manuscripts, 24 articles met the inclusion criteria of adults with implanted LVADs where clinical outcomes were defined based on anticoagulant and/or antiplatelet regimen. Most studies reported treatment with unfractionated heparin post-operatively which was transitioned to a vitamin K antagonist (VKA). Goal INR varied between 1.5-3.5. Antiplatelet regimens ranged from no treatment to dual therapy. Definition of major bleeding differed between trials and incidence varied between 0% and 58%. The available evidence could not demonstrate a clear benefit of aspirin compared with VKA therapy alone [stroke RR 1.02 (95% CI 0.49-2.1)]. There was a suggestion that treatment with aspirin and dipyridamole decreased the risk of thromboembolism compared to aspirin [RR 0.50 (0.36-0.68)], but the comparison is limited by differences in demographics, devices, and INR goals among studies. Additionally, most studies did not blind investigators to outcomes thus contributing to an increased risk for bias. Clinical equipoise exists as to the most appropriate antithrombotic therapy in LVAD patients. Randomization between regimens within a prospective trial is needed to define the treatment regimen that minimizes both bleeding and thrombotic complications.
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Affiliation(s)
- L M Baumann Kreuziger
- Department of Medicine/Hematology and Oncology, Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B Kim
- University of California San Francisco, San Francisco, CA, USA
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32
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Octreotide in the management of recurrent gastrointestinal bleed in patients supported by continuous flow left ventricular assist devices. ASAIO J 2015; 61:107-9. [PMID: 25232774 DOI: 10.1097/mat.0000000000000143] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Gastrointestinal (GI) bleeding is the most common cause of readmission in patients supported by continuous flow left ventricular assist devices (CF-LVAD). We describe our experience in the off-label use of octreotide in the management of recurrent GI bleed in this population. Of 116 patients implanted with a CF-LVAD at our institution, seven had recurrent GI bleeding unresponsive to conventional management and were started in chronic octreotide injections. Hospitalizations due to GI bleeding, number of packed red blood cells transfused, and number of endoscopic procedures were compared 3 months before and after octreotide treatment. In the overall cohort, there were no differences in these three endpoints. When one patient with differing characteristics was excluded from the analysis there was a trend (p = 0.06) to a reduction of hospitalizations due to GI bleeding, number of blood transfusions, and number of endoscopic procedures. Octreotide exhibit a favorable trend in the frequency of admissions, blood transfusions, and endoscopic procedures in most patients with recurrent GI bleed. Further prospective studies are needed to clarify its benefits in this population.
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33
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Gastrointestinal bleeding with continuous-flow left ventricular assist devices. Clin J Gastroenterol 2015; 8:63-7. [DOI: 10.1007/s12328-015-0551-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 12/25/2014] [Indexed: 12/27/2022]
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Octreotide for the Management of Gastrointestinal Bleeding in a Patient with a HeartWare Left Ventricular Assist Device. Case Rep Cardiol 2014; 2014:826453. [PMID: 25587457 PMCID: PMC4281453 DOI: 10.1155/2014/826453] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/01/2014] [Indexed: 12/11/2022] Open
Abstract
HeartWare is a third generation left ventricular assist device (LVAD), widely used for the management of advanced heart failure patients. These devices are frequently associated with a significant risk of gastrointestinal (GI) bleeding. The data for the management of patients with LVAD presenting with GI bleeding is limited. We describe a 56-year-old lady, recipient of a HeartWare device, who experienced recurrent GI bleeding and was successfully managed with subcutaneous (SC) formulations of octreotide.
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Critoph C, Chih S, Baumwol J. The world's longest-supported HeartWare ventricular assist device patient: 6 years and counting on minimal anticoagulation. Artif Organs 2014; 38:434-5. [PMID: 24773238 DOI: 10.1111/aor.12293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Christopher Critoph
- Advanced Heart Failure and Cardiac Transplantation, Royal Perth Hospital, Perth, Western Australia, Australia.
