1
|
Hammer Y, Xie J, Yang G, Bitar A, Haft JW, Cascino TM, Likosky DS, Pagani FD, Zhang M, Aaronson KD. Gastrointestinal bleeding following Heartmate 3 left ventricular assist device implantation: The Michigan Bleeding Risk Model. J Heart Lung Transplant 2024; 43:604-614. [PMID: 38065237 DOI: 10.1016/j.healun.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) results in frequent hospitalizations and impairs quality of life in durable left ventricular assist device (LVAD) recipients. Anticipation of these events before implantation could have important implications for patient selection and management. METHODS The study population included all adult HeartMate 3 (HM3) primary LVAD recipients enrolled in the STS Intermacs registry from January 2017 to December 2020. Using multivariable modeling methodologies, we investigated the relationships between preimplantation characteristics and postimplant bleeding, bleeding and death, and additional bleeding episodes on subsequent bleeding episodes and created a risk score to predict the likelihood of post-LVAD GIB based solely on preimplantation factors. RESULTS Of 6,425 patients who received an HM3 LVAD, 1,010 (15.7%) patients experienced GIB. Thirteen preimplantation factors were independent predictors of post-LVAD GIB. A risk score was created from these factors and calculated for each patient. By 3 years postimplant, GIB occurred in 11%, 26%, and 43% of low-, medium- and high-risk patients, respectively. Experiencing 1 post-LVAD GIB event was associated with an increased risk for further GIB events, with 33.9% of patients experiencing at least 1 recurrence. While post-LVAD GIB was associated with mortality, there was no relationship between number of GIB events and death. CONCLUSIONS The Michigan Bleeding Risk Model is a simple tool, which facilitates the prediction of post-LVAD GIB in HM3 recipients using 13 preimplant variables. The implementation of this tool may help in the risk stratification process and may have therapeutic and clinical implications in HM3 LVAD recipients.
Collapse
Affiliation(s)
- Yoav Hammer
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan.
| | - Jiaheng Xie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Guangyu Yang
- Institute of Statistics and Big Data, Renmin University of China, Beijing, China
| | - Abbas Bitar
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Jonathan W Haft
- Department of Cardiac Surgery, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Thomas M Cascino
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Min Zhang
- Tsinghua Univeristy, Vanke School of Public Health, Beijing, China
| | - Keith D Aaronson
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
2
|
Antonopoulos M, Bonios MJ, Dimopoulos S, Leontiadis E, Gouziouta A, Kogerakis N, Koliopoulou A, Elaiopoulos D, Vlahodimitris I, Chronaki M, Chamogeorgakis T, Drakos SG, Adamopoulos S. Advanced Heart Failure: Therapeutic Options and Challenges in the Evolving Field of Left Ventricular Assist Devices. J Cardiovasc Dev Dis 2024; 11:61. [PMID: 38392275 PMCID: PMC10888700 DOI: 10.3390/jcdd11020061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Heart Failure is a chronic and progressively deteriorating syndrome that has reached epidemic proportions worldwide. Improved outcomes have been achieved with novel drugs and devices. However, the number of patients refractory to conventional medical therapy is growing. These advanced heart failure patients suffer from severe symptoms and frequent hospitalizations and have a dismal prognosis, with a significant socioeconomic burden in health care systems. Patients in this group may be eligible for advanced heart failure therapies, including heart transplantation and chronic mechanical circulatory support with left ventricular assist devices (LVADs). Heart transplantation remains the treatment of choice for eligible candidates, but the number of transplants worldwide has reached a plateau and is limited by the shortage of donor organs and prolonged wait times. Therefore, LVADs have emerged as an effective and durable form of therapy, and they are currently being used as a bridge to heart transplant, destination lifetime therapy, and cardiac recovery in selected patients. Although this field is evolving rapidly, LVADs are not free of complications, making appropriate patient selection and management by experienced centers imperative for successful therapy. Here, we review current LVAD technology, indications for durable MCS therapy, and strategies for timely referral to advanced heart failure centers before irreversible end-organ abnormalities.
Collapse
Affiliation(s)
- Michael Antonopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Michael J Bonios
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stavros Dimopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Evangelos Leontiadis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Aggeliki Gouziouta
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Nektarios Kogerakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Antigone Koliopoulou
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Dimitris Elaiopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Ioannis Vlahodimitris
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Maria Chronaki
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Themistocles Chamogeorgakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Stamatis Adamopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| |
Collapse
|
3
|
Phan J, Elgendi K, Javeed M, Aranda JM, Ahmed MM, Vilaro J, Al-Ani M, Parker AM. Thrombotic and Hemorrhagic Complications Following Left Ventricular Assist Device Placement: An Emphasis on Gastrointestinal Bleeding, Stroke, and Pump Thrombosis. Cureus 2023; 15:e51160. [PMID: 38283491 PMCID: PMC10811971 DOI: 10.7759/cureus.51160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
The left ventricular assist device (LVAD) is a mechanical circulatory support device that supports the heart failure patient as a bridge to transplant (BTT) or as a destination therapy for those who have other medical comorbidities or complications that disqualify them from meeting transplant criteria. In patients with severe heart failure, LVAD use has extended survival and improved signs and symptoms of cardiac congestion and low cardiac output, such as dyspnea, fatigue, and exercise intolerance. However, these devices are associated with specific hematologic and thrombotic complications. In this manuscript, we review the common hematologic complications of LVADs.
Collapse
Affiliation(s)
- Joseph Phan
- Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Kareem Elgendi
- Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Masi Javeed
- Internal Medicine, HCA Healthcare/University of South Florida Morsani College of Medicine, Graduate Medical Education: Bayonet Point Hospital, Hudson, USA
| | - Juan M Aranda
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Mustafa M Ahmed
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Juan Vilaro
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Mohammad Al-Ani
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Alex M Parker
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, USA
| |
Collapse
|
4
|
Consolo F, Pieri M, Pazzanese V, Scandroglio AM, Pappalardo F. Longitudinal analysis of pump parameters over long-term support with the HeartMate 3 left ventricular assist device. J Cardiovasc Med (Hagerstown) 2023; 24:771-775. [PMID: 37409664 DOI: 10.2459/jcm.0000000000001522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
AIMS Recurrence of heart failure emerged as the main cause of long-term mortality in patients implanted with the HeartMate 3 (HM3) left ventricular assist device (LVAD). We aimed at deriving a possible mechanistic rationale of clinical outcomes and analyzed longitudinal changes in pump parameters over prolonged HM3 support to investigate long-term effects of pump settings on left ventricular mechanics. METHODS Data on pump parameters (i.e. pump speed, estimated flow, and pulsatility index) were prospectively recorded in consecutive HM3 patients following postoperative rehabilitation (baseline) and then at 6, 12, 24, 36, 48, and 60 months of support. RESULTS Data of 43 consecutive patients were analyzed. Pump parameters were set according to regular patients' follow-up, including clinical and echocardiographic assessment. We recorded a significant progressive increase in pump speed over the course of support: from 5200 (5050-5300) rpm at baseline to 5400 (5300-5600) rpm at 60 months of support ( P = 0.0007). Consistently with the increase in pump speed, a significant increase in pump flow ( P = 0.007) and a decrease in pulsatility index ( P = 0.005) were also recorded. CONCLUSION Our results reveal unique features of the HM3 on left ventricular activity. The need for progressive increase in pump support suggests indeed a lack of recovery and worsening of left ventricular function, which emerge as a possible mechanistic rationale of heart failure related mortality in HM3 patients. New algorithms to optimize pump settings should be envisioned to further improve LVAD-LV interaction and, ultimately, clinical outcomes in the HM3 population. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT03255928. CLINICALTRIALSGOV IDENTIFIER NCT03255928.