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Pirbodaghi T, Asgari S, Cotter C, Bourque K. Physiologic and hematologic concerns of rotary blood pumps: what needs to be improved? Heart Fail Rev 2014; 19:259-66. [PMID: 23549998 DOI: 10.1007/s10741-013-9389-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Over the past few decades, advances in ventricular assist device (VAD) technology have provided a promising therapeutic strategy to treat heart failure patients. Despite the improved performance and encouraging clinical outcomes of the new generation of VADs based on rotary blood pumps (RBPs), their physiologic and hematologic effects are controversial. Currently, clinically available RBPs run at constant speed, which results in limited control over cardiac workload and introduces blood flow with reduced pulsatility into the circulation. In this review, we first provide an update on the new challenges of mechanical circulatory support using rotary pumps including blood trauma, increased non-surgical bleeding rate, limited cardiac unloading, vascular malformations, end-organ function, and aortic valve insufficiency. Since the non-physiologic flow characteristic of these devices is one of the main subjects of scientific debate in the literature, we next emphasize the latest research regarding the development of a pulsatile RBP. Finally, we offer an outlook for future research in the field.
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Affiliation(s)
- Tohid Pirbodaghi
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland,
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37
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Jahren SE, Amacher R, Weber A, Most H, Flammer SA, Traupe T, Stoller M, de Marchi S, Vandenberghe S. Effects of Thoratec pulsatile ventricular assist device timing on the abdominal aortic wave intensity pattern. Am J Physiol Heart Circ Physiol 2014; 307:H1243-51. [PMID: 25320334 DOI: 10.1152/ajpheart.00085.2014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Arterial waves are seen as possible independent mediators of cardiovascular risks, and the wave intensity analysis (WIA) has therefore been proposed as a method for patient selection for ventricular assist device (VAD) implantation. Interpreting measured wave intensity (WI) is challenging, and complexity is increased by the implantation of a VAD. The waves generated by the VAD interact with the waves generated by the native heart, and this interaction varies with changing VAD settings. Eight sheep were implanted with a pulsatile VAD (PVAD) through ventriculoaortic cannulation. The start of PVAD ejection was synchronized to the native R wave and delayed between 0 and 90% of the cardiac cycle in 10% steps or phase shifts (PS). Pressure and velocity signals were registered, with the use of a combined Doppler and pressure wire positioned in the abdominal aorta, and used to calculate the WI. Depending on the PS, different wave interference phenomena occurred. Maximum unloading of the left ventricle (LV) coincided with constructive interference and maximum blood flow pulsatility, and maximum loading of the LV coincided with destructive interference and minimum blood flow pulsatility. We believe that noninvasive WIA could potentially be used clinically to assess the mechanical load of the LV and to monitor the peripheral hemodynamics such as blood flow pulsatility and risk of intestinal bleeding.
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Affiliation(s)
| | - Raffael Amacher
- Institute for Dynamic Systems and Control, ETH Zurich, Zurich, Switzerland
| | - Alberto Weber
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Henriette Most
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Shannon Axiak Flammer
- Department of Clinical Veterinary Medicine, University of Bern, Bern, Switzerland; and
| | - Tobias Traupe
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Michael Stoller
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Stefano de Marchi
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Stijn Vandenberghe
- Institute for Dynamic Systems and Control, ETH Zurich, Zurich, Switzerland; ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
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Bozkurt S, van Tuijl S, Schampaert S, van de Vosse FN, Rutten MC. Arterial pulsatility improvement in a feedback-controlled continuous flow left ventricular assist device: An ex-vivo experimental study. Med Eng Phys 2014; 36:1288-95. [DOI: 10.1016/j.medengphy.2014.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 05/31/2014] [Accepted: 07/02/2014] [Indexed: 10/25/2022]
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Chan CHH, Pieper IL, Fleming S, Friedmann Y, Foster G, Hawkins K, Thornton CA, Kanamarlapudi V. The Effect of Shear Stress on the Size, Structure, and Function of Human von Willebrand Factor. Artif Organs 2014; 38:741-50. [DOI: 10.1111/aor.12382] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Chris Hoi Houng Chan
- Institute of Life Science; College of Medicine; Swansea University; Swansea Wales UK
| | - Ina Laura Pieper
- Institute of Life Science; College of Medicine; Swansea University; Swansea Wales UK
| | - Scott Fleming
- Institute of Life Science; College of Medicine; Swansea University; Swansea Wales UK