Collapse
Affiliation(s)
| | - Marina Pieri
- Università Vita Salute San Raffaele, Milano
- Department of Anesthesia and Intensive Care, Cardiothoracic Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, Cardiothoracic Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| |
Collapse
|
5
|
Wu S, Lv M, Ma F, Feilong Z, Fang G, Zhang J. A new model (Alfalfa-Warfarin-GIB) for predicting the risk of major gastrointestinal bleeding in warfarin patients. Eur J Clin Pharmacol 2023; 79:1195-1204. [PMID: 37392366 DOI: 10.1007/s00228-023-03533-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND This study aimed to analyze the factors influencing warfarin-related major gastrointestinal bleeding (GIB) and to develop a score that would provide a reference for assessing the risk of major GIB associated with warfarin treatment. METHODS This was a retrospective analysis of clinical and follow-up data from warfarin-treated patients. Scores were analyzed using logistic regression. The area under the subject working characteristic curve (AUC), sensitivity, specificity, and Hosmer-Lemeshow test were used to evaluate the scoring performance. RESULTS A total of 1591 patients who met the requirements for warfarin use were included in this study, and 46 developed major GIB. After univariate analysis as well as multivariate logistic regression analysis, nine factors were found to be associated with increased risk of major GIB, namely age ≥ 65 years, history of peptic ulcer, history of major bleeding, abnormal liver function, abnormal renal function, cancer, anemia, labile international normalized ratio, and combination of antiplatelet agents/non-steroidal anti-inflammatory drugs. The Alfalfa-Warfarin-GIB score was constructed using these nine factors. The AUC and Bootstrap method-corrected AUC of the Alfalfa-Warfarin-GIB score were 0.916 (95% CI: 0.862-0.970, P < 0.001) and 0.919 (95% CI: 0.860-0.967, P < 0.001), respectively, which were higher than those of the HAS-BLED score (AUC = 0.868, 95% CI: 0.812-0.924, P < 0.001). CONCLUSION Based on nine risk factors, the Alfalfa-Warfarin-GIB score was constructed to predict the risk of warfarin-related major GIB. The newly developed Alfalfa-Warfarin-GIB score has a better predictive value than the HAS-BLED score and may be an effective tool to help reduce the occurrence of major GIB in patients on warfarin.
Collapse
Affiliation(s)
- Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Meina Lv
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Fuxin Ma
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Zhang Feilong
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Guanhua Fang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
| |
Collapse
|
6
|
Mohamed MS, Shehadah A, Hashem A, Chand S, Bapaye J, Khalouf A, Rai D, Peter S. Gastrointestinal Bleeding in Patients Supported with Left Ventricular Assist Devices: The Journey from Bridging to Destination. Am J Cardiol 2023; 201:71-77. [PMID: 37352668 DOI: 10.1016/j.amjcard.2023.05.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/15/2023] [Accepted: 05/31/2023] [Indexed: 06/25/2023]
Abstract
End-stage heart failure is a prevalent and fatal cardiovascular disease. Almost 1 in 4 cases of mortality in the United States is attributed to heart failure. Left ventricular assist devices (LVADs) have emerged as a safe destination therapy or bridge to transplant. Despite remarkable results, LVAD is associated with significant adverse events, such as gastrointestinal bleeding (GIB). In this review, we aimed to understand the incidence and prevalence, pathophysiologic mechanisms, predictors, diagnostic mechanisms, management, and preventative measures of GIB in patients with an LVAD. GIB is a common adverse event in patients with an LVAD with an incidence of 15% to 25%. The exact pathogenesis of GIB is poorly understood. However, different mechanisms of bleeding have been described, such as arteriovenous malformations, acquired von Willebrand syndrome, coagulopathy, and treatment with antithrombotic therapy. Upper GIB is the most common site of GIB in patients with an LVAD. The management of GIB in patients with LVAD includes ensuring hemodynamic stability, holding or reversing antithrombotic therapy, and investigating and controlling the source of GIB through diagnostic and interventional endoscopic and radiologic means. Prophylactic medication use (e.g., danazol, octreotide, and bevacizumab) can decrease the risk of GIB in patients with an LVAD by decreasing arteriovenous malformations. Despite that the overall risk of GIB has decreased with new advancements in LVAD technology, further studies are needed regarding predictors, risk stratification, and optimal antithrombotic therapy to minimize the morbidity and mortality in patients with an LVAD. In conclusion, prompt diagnosis and management in a multidisciplinary team approach are crucial and lifesaving in such a life-threatening condition.
Collapse
Affiliation(s)
| | - Ahmed Shehadah
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Anas Hashem
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Swati Chand
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Amani Khalouf
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Devesh Rai
- Sands Constellation Heart Institute, Rochester General Hospital, Rochester, New York
| | - Shajan Peter
- Department of Gastroenterology, University of Alabama, Birmingham, Alabama
| |
Collapse
|
7
|
Consolo F, Pappalardo F. New Antithrombotic Strategies to Improve Outcomes With the HeartMate 3. ASAIO J 2023; 69:e3-6. [PMID: 35947801 DOI: 10.1097/MAT.0000000000001794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
|
8
|
Lv M, Jiang S, Wu T, Huang N, Chen X, Chen C, Zhang J. A new model to predict the risk of major gastrointestinal bleeding in patients on direct oral anticoagulants (dabigatran and rivaroxaban). Br J Clin Pharmacol 2023; 89:253-260. [PMID: 35971682 DOI: 10.1111/bcp.15491] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 07/04/2022] [Accepted: 08/01/2022] [Indexed: 11/27/2022] Open
Abstract
AIMS The aim of this study was to identify factors associated with gastrointestinal bleeding (GIB) in patients on direct oral anticoagulants (DOACs) and develop a risk score that would provide an effective tool for the clinical assessment of GIB. METHODS This was a multicentre retrospective analysis of clinical and follow-up data of patients treated with DOACs. The score was developed through logistic regression. The performance of score was evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, specificity and Hosmer-Lemeshow test. RESULTS The 11 903 patients had a mean age of 65.1 years. In multivariate analysis, age ≥65 years, alcohol use, history of peptic ulcer, history of major bleeding, abnormal liver function or renal function, cancer, platelet count <100 × 109 /L, anaemia, and concurrent antiplatelet agent or non-steroidal anti-inflammatory drug treatment were independent risk factors for GIB, and concurrent treatment with gastrointestinal protective agents were a protective factor. The Alfalfa-DOAC-GIB score was constructed using these 12 factors. The AUC of the Alfalfa-DOAC-GIB score was 0.77 (95% CI 0.74-0.81), which was higher than that of the HAS-BLED score (0.69; 95% CI 0.65-0.72) and the New score (0.65; 95% CI 0.61-0.68). CONCLUSIONS Based on 12 factors, we developed a gastrointestinal bleeding risk score. The newly developed Alfalfa-DOAC-GIB score has better predictive value than the HAS-BLED score and the New score, and might be an effective tool to help reduce the occurrence of GIB in patients using DOACs.
Collapse
Affiliation(s)
- Meina Lv
- Department of Pharmacy, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Nianxu Huang
- Department of Pharmacy, Taikang Tongji (Wuhan) Hospital, Wuhan, China
| | - Xia Chen
- Department of Pharmacy, Fuling Hospital of Chongqing University, Chongqing, China
| | - Chunmei Chen
- Department of Neurosurgery, Fujian Medical University Union Hospital, Fujian, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fujian, China
| |
Collapse
|
9
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
10
|
Graves JM, Pruett C, Stephenson K, Deych E, Yang BQ, Vader JM, Gage BF. Established Clinical Prediction Rules for Bleeding had Mediocre Discrimination in Left Ventricular Assist Device Recipients. ASAIO J 2022. [PMID: 36228628 DOI: 10.1097/MAT.0000000000001816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Left ventricular assist devices (LVAD) reduce mortality in patients with end-stage heart failure, but LVAD management is frequently complicated by bleeding. Bleeding prediction post-LVAD implantation is challenging as prediction rules for hemorrhage have not been rigorously studied in this population. We aimed to validate clinical prediction rules for bleeding, derived in the atrial fibrillation and venous thromboembolism populations, in an LVAD cohort. This was a retrospective cohort study of LVAD recipients at an academic center. The primary end-point was time to gastrointestinal bleed or intracranial hemorrhage after implant; the secondary end-point was time to any major hemorrhage after hospital discharge. Four hundred and eighteen patients received an LVAD (135 HeartMate II, 125 HeartMate 3, 158 HVAD) between November 2009 and January 2019. The primary end-point occurred in 169 (40.4%) patients with C-statistics ranging 0.55-0.58 (standard deviation [SD] 0.02 for all models). The secondary end-point occurred in 167 (40.0%) patients with C-statistics ranging 0.53-0.58 (SD 0.02 for all models). Modifying the age and liver function thresholds increased the C-statistic range to 0.56-0.60 for the primary and secondary end-points. In a sensitivity analysis of HeartMate 3 patients, prediction rules performed similarly. Existing prediction rules for major bleeding had mediocre discrimination in an LVAD cohort.
Collapse
|
11
|
Xanthopoulos A, Magouliotis DE, Tryposkiadis K, Zotos PA, Spiliopoulos K, Athanasiou T, Giamouzis G, Skoularigis J, Starling RC, Triposkiadis F. Post-Implant Phosphodiesterase-5 Inhibitors in Patients with Left Ventricular Assist Device: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11. [PMID: 36294308 DOI: 10.3390/jcm11205988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Despite the improvement in left ventricular assist device (LVAD) technology and the advent of third-generation LVADs, hemocompatibility-related events remain a significant issue. Therefore, new pharmacological treatments are necessary to optimize patient management and to further reduce hemocompatibility-related events. The purpose of the present systematic review and meta-analysis was to summarize the existing data regarding the safety and efficacy of post-implant phosphodiesterase-5 inhibitors (PDE-5i) on hemocompatibility-related events. Methods: Among the 258 articles in Pubmed, Scopus, and CENTRAL that were retrieved (1990−2022), 15 studies were included in the qualitative synthesis, and 9 studies were included in the quantitative synthesis. The fixed-effects model was used because it is statistically sound for combining a very small number of studies. The primary endpoint of the study was all-cause mortality, whereas the secondary endpoints were ischemic stroke, pump thrombosis, and gastrointestinal bleeding. Results: Mortality was significantly lower in the PDE-5i group vs. the control group (OR: 0.92 [95% CI: 0.85, 0.98]; p = 0.02). The secondary endpoints ischemic stroke (OR: 0.87 [95% CI: 0.78, 0.98]; p = 0.02) and pump thrombosis (OR: 0.90 [95% CI: 0.82, 0.99]; p = 0.04) were also lower in the PDE-5i group. The incidence of gastrointestinal bleeding was significantly higher in patients with LVAD receiving PDE-5i (OR: 1.26 [95% CI: 1.11, 1.44]; p < 0.01). In the overall analysis, the heterogeneity of outcomes was low, except for pump thrombosis. Conclusions: The use of PDE-5i post-implant was associated with lower mortality and thrombotic events but with a higher risk of gastrointestinal bleeding.
Collapse
|
12
|
Dailey J, Nguyen LH, Kohli A, Ha JB, Russell MB, Dhingra R, Kiernan MS, Thomas MF, Coglianese EC, Sterling MJ, Yacavone RF, Natov N, Richter JM. A Multicenter Study of Left Ventricular Assist Device-Related Gastrointestinal Bleeding. Clin Transl Gastroenterol 2022; 13:e00526. [PMID: 36007177 PMCID: PMC9624495 DOI: 10.14309/ctg.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Continuous left ventricular assist devices (LVADs) offer hemodynamic support in advanced and decompensated heart failure but are often complicated by gastrointestinal bleeding (GIB) in medically fragile patients. METHODS We performed a retrospective analysis of 475 consecutive patients who underwent LVAD implantation at the Massachusetts General Hospital and Tufts Medical Center from 2008 to 2019 and identified 128 patients with clinically significant GIB. Clinical characteristics of each bleeding event, including procedures and interventions, were recorded. We examined LVAD patients with overt and occult presentations to determine diagnostic endoscopic yield and analyzed predictors of recurrent GIB. RESULTS We identified 128 unique patients with LVAD implantation complicated by GIB. No significant difference was observed based on study center, underlying cardiomyopathy, race/ethnicity, serum indices, and medications used. Overt bleeders presented more commonly during LVAD implantation admission ( P = 0.001) than occult bleeders. Occult bleed presentations had only 1 lower and no middle GI bleed source identified, despite similar workups to overt bleeds. Destination therapy (e.g., among nontransplant candidates) LVAD implantation (odds ratio 2.38, 95% confidence interval 1.05-5.58) and a history of GIB (odds ratio 3.85, 95% confidence interval 1.29-12.7) were independently associated with an increased risk of recurrent GIB-related hospitalization. DISCUSSION Our findings confirm a high rate of GIB, especially in destination LVAD patients, and show a low diagnostic yield for colonoscopy and middle GI bleed assessments in LVAD patients with occult bleeds. Overt bleeding was more common and associated with vascular malformations. Although endoscopic interventions stopped active hemorrhage, GIB often recurred.
Collapse
Affiliation(s)
- Joseph Dailey
- Division of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Long H. Nguyen
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Clinical and Translational Epidemiology Unit, Boston, Massachusetts, USA
| | - Arushi Kohli
- Division of Gastroenterology, Boston Medical Center, Boston, Massachusetts, USA
| | - Jasmine B. Ha
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael B. Russell
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Rohit Dhingra
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Michael S. Kiernan
- Department of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Molly F. Thomas
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin C. Coglianese
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Transplant Center, Boston, Massachusetts, USA
| | - Mark J. Sterling
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Robert F. Yacavone
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nikola Natov
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
| | - James M. Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
13
|
Morris KL, Haleem A, Garcia-Cortes R, Patel A, Thomas J, Sudharshan S, Chaudhry SP, Ravichandran A. A Single-center Experience of CardioMEMS in Patients With Left Ventricular Assist Devices. ASAIO J 2022; 68:e116-e117. [PMID: 34593683 DOI: 10.1097/mat.0000000000001568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Kathleen L Morris
- From the Department of Cardiology and Advanced Heart Failure and Cardiac Transplantation, Ascension St. Vincent Hospital, Indianapolis, Indiana
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Auschra B, Wilhelm MJ, Husung C, Jenewein J, Flammer AJ, Jellestad L. The use of serotonin reuptake inhibitors increases the risk of bleeding in patients with assist devices. BMC Cardiovasc Disord 2022; 22:121. [PMID: 35317724 PMCID: PMC8939197 DOI: 10.1186/s12872-022-02557-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 03/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Bleedings are frequent and dreaded complications in heart failure patients with ventricular assist devices (VAD). Serotonin reuptake inhibitor (SRI) antidepressants are widely used to treat depression in these patients, though they are attributed an increased risk of bleeding due to their modification of hemostasis. Evidence on bleeding risk of VAD patients under SRI medication is scarce and limited. We therefore aimed to assess if SRI use is associated with an elevated bleeding risk in this particularly vulnerable population. Methods We analyzed the medical records of 92 VAD patients at the University Heart Center Zurich between September 2004 and April 2018 for the occurrence of bleedings and the concomitant use of an SRI. Bleeding was defined as any type of post-implantation bleeding requiring medical treatment. We performed univariate analyses and linear mixed-effects models, adjusting for baseline clinical characteristics as potential predictors to identify differences in bleeding rates in patients with vs. without SRI intake. Results The cohort comprised 60.9% of patients with a continuous-flow VAD and 39.1% with a pulsatile-flow VAD. A total of 77.2% of patients experienced at least one bleeding incident. Overall, 28.6% of bleedings occurred under SRI therapy. A generalized linear mixed model showed a predictive effect of SRI medication on bleeding rate, independent of VAD type (z = 2.091, p = 0.037). Conclusions Bleeding events in heart failure patients occur frequently after VAD implantation. Patients with SRI medication were at increased risk of bleeding. The indication and use of SRI, therefore, should be considered carefully.
Collapse
Affiliation(s)
- Bianca Auschra
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Markus J Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Claudia Husung
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Josef Jenewein
- Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Andreas J Flammer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Lena Jellestad
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
15
|
Varshney AS, DeFilippis EM, Cowger JA, Netuka I, Pinney SP, Givertz MM. Trends and Outcomes of Left Ventricular Assist Device Therapy: JACC Focus Seminar. J Am Coll Cardiol 2022; 79:1092-1107. [PMID: 35300822 DOI: 10.1016/j.jacc.2022.01.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/29/2021] [Accepted: 01/11/2022] [Indexed: 12/27/2022]
Abstract
As the prevalence of advanced heart failure continues to rise, treatment strategies for select patients include heart transplantation or durable left ventricular assist device (LVAD) support, both of which improve quality of life and extend survival. Recently, the HeartMate 3 has been incorporated into clinical practice, the United Network for Organ Sharing donor heart allocation system was revised, and the management of LVAD-related complications has evolved. Contemporary LVAD recipients have greater preoperative illness severity, but survival is higher and adverse event rates are lower compared with prior eras. This is driven by advances in device design, patient selection, surgical techniques, and long-term management. However, bleeding, infection, neurologic events, and right ventricular failure continue to limit broader implementation of LVAD support. Ongoing efforts to optimize management of patients implanted with current devices and parallel development of next-generation devices are likely to further improve outcomes for patients with advanced heart failure.