| | - Yasmin Friedmann
- Institute of Life Science; College of Medicine; Swansea University; Swansea Wales UK
| | - Graham Foster
- Institute of Life Science; Calon Cardio-Technology Ltd; Swansea Wales UK
| | - Karl Hawkins
- Institute of Life Science; College of Medicine; Swansea University; Swansea Wales UK
| | - Catherine A. Thornton
- Institute of Life Science; College of Medicine; Swansea University; Swansea Wales UK
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40
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Draper KV, Huang RJ, Gerson LB. GI bleeding in patients with continuous-flow left ventricular assist devices: a systematic review and meta-analysis. Gastrointest Endosc 2014; 80:435-446.e1. [PMID: 24975405 DOI: 10.1016/j.gie.2014.03.040] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 03/24/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with left ventricular assist devices (LVADs) are at increased risk of GI bleeding (GIB), primarily from GI angiodysplastic lesions (GIAD). OBJECTIVE To perform meta-analysis of the medical literature in order to determine prevalence and risk factors for GIB. DESIGN A literature search was performed to identify studies reporting GIB in LVAD patients. We extracted rates of prevalence, rebleeding, and overall mortality from each study. Pooled event rates and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. SETTING Meta-analysis of 17 case-control and cohort studies. PATIENTS A total of 1839 LVAD patients of whom 1697 (92%) had continuous-flow LVADs. RESULTS The pooled prevalence of GIB in LVAD patients was 23% (95% CI, 20.5%-27%). Subgroup analysis demonstrated that older age (standard difference in means (SDm), 0.69; 95% CI, 0.23-1.15), and elevated creatinine (SDm, 0.65; 95% CI, 0.12-1.18, P = .02) were associated with GIB. Risk factors not associated with GIB included LVAD as destination therapy (OR 1.85; 95% CI, 0.8-4.3), prior history of GIB (OR 2.22; 95% CI, 0.83-5.96), hypertension (OR 1.6; 95% CI, 0.87-2.97), and/or the presence of a continuous-flow LVAD (OR 4.5; 95% CI, 2.1-9.5). Recurrence of GIB occurred in 9.3% (95% CI, 7%-12%), with a GIB mortality rate of 23% (95% CI, 16%-32%). The pooled event rates were 48% (95% CI, 39%-57%) for upper GIB, 22% (95% CI, 16%-31%) for lower GIB, and 15% (95% CI, 8%-25%) for small-bowel bleeding. GIAD in the proximal GI tract were the most common cause of GIB (29%). LIMITATIONS Lack of information regarding endoscopic therapy and follow-up in most studies. CONCLUSIONS The prevalence of GIB is increased in patients with continuous-flow LVADs, primarily secondary to the presence of GIAD.
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Affiliation(s)
- Karen V Draper
- Division of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Robert J Huang
- Division of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Lauren B Gerson
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
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41
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Gutsche JT, Atluri P, Augoustides JG. Treatment of ventricular assist-device-associated gastrointestinal bleeding with hormonal therapy. J Cardiothorac Vasc Anesth 2014; 27:939-43. [PMID: 24054188 DOI: 10.1053/j.jvca.2013.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Indexed: 12/16/2022]
Affiliation(s)
- Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA.
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42
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Gastrointestinal bleeding in patients with ventricular assist devices is highest immediately after implantation. ASAIO J 2014; 59:480-5. [PMID: 23995990 DOI: 10.1097/mat.0b013e3182a4b434] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular assist device implantation is associated with gastrointestinal bleeding (GIB); however, outcomes in terms of initial and repeat GIB risk, severity, location of lesions, and endoscopic interventions need to be better defined. Consecutive patients from a database of adult patients with ventricular assist devices (VADs) implanted between January 1, 2000, and December 31, 2010, at a single center were reviewed and followed through May 31, 2011, in a retrospective manner. The GIB events were further classified by severity, lesion location, and lesion type. Hazard analysis models were calculated for the time to GIB events. Of 166 patients with a VAD, 38 patients experienced 84 GIB events. Seventeen patients experienced ≥2 GIB events. Maximal hazard for the first bleeding event was 2.23 events/patient-year at 21 days and declined to the constant hazard by 71 days postimplantation. The hazard for recurrent GIB was greatest immediately after the first GIB event. When considering all GIB events, most lesions (68%) were located in the proximal bowel. Angiodysplasia was the most common lesion type (17.5%) seen on endoscopy when all GIB events were considered, whereas ulcers were the most common type (13.8%) seen in initial GIB events. The actuarial risk of initial GIB events peaks in the first 3 months after VAD implantation followed by a stable lower risk of bleeding. The hazard for recurrent GIB events is substantially increased immediately after the initial GIB.