Collapse
Affiliation(s)
- Anubodh S Varshney
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ersilia M DeFilippis
- Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/ersied727
| | | | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic. https://twitter.com/netuka_ivan
| | - Sean P Pinney
- University of Chicago Medicine, Chicago, Illinois, USA. https://twitter.com/spinneymd
| | - Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
16
|
Xanthopoulos A, Wolski K, Wang Q, Blackstone EH, Randhawa VK, Soltesz EG, Young JB, Nissen SE, Estep JD, Triposkiadis F, Starling RC. Postimplant Phosphodiesterase-5 Inhibitor Use in Centrifugal Flow Left Ventricular Assist Devices. JACC Heart Fail 2022; 10:89-100. [PMID: 35115092 DOI: 10.1016/j.jchf.2021.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study examined the association between phosphodiesterase-5 inhibitor (PDE-5i) use and outcomes in patients with contemporary centrifugal flow left ventricular assist devices (LVADs). BACKGROUND PDE-5i use may affect outcomes in patients with continuous flow LVADs. METHODS Patients enrolled in INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support), with HeartMate 3 (n = 4,628) or HeartWare Ventricular Assist Device (HVAD) (n = 2,601) implant were included in the analysis. The mean duration of follow-up was 11.94 ± 8.65 months. PDE-5is were used in 2,173 patients. The primary endpoint was the composite of all-cause mortality, ischemic stroke, and pump thrombosis. Propensity matching and stabilized inverse probability of treatment weights were used to adjust for baseline differences between patients receiving and not receiving PDE-5i. Adjusted Cox proportional hazards analysis was performed for each outcome. RESULTS The primary endpoint was lower in the PDE-5i group (adjusted HR: 0.77; 95% CI: 0.69-0.86; P < 0.0001; HeartMate 3: adjusted HR: 0.77; 95% CI: 0.64-0.92; P = 0.0044; HVAD: adjusted HR: 0.76; 95% CI: 0.66-0.88; P = 0.0002). All-cause mortality was lower with PDE-5is (adjusted HR: 0.75; 95% CI: 0.65-0.86; P < 0.0001; HeartMate 3: adjusted HR: 0.70; 95% CI: 0.57-0.86; P = 0.0007; HVAD: adjusted HR: 0.78; 95% CI: 0.65-0.94; P = 0.0098) and fewer ischemic strokes with PDE-5is were observed (adjusted HR: 0.71; 95% CI: 0.56-0.89; P = 0.003; HeartMate 3: adjusted HR: 0.67; 95% CI: 0.45-0.99; P = 0.045; HVAD: adjusted HR: 0.73; 95% CI: 0.56-0.97; P = 0.03). LVAD thrombosis was unchanged with PDE-5is, with overall low event rates observed. CONCLUSIONS Postimplant PDE-5i use was associated with lower mortality and ischemic strokes in patients with centrifugal flow LVADs.
Collapse
Affiliation(s)
- Andrew Xanthopoulos
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
| | - Kathy Wolski
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio, USA
| | - Qiuqing Wang
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varinder Kaur Randhawa
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward G Soltesz
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - James B Young
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio, USA
| | - Jerry D Estep
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Randall C Starling
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| |
Collapse
|
17
|
Hendren NS, Segar MW, Zhong L, Michelis KC, Drazner MH, Young JB, Tang WHW, Pandey A, Grodin JL. Phenomapping a Novel Classification System for Patients With Destination Therapy Left Ventricular Assist Devices. Am J Cardiol 2022; 164:93-99. [PMID: 34815060 DOI: 10.1016/j.amjcard.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022]
Abstract
Patients with continuous flow destination therapy (DT) left ventricular assist devices (LVAD) comprise a heterogeneous population. We hypothesized that phenotypic clustering of individuals with DT LVADs by their implantation characteristics will be associated with different long-term risk profiles. We analyzed 5,999 patients with continuous flow DT LVADs in Interagency Registry for Mechanically Assisted Circulatory Support using 18 continuous variable baseline characteristics. We Z-transformed the variables and applied a Gaussian finite mixture model to perform unsupervised clustering resulting in identification of 4 phenogroups. Survival analyses considered the competing risk for cumulative incidence of transplant or the composite end point of death or heart transplant where appropriate. Phenogroup 1 (n = 1,163, 19%) was older (71 years) and primarily white (81%). Phenogroups 2 (n = 648, 11%) and 3 (n = 3,671, 61%) were of intermediate age (70 and 62 years), weight (85 and 87 kg), and ventricular size. Phenogroup 4 (n = 517, 9%) was younger (40 years), heavier (108 kg), and more racially diverse. The cumulative incidence of death, heart transplant, bleeding, LVAD malfunction, and LVAD thrombosis differed among phenogroups. The highest incidence of death and the lowest rate of heart transplant was seen in phenogroup 1 (p <0.001). For adverse outcomes, phenogroup 4 had the lowest incidence of bleeding, whereas LVAD device thrombosis and malfunction were lowest in phenogroup 1 (p <0.001 for all). Finally, the incidence of stroke, infection, and renal dysfunction were not statistically different. In conclusion, the present unsupervised machine learning analysis identified 4 phenogroups with different rates of adverse outcomes and these findings underscore the influence of phenotypic heterogeneity on post-LVAD implantation outcomes.
Collapse
Affiliation(s)
- Nicholas S Hendren
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas
| | - Matthew W Segar
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas
| | - Lin Zhong
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katherine C Michelis
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Division of Cardiology, Department of Internal Medicine, North Texas VA Medical Center, Dallas, Texas
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - James B Young
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas.
| |
Collapse
|
18
|
Truong VT, Shreenivas S, Mazur W, Egnaczyk GF, Palmer C, Rao SD, Rame JE, Chung ES. Left Ventricular End-Diastolic Dimension and Clinical Outcomes After Centrifugal Flow Left Ventricular Assist Device Implantation. ASAIO J 2022; 68:220-225. [PMID: 33927084 DOI: 10.1097/mat.0000000000001449] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The impact of preoperative end-diastolic left ventricular dimension (preLVEDD) on long-term outcomes with centrifugal continuous-flow left ventricular assist device (CF-LVAD) is not well established. Accordingly, we performed an analysis of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry to study this relationship. All patients with centrifugal CF-LVAD in the INTERMACS registry from June 2006 to December 2017 were screened. The final study group consisted of 3,304 patients. After a median follow-up of 9.0 months (interquartile range [IQR], 4.2-18.8 months), 2,596 (79%) patients were alive. After adjusting for significant covariates, increased preLVEDD was associated with lower mortality (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84-0.98; p = 0.01), stroke (HR, 0.85; 95% CI, 0.77-0.93; p < 0.001), and gastrointestinal bleeding (HR, 0.88; 95% CI, 0.80-0.97; p = 0.01), although there were more arrhythmias (HR, 1.14; 95% CI, 1.05-1.24; p = 0.003). Our study suggests that preLVEDD is an independent predictor of mortality and adverse events in patients treated with centrifugal CF-LVAD. preLVEDD should be considered an important preimplant variable for risk stratification when considering a CF-LVAD.
Collapse
Affiliation(s)
- Vien T Truong
- From the The Christ Hospital Health Network, Cincinnati, Ohio
- The "Lindner" Research Center, Cincinnati, Ohio
| | | | - Wojciech Mazur
- From the The Christ Hospital Health Network, Cincinnati, Ohio
| | | | - Cassady Palmer
- From the The Christ Hospital Health Network, Cincinnati, Ohio
| | - Sriram D Rao
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Advanced Cardiac and Pulmonary Vascular Disease, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Eugene S Chung
- From the The Christ Hospital Health Network, Cincinnati, Ohio
| |
Collapse
|
19
|
Peivandi A, Welp H, Scherer M, Sindermann JR, Wagner NM, Dell'Aquila AM. An external validation study of the Utah Bleeding Risk Score. Eur J Cardiothorac Surg 2022; 62:6506259. [PMID: 35024851 DOI: 10.1093/ejcts/ezab572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/25/2021] [Accepted: 12/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices (CF-LVAD) impairs quality of life and increases hospitalization rate. The Utah Bleeding Risk Score (UBRS) has been created to predict gastrointestinal bleeding (GIB) in patients on left ventricular assist device. We here aimed to externally validate UBRS on our cohort of CF-LVAD patients. METHODS Utah Bleeding Risk Score was calculated, GIB events summarized on follow-up and patients stratified into 3 risk groups. Predictive ability of UBRS was examined at 3 years and during whole support time and person time incidence rates correlated to UBRS. In a sub-analysis, single effects of UBRS variables on freedom from GIB were assessed. RESULTS A total of 111 CF-LVAD patients were included. The median UBRS was 2 (3-1). Receiver operating characteristic curve analysis showed an area under the curve of 0.519 (P = 0.758, 95% confidence interval = 0.422-0.615) at 3 years and an area under the curve of 0.515 (P = 0.797, 95% confidence interval = 0.418-0.611) during whole support time. No significant difference was observed in UBRS between bleeders and non-bleeders (P = 0.80). No significant difference in freedom from GIB was observed (P3 years = 0.7; Psupport-time = 0.816) and no independent significance regarding the freedom from bleeding at 3 years for any variable was observed. Coronary artery disease was associated with higher risk of GIB beyond the 3rd year (P = 0.048). CONCLUSIONS UBRS was not able to predict GIB and therefore not applicable in our cohort of patients. Coronary artery disease could lead to a higher risk for GIB during support time. An additional validation in a larger cohort is advisable.