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43
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Sabashnikov A, Mohite PN, Simon AR, Popov AF. HeartWare miniaturized intrapericardial ventricular assist device: advantages and adverse events in comparison to contemporary devices. Expert Rev Med Devices 2014; 10:441-52. [DOI: 10.1586/17434440.2013.811851] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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44
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Ballew CC, Surratt JF, Collins TL, Shah N. Gastrointestinal bleeding in patients with ventricular assist devices: what every cardiac nurse should know. Prog Transplant 2013; 23:229-34. [PMID: 23996942 DOI: 10.7182/pit2013954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patients with end-stage heart failure are increasingly being treated with implantation of a long-term ventricular assist device. As the use of these devices has grown, health care providers have been faced with managing clinically significant gastrointestinal bleeding in this population. Gastrointestinal bleeding is not uncommon and is reported to occur in 13% to 44% of patients treated with ventricular assist devices. Interestingly, because patients with ventricular assist devices are housed on units accustomed to managing the device, cardiac nurses are often asked about the management of gastrointestinal bleeding. This article describes the possible causes of, the array of diagnostic procedures for, and treatments for this complication. It is critical to develop an understanding of this topic so cardiac nurses can partner with other subspecialty groups to manage this population.
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Affiliation(s)
- Carole C Ballew
- University of Virginia Health System, Charlottesville, VA, USA.
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45
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Coutance G, Saplacan V, Belin A, Repessé Y, Buklas D, Massetti M. Octreotide for recurrent intestinal bleeding due to ventricular assist device. Asian Cardiovasc Thorac Ann 2013; 22:350-2. [PMID: 24585917 DOI: 10.1177/0218492312474902] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We report the case of a 64-year-old Jarvik 2000 recipient with a high risk of bleeding (anticoagulation treatment and acquired von Willebrand disease), who presented with intractable gastrointestinal hemorrhage due to severe gastric angiodysplasia. He was successfully treated with long-acting octreotide.
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46
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Ozturk T, Nalcaci S, Ozturk P, Engin C, Yagdi T, Akkin C, Ozbaran M. Fundus fluorescein angiographic findings in patients who underwent ventricular assist device implantation. Artif Organs 2013; 37:816-20. [PMID: 23826834 DOI: 10.1111/aor.12123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Disruption of microcirculation in various tissues as a result of deformed blood rheology due to ventricular assist device (VAD) implantation causes novel arteriovenous malformations. Capillary disturbances and related vascular leakage in the retina and choroidea may also be seen in patients supported by VADs. We aimed to evaluate retinal vasculature deteriorations after VAD implantation. The charts of 17 patients who underwent VAD implantation surgery for the treatment of end-stage heart failure were retrospectively reviewed. Eight cases (47.1%) underwent pulsatile pump implantation (Berlin Heart EXCOR, Berlin Heart Mediprodukt GmbH, Berlin, Germany); however, nine cases (52.9%) had continuous-flow pump using centrifugal design (HeartWare, HeartWare Inc., Miramar, FL, USA). Study participants were selected among the patients who had survived with a VAD for at least 6 months, and results of detailed ophthalmologic examinations including optic coherence tomography (OCT) and fundus fluorescein angiography (FA) were documented. All of the 17 patients were male, with a mean age of 48.5 ± 14.8 years (15-67 years). Detailed ophthalmologic examinations including the evaluation of retinal vascular deteriorations via FA were performed at a mean of 11.8 ± 3.7 months of follow-up (6-18 months). Mean best-corrected visual acuity and intraocular pressure were found as logMAR 0.02 ± 0.08 and 14.6 ± 1.9 mm Hg, respectively in the study population. Dilated fundoscopy revealed severe focal arteriolar narrowing in two patients (11.8%), and arteriovenous crossing changes in four patients (23.5%); however, no pathological alteration was present in macular OCT scans. In patients with continuous-flow blood pumps, mean arm-retina circulation time (ARCT) and arteriovenous transit time (AVTT) were found to be 16.8 ± 3.0 and 12.4 ± 6.2 s, respectively; whereas those with pulsatile-flow blood pumps were found to be 17.4 ± 3.6 and 14.0 ± 2.1 s in patients (P=0.526 and P=0.356, respectively). FA also revealed a tendency for increased frequency of dye leakage from the optic disc in our study population. Except for remarkable delays in both ARCT and AVTT as well as a tendency for increased frequency of dye leakage from the optic disc, ophthalmologic evaluations revealed no other significant pathology or vascular deterioration in the retina that could be attributed to artificial heart systems.