Collapse
Affiliation(s)
- Armin Peivandi
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Henryk Welp
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Mirela Scherer
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Jürgen R Sindermann
- Interdisciplinary Heart Failure Section, University Hospital Muenster, Muenster, Germany
| | - Nana-Maria Wagner
- Department of Anesthesiology, Intensive Care and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| |
Collapse
|
20
|
Klajda M, Trachtenberg B, Araujo R, Estep JD, Masotti M, Teigen L, Schultz J, John R, Martin C, Suarez EE, Cogswell R. Pre-Operative Sarcopenia is Predictive of Recurrent Gastrointestinal Bleeding on Left Ventricular Assist Device Support: A Multicenter Analysis. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 12/13/2021] [Accepted: 01/03/2022] [Indexed: 12/19/2022] Open
|
21
|
Diakos NA, Taleb I, Kyriakopoulos CP, Shah KS, Javan H, Richins TJ, Yin MY, Yen C, Dranow E, Bonios MJ, Alharethi R, Koliopoulou AG, Taleb M, Fang JC, Selzman CH, Stellos K, Drakos SG. Circulating and Myocardial Cytokines Predict Cardiac Structural and Functional Improvement in Patients With Heart Failure Undergoing Mechanical Circulatory Support. J Am Heart Assoc 2021; 10:e020238. [PMID: 34595931 PMCID: PMC8751895 DOI: 10.1161/jaha.120.020238] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Recent prospective multicenter data from patients with advanced heart failure demonstrated that left ventricular assist device (LVAD) support combined with standard heart failure medications, induced significant cardiac structural and functional improvement, leading to high rates of LVAD weaning in selected patients. We investigated whether preintervention myocardial and systemic inflammatory burden could help identify the subset of patients with advanced heart failure prone to LVAD-mediated cardiac improvement to guide patient selection, treatment, and monitoring. Methods and Results Ninety-three patients requiring durable LVAD were prospectively enrolled. Myocardial tissue and blood were acquired during LVAD implantation, for measurement of inflammatory markers. Cardiac structural and functional improvement was prospectively assessed via serial echocardiography. Eleven percent of the patients showed significant reverse remodeling following LVAD support (ie, responders). Circulating tumor necrosis factor alpha, interleukin (IL)-4, IL-5, IL-6, IL-7, IL-13, and interferon gamma were lower in responders, compared with nonresponders (P<0.05, all comparisons). The myocardial tissue signal transducer and activator of transcription-3, an inflammatory response regulator, was less activated in responders (P=0.037). Guided by our tissue studies and a multivariable dichotomous regression analysis, we identified that low levels of circulating interferon gamma (odds ratio [OR], 0.06; 95% CI, 0.01-0.35) and tumor necrosis factor alpha (OR, 0.05; 95% CI, 0.00-0.43), independently predict cardiac improvement, creating a 2-cytokine model effectively predicting responders (area under the curve, 0.903; P<0.0001). Conclusions Baseline myocardial and systemic inflammatory burden inversely correlates with cardiac improvement following LVAD support. A circulating 2-cytokine model predicting significant reverse remodeling was identified, warranting further investigation as a practical preintervention tool in identifying patients prone to LVAD-mediated cardiac improvement and device weaning.
Collapse
Affiliation(s)
- Nikolaos A. Diakos
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,Present address:
Division of CardiologyColumbia University Medical CenterNew YorkNY
| | - Iosif Taleb
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Christos P. Kyriakopoulos
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Kevin S. Shah
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Hadi Javan
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Tyler J. Richins
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT
| | - Michael Y. Yin
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Chi‐Gang Yen
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Elizabeth Dranow
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Michael J. Bonios
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT,Present address:
Onassis Cardiac Surgery CenterAthensGreece
| | - Rami Alharethi
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Antigone G. Koliopoulou
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT,Present address:
Onassis Cardiac Surgery CenterAthensGreece
| | - Mariam Taleb
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT
| | - James C. Fang
- University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Craig H. Selzman
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| | - Konstantinos Stellos
- Cardiovascular Research CentreNewcastle University & Cardiothoracic CentreNewcastle upon Tyne HospitalsNewcastleUK
| | - Stavros G. Drakos
- Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of UtahSalt Lake CityUT,University of Utah Health and School of Medicine, Intermountain Medical Center, George E. Wahlen Department of Veterans Affairs Medical CenterU.T.A.H. (Utah Transplant Affiliated Hospitals) Cardiac Transplant ProgramSalt Lake CityUT
| |
Collapse
|
22
|
Abstract
Left ventricular assist devices (LVADs) are indicated in inotrope-dependent heart failure (HF) patients with pure or predominant LV dysfunction. Survival benefit is less clear in ambulatory, advanced HF. Timing is crucial: early, unnecessary exposure to the risks of surgery, and device-related complications (infections, stroke, and bleeding) should be weighed against the probability of dying or developing irreversible right ventricular and/or end-organ dysfunction while deferring implant. The interplay between LVAD and heart transplantation depends largely on donor availability and allocation rules. Postoperatively, quality of life depends on patients' expectations and is influenced by complications. Patients' preferences, prognosis, and alternative options-including palliation-should be openly discussed and reviewed before and after the operation.
Collapse
Affiliation(s)
- Maria Frigerio
- 2nd Section of Cardiology, Heart Failure and Transplant Unit, DeGasperis CardioCenter, Niguarda Great Metropolitan Hospital, Milan, Italy.
| |
Collapse
|
23
|
Stern B, Maheshwari P, Gorrepati VS, Bethards D, Chintanaboina J, Boehmer J, Clarke K. Initial endoscopic intervention is not associated with reduced risk of recurrent gastrointestinal bleeding in left ventricular assist device patients. Ann Gastroenterol 2021; 34:660-668. [PMID: 34475736 PMCID: PMC8375646 DOI: 10.20524/aog.2021.0656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/23/2020] [Indexed: 11/11/2022] Open
Abstract
Background Left ventricular assist devices (LVADs) are increasingly used for mechanical support of end-stage heart failure. Gastrointestinal bleeding (GIB) confers a significant morbidity in LVAD patients, with rates of up to 30% at 5 years. We assessed predictors of index and recurrent GIB (rGIB) in LVAD patients to risk stratify patients and evaluate if endoscopic approach and intervention at index GIB impacted rGIB. Methods A retrospective chart review of all LVAD patients at our institution from 01/01/2006 to 31/10/2016 was completed. Predictors for index and recurrent GIB were analyzed. Multivariate logistic regression analysis was created using only statistically significant dependent variables and adjusted for demographic variables. Results A total of 77/214 (36%) patients developed GIB, and 38/214 (17.8%) developed rGIB. Destination therapy (P=0.01), longer duration of LVAD (P=0.03), and low albumin (<3.5 g/dL) (P<0.001) were associated with increased risk of index GIB. Charlson Comorbidity Index, heart failure etiology, and Medicare were predictors of index GIB on univariate analysis, but this was not seen on multivariate analysis. Performing an endoscopy with/without intervention, non- angioectasia lesions, and location of bleeding were not statistically significant predictors of rGIB. Longer duration of hospitalization appeared to be protective for rGIB on univariate analysis. Conclusions Index endoscopy and intervention is not associated with reduced risk of rGIB in LVAD patients. Several independent factors are associated with the risk of index GIB. Albumin is a potentially modifiable risk factor, and likely contributes to bleeding through poor nutrition. It is a surrogate marker for systemic illness, and may have pharmacologic implications.