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Affiliation(s)
- Taylan Ozturk
- Department of Ophthalmology, Dokuz Eylul University School of Medicine, Izmir, Turkey
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47
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Wever-Pinzon O, Selzman CH, Drakos SG, Saidi A, Stoddard GJ, Gilbert EM, Labedi M, Reid BB, Davis ES, Kfoury AG, Li DY, Stehlik J, Bader F. Pulsatility and the risk of nonsurgical bleeding in patients supported with the continuous-flow left ventricular assist device HeartMate II. Circ Heart Fail 2013; 6:517-26. [PMID: 23479562 DOI: 10.1161/circheartfailure.112.000206] [Citation(s) in RCA: 173] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bleeding is an important cause of morbidity and mortality in patients with continuous-flow left ventricular assist devices (LVADs). Reduced pulsatility has been implicated as a contributing cause. The aim of this study was to assess the effects of different degrees of pulsatility on the incidence of nonsurgical bleeding. METHODS AND RESULTS The Utah Transplantation Affiliated Hospitals (U.T.A.H.) heart failure and transplant program databases were queried for patients with end-stage heart failure who required support with the continuous-flow LVAD HeartMate II (Thoratec Corp, Pleasanton, CA) between 2004 and 2012. Pulsatility was evaluated by means of the LVAD parameter pulsatility index (PI) and by the echocardiographic assessment of aortic valve opening during the first 3 months of LVAD support. PI was analyzed as a continuous variable and also stratified according to tertiles of all the PI measurements during the study period (low PI: <4.6, intermediate PI: 4.6-5.2, and high PI: >5.2). Major nonsurgical bleeding associated with a decrease in hemoglobin ≥2 g/dL (in the absence of hemolysis) was the primary end point. A total of 134 patients (median age of 60 [interquartile range: 49-68] years, 78% men) were included. Major bleeding occurred in 33 (25%) patients (70% gastrointestinal, 21% epistaxis, 3% genitourinary, and 6% intracranial). In multivariable analysis, PI examined either as a categorical variable, low versus high PI (hazard ratio, 4.06; 95% confidence interval, 1.35-12.21; P=0.04), or as a continuous variable (hazard ratio, 0.60; 95% confidence interval, 0.40-0.92; P=0.02) was associated with an increased risk of bleeding. CONCLUSIONS Reduced pulsatility in patients supported with the continuous-flow LVAD HeartMate II is associated with an increased risk of nonsurgical bleeding, as evaluated by PI.
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Affiliation(s)
- Omar Wever-Pinzon
- Utah Transplantation Affiliated Hospitals, Cardiac Transplant Program, Salt Lake City, UT, USA.
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Hoffmeier A, Welp H, Rukosujew A, Scherer M, Martens S, Köhler M, Scheld H, Sindermann J. Blutungen am VAD-System. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-012-0937-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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49
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Pirbodaghi T, Axiak S, Weber A, Gempp T, Vandenberghe S. Pulsatile control of rotary blood pumps: Does the modulation waveform matter? J Thorac Cardiovasc Surg 2012; 144:970-7. [DOI: 10.1016/j.jtcvs.2012.02.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 12/29/2011] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
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50
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Pulsed or continuous flow in long-term assist devices: a debated topic. Transplant Rev (Orlando) 2012; 26:241-5. [PMID: 22835486 DOI: 10.1016/j.trre.2012.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 06/11/2012] [Indexed: 01/23/2023]
Abstract
The end-stage cardiomyopathy is an increasing worldwide problem. Cardiac transplantation lacks sufficient donors to treat all patients, and there is thus debate about alternative strategies. The use of left ventricular assist devices for long-term support is increasing with a positive impact on patient survival. Although there is an ongoing debate regarding the risks and benefits of maintaining pulsatile flow during long-term ventricular assist device support, there has been a significant move towards implantation of continuous flow devices due to the lower surgical morbidity and better long-term reliability of these pumps. The following is a review of the literature on continuous and pulsatile flow for long-term support. Starting from the definition of flow, we analyze the current evidence and consider gastrointestinal complications.
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