Collapse
Affiliation(s)
- Benjamin Stern
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Benjamin Stern, Venkata S. Gorrepati, Deborah Bethards, Kofi Clarke)
| | - Parth Maheshwari
- Department of Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Parth Maheshwari)
| | - Venkata S Gorrepati
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Benjamin Stern, Venkata S. Gorrepati, Deborah Bethards, Kofi Clarke)
| | - Deborah Bethards
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Benjamin Stern, Venkata S. Gorrepati, Deborah Bethards, Kofi Clarke)
| | - Jayakrishna Chintanaboina
- Division of Gastroenterology, University of California San Francisco Fresno, Fresno, CA, USA (Jayakrishna Chintanaboina)
| | - John Boehmer
- Division of Cardiology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (John Boehmer)
| | - Kofi Clarke
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA (Benjamin Stern, Venkata S. Gorrepati, Deborah Bethards, Kofi Clarke)
| |
Collapse
|
24
|
Sorensen EN, Plazak ME, Dees LM, Klass WJ, Ziegler LA, Ledroux SN, Griffith BP, Feller ED. Comparison of two individualized antithrombotic protocols in HeartWare HVAD recipients. Artif Organs 2021; 46:117-127. [PMID: 34425001 DOI: 10.1111/aor.14055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/14/2021] [Accepted: 08/11/2021] [Indexed: 12/27/2022]
Abstract
We previously reported low rates of pump thrombosis and hemorrhagic stroke, but increased bleeding, under our original antithrombosis protocol (P1) in HeartWare recipients. We designed and implemented a revised protocol (P2) to reduce complexity and bleeding. Thrombelastography and PFA-100 guide antiplatelet titration. Goals for P2 were altered to decrease antiplatelet use and anticoagulation intensity. We compared the incidence and rates of gastrointestinal bleeding (GIB), embolic (eCVA) and hemorrhagic (hCVA) stroke, pump thrombosis (PT), and total bleeding (GIB+hCVA), total thrombosis (eCVA+PT), and total events between P1 and P2. Laboratory and medication data were assessed. Patients with and without hemocompatibility-related adverse events (HRAEs) were compared. The study included 123 patients (P1: 65; P2: 58). GIB rate decreased (P1: 0.66; P2 0.30 EPPY, P = .003). CVA rates and incidence were statistically similar, although hCVA incidence increased (P1: 3%; P2: 12%, P = .06). Incidence (P1: 3%; P2: 16%, P = .02) and rate (P1: 0.03; P2: 0.12 EPPY, P = .08) of PT increased. Incidence and rate of overall HRAEs and thrombotic events were similar, while bleeding rate decreased (P1: 0.69; P2: 0.40 EPPY, P = .02). Twelve-month medication burden decreased. Compared to non-HRAE patients, patients with bleeding HRAEs had more antiplatelet and pentoxifylline use, but less statin use; and lower PFAs. Patients with thrombotic HRAEs had less dual antiplatelet use, lower INRs, R-times, and PFA-ADP values. A revised antithrombotic protocol decreased GIB and overall hemorrhagic HRAE rate and medication burden. Unfortunately, PT increased. Non-HRAE and HRAE patients differed in anticoagulation and antiplatelet intensity. These differences will guide the revision of P2.
Collapse
Affiliation(s)
- Erik N Sorensen
- Division of Perioperative Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Michael E Plazak
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Lynn M Dees
- Division of Cardiology, Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Wyatt J Klass
- Division of Perioperative Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Luke A Ziegler
- Procirca/University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shannon N Ledroux
- Division of Cardiology, Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Bartley P Griffith
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Erika D Feller
- Division of Cardiology, Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| |
Collapse
|
25
|
Palchaudhuri S, Dhawan I, Parsikia A, Birati EY, Wald J, Siddique SM, Fisher LR. Does endoscopic intervention prevent subsequent gastrointestinal bleeding in patients with left ventricular assist devices? A retrospective study. World J Gastroenterol 2021; 27:3877-3887. [PMID: 34321851 PMCID: PMC8291026 DOI: 10.3748/wjg.v27.i25.3877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/19/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with left ventricular assist devices (LVADs) are at increased risk for recurrent gastrointestinal bleeding (GIB) and repeat endoscopic procedures. We assessed the frequency of endoscopy for GIB in patients with LVADs and the impact of endoscopic intervention on preventing a subsequent GIB.
AIM To evaluate for an association between endoscopic intervention and subsequent GIB. Secondary aims were to assess the frequency of GIB in our cohort, describe GIB presentations and sources identified, and determine risk factors for recurrent GIB.
METHODS We conducted a retrospective cohort study of all patients at a large academic institution who underwent LVAD implantation from January 2011 – December 2018 and assessed all hospital encounters for GIB through December 2019. We performed a descriptive analysis of the GIB burden and the outcome of endoscopic procedures performed. We performed multivariate logistic regression to evaluate the association between endoscopic intervention and subsequent GIB.
RESULTS In the cohort of 295 patients, 97 (32.9%) had at least one GIB hospital encounter. There were 238 hospital encounters, with 55.4% (132/238) within the first year of LVAD implantation. GIB resolved on its own by discharge in 69.8% (164/235) encounters. Recurrent GIB occurred in 55.5% (54/97) of patients, accounting for 59.2% (141/238) of all encounters. Of the 85.7% (204/238) of encounters that included at least one endoscopic evaluation, an endoscopic intervention was performed in 34.8% (71/204). The adjusted odds ratio for subsequent GIB if an endoscopic intervention was performed during a GIB encounter was not significant (odds ratio 1.18, P = 0.58).
CONCLUSION Patients implanted with LVADs whom experience recurrent GIB frequently undergo repeat admissions and endoscopic procedures. In this retrospective cohort study, adherence to endoscopic guidelines for performing endoscopic interventions did not significantly decrease the odds of subsequent GIB, thus suggesting the uniqueness of the LVAD population. A prospective study is needed to identify patients with LVAD at risk of recurrent GIB and determine more effective management strategies.
Collapse
Affiliation(s)
- Sonali Palchaudhuri
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Ishita Dhawan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Afshin Parsikia
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Edo Y Birati
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Joyce Wald
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Shazia Mehmood Siddique
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Laurel R Fisher
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| |
Collapse
|
26
|
Affiliation(s)
- Sai Kiran Bhagra
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Stephen Pettit
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Jayan Parameshwar
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
27
|
Aigner P, Schlöglhofer T, Plunger LC, Beitzke D, Wielandner A, Schima H, Zimpfer D, Moscato F. Pump position and thrombosis in ventricular assist devices: Correlation of radiographs and CT data. Int J Artif Organs 2021; 44:956-964. [PMID: 34088235 PMCID: PMC8581720 DOI: 10.1177/03913988211017552] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Malpositioning of left ventricular assist devices (LVAD) is a risk factor for thrombosis, but its identification from clinical imaging remains challenging. X-rays and CT scans were analyzed and parameters identified that correlated to pump thrombosis. Retrospective imaging data of patients (n = 115) with HeartmateII (HMII) or HVAD were analyzed in two groups (pump-thrombosis PT, n = 15 vs matched control group NT, n = 15) using routine X-rays and CT scans. In CT, directional deviations of the inflow cannula in three-chamber and two-chamber view (α and β angles) were identified. In HVAD PT frontal radiographs showed reduced pump body area and smaller minor axis (PT 41.3 ± 4.8 mm vs NT 34.9 ± 6.0 mm, p = 0.026), and in the lateral radiographs the visibility of the inflow cannula served as a predictive parameter for PT. In HMII patients, no parameters were associated with PT. The angle α differed significantly (NT −1.2 ± 7.5°, PT −22.0 ± 4.7°, p = 0.006) in HVAD patients. Further, correlations of x-ray parameters with CT angles α and β showed that radiographs can be used to identify malpositioned pumps. Well-aligned inflow cannula positions are essential. HVAD patients with a posterior rotation of the inflow cannula have a higher risk of pump thrombosis. This risk can reliably be identified from routine radiographs.
Collapse
Affiliation(s)
- Philipp Aigner
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Thomas Schlöglhofer
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Division for Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Lea Carmen Plunger
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Dietrich Beitzke
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Alice Wielandner
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Heinrich Schima
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Division for Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Division for Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| |
Collapse
|
28
|
Jennings DL, Truby LK, Littlefield AJ, Ciolek AM, Marshall D, Jain R, Topkara VK. Impact of heart failure drug therapy on rates of gastrointestinal bleeding in LVAD recipients: An INTERMACS analysis. Int J Artif Organs 2021; 44:965-971. [PMID: 33977770 DOI: 10.1177/03913988211013366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Gastrointestinal bleeding (GIB) remains a common and vexing complication of left ventricular assist device (LVAD) support. Recent single-center analyses suggest that ACE inhibitors (ACEi)/angiotensin receptor blockers (ARB) and digoxin may prevent GIB in LVAD patients. Here we evaluate the effect of guideline-directed medical therapies (GDMT) for heart failure (HF) on rates of GIB through analysis of the INTERMACS registry database. METHODS Thirteen thousand seven hundred thirty-two patients who received a continuous-flow LVAD and were on antiplatelet therapy and anticoagulation with warfarin after 3 months of pump support were included in the analysis. GIB events following implant were assessed based on receipt of ACEi/ARB, beta-blockers (BB), mineralocorticoid receptor antagonist (MRA), amiodarone, digoxin, loop diuretics, and phosphiesterase-5 inhibitors (PDE5). Backwards stepwise cox regression was used to control for confounding of each drug class on each other, as well as for clinical variables like age, gender, renal function, HF etiology, and device strategy. RESULTS After 3 months of pump support medications used in LVAD patients were BB (65.0%), ACEi/ARB (51.7%), Amio (43.7%), MRA (37.9%), and loop diuretics (70.1%). In patients with available data, PDE and digoxin use were 18.2% and 16.9%, respectively. The overall incidence of GIB was 19.5% at 2 years of support. After adjustment for other clinical variables, loop diuretics (HR 1.274, p < 0.001) and PDE5 (HR 1.241, p < 0.001) use were associated with increased risk of GIB, while use of BB (HR 0.871, p = 0.006) was associated with lower risk of GIB. ACEi/ARB (HR 1.002, p = 0.971), Amio (HR 1.083, p = 0.106), AA (HR 0.967, p = 0.522) or digoxin (HR 1.087, p = 0.169) did not affect GIB rates on LVAD support (Figure). CONCLUSION Despite recent reports, ACEi/ARB, MRA, Amio, and digoxin use does not appear to be associated with GIB during LVAD support. The heightened risk seen in those on loop diuretics may reflect venous congestion in these patients, while antiplatelet effects of PDE5 could drive the higher risk of GIB.
Collapse
Affiliation(s)
- Douglas L Jennings
- Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, NY, USA.,Department of Pharmacy, NewYork-Presbyterian Hospital Columbia University Irving Medical Center, New York, NY, USA
| | - Lauren K Truby
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Audrey J Littlefield
- Department of Pharmacy, NewYork-Presbyterian Hospital Weill Cornell Medical Center, New York, NY, USA
| | - Alana M Ciolek
- Department of Pharmacy, NewYork-Presbyterian Hospital Columbia University Irving Medical Center, New York, NY, USA
| | - Dylan Marshall
- Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Rashmi Jain
- Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, NY, USA
| |
Collapse
|
29
|
Nakamura M, Imamura T, Hori M, Nakagaito M, Ueno H, Yokoyama S, Doi T, Fukahara K, Kinugawa K. Regulation of Angiopoietin-2 Before and After Mechanical Circulatory Support Therapy. ASAIO J 2021; 67:53-58. [PMID: 32740126 DOI: 10.1097/mat.0000000000001189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Gastrointestinal bleeding (GIB) during mechanical circulatory support (MCS) is a major unsolved comorbidity. Inadequate activation of angiopoietin-2-related systems is considered as a major cause of GIB. However, the regulation of angiopoietin-2 remains unknown. Consecutive 20 patients who received continuous-flow MCS therapy (MCS group) and 12 with advanced heart failure (HF; HF group) were prospectively enrolled and their angiopoetin-2 levels were compared. Angiopoietin-2 level had a moderate correlation with log10 B-type natriuretic peptide (BNP; r = 0.39, p < 0.001). The MCS group had significantly higher angiopoietin-2 level divided by log10 BNP compared with the HF group (2.80 ± 0.20 vs. 1.88 ± 0.17, p < 0.001). Angiopoetin-2 had a moderate correlation with central venous pressure and C-reactive protein during the MCS support (r = 0.51 and r = 0.45, respectively). Higher angiopoietin-2 level divided by log10 BNP (> 4.3) was significantly associated with the occurrence of GIB with a hazard ratio of 296 (95% confidence interval 2.24-38620, p = 0.0224). Angiopoietin-2 was already elevated in the HF cohort and more elevated following MCS initiation. Among the MCS cohort, angiopoietin-2 was particularly elevated in patients with systemic congestion and inflammation and was associated with higher incidence of GIB.
Collapse
Affiliation(s)
| | | | - Masakazu Hori
- From the Second Department of Internal Medicine; and
| | | | - Hiroshi Ueno
- From the Second Department of Internal Medicine; and
| | - Shigeki Yokoyama
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | - Toshio Doi
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | - Kazuaki Fukahara
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | | |
Collapse
|
30
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
31
|
Elzeneini M, Mahmoud A, Elsayed AH, Taha Y, Meece LE, Al-Ani M, Jeng EI, Arnaoutakis GJ, Vilaro JR, Parker AM, Aranda J, Ahmed MM. Predictors of perioperative bleeding in left ventricular assist device implantation. Am Heart J Plus 2021; 2:100006. [PMID: 38560584 PMCID: PMC10978136 DOI: 10.1016/j.ahjo.2021.100006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 04/04/2024]
Abstract
Study objective Early bleeding is a common source of morbidity associated with left ventricular assist device (LVAD) implantation. Our objective was to identify potential predictors of peri-implant bleeding. Methods We conducted a retrospective cohort study of LVAD implants at our institution between January 2010 and November 2018. A total of 210 patients were included. Data were collected for the duration of implant hospitalization, including perioperative invasive hemodynamics, echocardiography and operative details, antiplatelet and anticoagulant use, bleeding events and blood product use, and thromboembolic events. Peri-operative bleeding was defined as a transfusion requirement of >4 units of packed red blood cells in the intraoperative and first 7 days postoperative period, or a major 7-day post-implant overt bleeding event requiring procedural intervention. Results Perioperative bleeding occurred in 32% of patients and required surgical re-exploration in 9%. Multivariable logistic regression analysis identified history of previous sternotomy (OR 2.63, 95% CI 1.29 to 5.35, p-value 0.008), preoperative glomerular filtration rate <60 ml/min (OR 2.58, 95% CI 1.34 to 4.94, p-value 0.004), preoperative right atrial pressure >13 mm Hg (OR 2.36, 95% CI 1.19 to 4.67, p-value 0.014) and concomitant tricuspid valve repair (OR 2.48, 95% CI 1.23 to 5.01, p-value 0.011) as independent predictors of perioperative bleeding. In-hospital thromboembolic events occurred in 5% of patients, but there were no significant predictors for them. Conclusions Elevated right atrial pressure appears to be a reversible risk factor for early bleeding that should be targeted during pre-implant optimization of LVAD candidates.
Collapse
Affiliation(s)
- Mohammed Elzeneini
- Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Ahmad Mahmoud
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Abdelrahman H. Elsayed
- Division of Pharmacotherapy & Translational Research, University of Florida, Gainesville, FL, USA
| | - Yasmeen Taha
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Lauren E. Meece
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Mohammad Al-Ani
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Eric I. Jeng
- Division of Thoracic & Cardiovascular Surgery, University of Florida, Gainesville, FL, USA
| | - George J. Arnaoutakis
- Division of Thoracic & Cardiovascular Surgery, University of Florida, Gainesville, FL, USA
| | - Juan R. Vilaro
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Alex M. Parker
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Juan Aranda
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Mustafa M. Ahmed
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| |
Collapse
|
32
|
Lv M, Zheng X, Wu T, Chen W, Jiang S, Zhang H, Xu F, Zhang J. A New Score for Predicting Acute Gastrointestinal Bleeding in Patients Administered Oral Antiplatelet Drugs. Front Pharmacol 2021; 11:571605. [PMID: 33519436 PMCID: PMC7841335 DOI: 10.3389/fphar.2020.571605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/02/2020] [Indexed: 12/21/2022] Open
Abstract
Antiplatelet drugs may increase the risk of gastrointestinal bleeding. Currently, there is no specific score for predicting the risk of gastrointestinal bleeding caused by oral antiplatelet drugs. In this study, the gastrointestinal bleeding risk score was established and compared with the CRUSADE score in order to reduce the occurrence of clinical gastrointestinal bleeding events. Our study included 4052 patients who received oral antiplatelet drugs. Data were obtained from the patient medical records inpatient system. Cases of acute gastrointestinal bleeding and mortality were recorded. The bleeding score was established by logistic regression, area under the receiver operating characteristic curve, and the Hosmer–Lemeshow test. Finally, 171 patients had acute gastrointestinal bleeding. The mortality rates of patients in the bleeding and nonbleeding groups were 24.6 and 4.7%, respectively. A multivariate analysis revealed that an age of >65 years, anemia, recent major bleeding, a history of gastrointestinal bleeding, combined oral anticoagulants, and dual antiplatelet therapy are risk factors, and combined proton pump inhibitors are protective factors for acute gastrointestinal bleeding. We used these risk factors to establish a score for predicting acute gastrointestinal bleeding, named (ABC)2D score. The area under the curve for (ABC)2D score was 0.857 (p < 0.001), higher than the CRUSADE score of 0.693 (p < 0.001). The Hosmer–Lemeshow p value was 0.324. We developed the (ABC)2D score based on seven risk factors (i.e., age, anemia, recent major bleeding, a history of gastrointestinal bleeding, no-proton pump inhibitors use, combined oral anticoagulants, and dual antiplatelet therapy). (ABC)2D score was superior to the CRUSADE score. This new risk-scoring model may help to identify patients at a significant risk of gastrointestinal bleeding.
Collapse
Affiliation(s)
- Meina Lv
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Xiaochun Zheng
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Hongqin Zhang
- Department of Pharmacy, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Fangda Xu
- Department of Information, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| |
Collapse
|
33
|
Sun X, Su Y, Liu X, Zhang Y, He Y, Han W, Chen Q, Chen H, Wang Y, Cheng Y, Liu F, Wang F, Chen Y, Zhang G, Mo X, Fu H, Chen Y, Wang J, Zhu X, Xu L, Liu K, Huang X, Zhang X. Overt gastrointestinal bleeding following haploidentical haematopoietic stem cell transplantation: incidence, outcomes and predictive models. Bone Marrow Transplant 2021; 56:1341-51. [PMID: 33414512 DOI: 10.1038/s41409-020-01187-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/18/2020] [Accepted: 12/02/2020] [Indexed: 01/04/2023]
Abstract
Gastrointestinal bleeding (GIB) accounts for a significant proportion of life-threatening bleeding cases occurring after allogeneic haematopoietic stem cell transplantation (allo-HSCT). However, data on GIB after haploidentical HSCT (haplo-HSCT) are not available. A total of 3180 patients received haplo-HSCT at Peking University People's Hospital from January 2015 to November 2019, and GIB occurred in 188 of these patients (incidence of 5.9%). Platelet counts <30 × 109/L, viral hepatitis, acute kidney injury (AKI), gastrointestinal disease or bleeding before HSCT and sinusoidal obstruction syndrome (SOS) were determined to be significant risk factors for the occurrence of GIB after haplo-HSCT. Grade III-IV acute graft-versus-host disease (aGVHD), AKI, thrombotic microangiopathy (TMA), disseminated intravascular coagulation (DIC) and gastrointestinal disease or bleeding before HSCT were significantly related to mortality in patients with GIB after haplo-HSCT. The predictive models developed for the occurrence and mortality of GIB performed well in terms of discrimination, and they might assist clinicians with personalised strategies for GIB prevention and treatment in patients after haplo-HSCT.
Collapse
|
34
|
Jawaid O, Gaddy A, Omar HR, Guglin M. Ventricular Assist Devices and Chronic Kidney Replacement Therapy: Technology and Outcomes. Adv Chronic Kidney Dis 2021; 28:37-46. [PMID: 34389136 DOI: 10.1053/j.ackd.2021.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/12/2020] [Accepted: 01/04/2021] [Indexed: 11/11/2022]
Abstract
Heart failure and kidney failure are very common conditions, precipitating and exacerbating each other. Left ventricular assist devices (LVADs) represent a relatively new technology for treatment of advanced heart failure. Kidney dysfunction, if present, makes candidate selection for LVADs challenging and contributes to multiple complications while the patients are on an LVAD support. Although kidney function generally improves after LVAD implantation, some patients develop acute and then chronic kidney disease sometimes requiring kidney replacement therapies (KRTs). Overall, chronic KRT in LVAD recipients is feasible and well tolerated, but routine technique of blood pressure monitoring should be adjusted to the continuous blood flow. Both hemodialysis and peritoneal dialysis can be used. Unique challenges for chronic KRT posed by the presence of LVAD are discussed in this review.
Collapse
|
35
|
Plazak ME, Hankinson SJ, Sorensen EN, Reed BN, Ravichandran B, Ton VK. Novel Use of Tamoxifen to Reduce Recurrent Gastrointestinal Bleeding in Patients with Left Ventricular Assist Devices. J Cardiovasc Transl Res 2020; 14:484-491. [PMID: 33175315 DOI: 10.1007/s12265-020-10084-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022]
Abstract
Gastrointestinal bleeding (GIB) is a frequent complication in patients with continuous-flow left ventricular assist devices (LVAD). We retrospectively evaluated eight patients implanted with a HeartWare LVAD between July 2017 and June 2020 who experienced at least one episode of GIB and were started on tamoxifen 20 mg once daily for secondary prevention. Tamoxifen was associated with a significant decrease in major GIB from a median of 3 (IQR 1.4-7) events/patient-year pre-tamoxifen initiation to 0 (IQR 0-0.9) events/patient-year post-tamoxifen initiation (p = 0.02). Transfusion of packed red blood cells also decreased from 16.8 (IQR 9.9-30.6) units/patient-year pre-tamoxifen initiation to 1.5 (IQR 0-7.5) units/patient-year post-tamoxifen (p = 0.04). Tamoxifen was well tolerated and no thromboembolic complications were observed. This small cohort study suggests that tamoxifen is associated with reduced GIB and transfusion requirements, with no apparent increase in thrombotic risk. A larger, randomized study is warranted to confirm the results of this exploratory analysis. Graphical abstract.
Collapse
Affiliation(s)
- Michael E Plazak
- University of Maryland Medical Center, 22 South Greene Street, Suite 400, Baltimore, MD, 21201, USA.
| | - Stephen J Hankinson
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Erik N Sorensen
- Division of Perioperative Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Brent N Reed
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Bharath Ravichandran
- University of Maryland Medical Center, 22 South Greene Street, Suite 400, Baltimore, MD, 21201, USA
| | - Van-Khue Ton
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Harvard Medical School, Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
36
|
Lv MN, Zheng XC, Zhang HQ, Xu FD, Wu TT, Chen WJ, Xia XT, Fu JL, Jiang SJ, Zhang JH. Comparison of clinical performance of four gastrointestinal bleeding risk scores in Chinese patients with atrial fibrillation receiving oral anticoagulants. J Thromb Thrombolysis 2021; 51:136-42. [PMID: 32462540 DOI: 10.1007/s11239-020-02152-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Gastrointestinal bleeding is the most common bleeding complication during anticoagulant therapy. A reliable bleeding risk score can help the clinician assess risk of bleeding in individual patients and select the anticoagulant regimen. This study retrospectively analyzed the data of patients with atrial fibrillation who received anticoagulant therapy from July 2015 to December 2018 at two centers-the Fujian Medical University Union Hospital and Fuzhou Second Hospital Affiliated to Xiamen University. Demographic data, clinical findings, and laboratory results were collected from the hospital records. Patients were followed up for 6 months. The performance of four bleeding risk scores (New Score, RIETE Score, Cuschieri et al. Score, de Groot et al. Score) for prediction of gastrointestinal bleeding was assessed using the area under the curve. A total of 3462 patients (mean age, 66.3 ± 11.5 years; 59.6% males; 1055 direct oral anticoagulants users and 2407 warfarin users) were followed up for 6 months. While 99/3462 (2.9%) patients had gastrointestinal bleeding. The area under the curves for the New, RIETE, Cuschieri et al., de Groot et al. scores were 0.652 (95% CI 0.576-0.728), 0.862 (95% CI 0.809-0.914), 0.606 (95% CI 0.527-0.685), and 0.873 (95% CI 0.816-0.929), respectively. Among the four BRSs evaluated, the RIETE score and the de Groot et al. score appear to have the good predictive value, while the NEW score and the Cuschieri et al. score did not sufficiently predict gastrointestinal bleeding risk within the study Chinese population.
Collapse
|
37
|
Kilic A, Seese L, Pagani F, Kormos R. Identifying Temporal Relationships Between In-Hospital Adverse Events After Implantation of Durable Left Ventricular Assist Devices. J Am Heart Assoc 2020; 9:e015449. [PMID: 32285751 PMCID: PMC7428534 DOI: 10.1161/jaha.119.015449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background This study evaluated the impact of adverse events (AEs) on the development of subsequent AEs after left ventricular assist device (LVAD) surgery. Methods and Results The INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) was used to identify primary durable LVADs implanted between 2006 and 2016. The temporal relationships between AEs occurring during the index hospitalization were evaluated using separate risk‐adjusted Cox proportional hazard models. LVADs were implanted in 18 763 patients. The strongest positive relationships were renal failure leading to hepatic dysfunction (hazard ratio [HR], 6.62; 95% CI, 5.12–8.54; P<0.001), respiratory failure leading to renal failure (HR, 5.51; 95% CI, 4.79–6.34; P<0.001), respiratory failure leading to hepatic dysfunction (HR, 4.36; 95% CI, 3.25–5.83; P<0.001), renal failure leading to respiratory failure (HR, 4.18; 95% CI, 3.76–4.64; P<0.001), and renal failure leading to right ventricular assist device implant (HR, 3.70; 95% CI, 2.31–5.90; P<0.001). Although bleeding, infection, and right ventricular assist device implant were each associated with several subsequent AEs, the magnitude of association was less substantial. The lowest 1‐year post‐LVAD survival was associated with the primary AEs of renal failure (68.1%) and respiratory failure (70.7%) (log‐rank P<0.001). Conclusions Most in‐hospital AEs after LVAD implantation have a significant association with the development of subsequent AEs, with the most profound impact associated with primary renal or respiratory failure, which are also associated with the lowest 1‐year survival. Targeting the reduction of renal or respiratory failure as the primary AE after LVAD surgery would likely yield the greatest reductions in overall AE burden and subsequent mortality.
Collapse
Affiliation(s)
- Arman Kilic
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh PA
| | - Laura Seese
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh PA
| | - Francis Pagani
- Department of Cardiac Surgery University of Michigan Ann Arbor MI
| | - Robert Kormos
- Division of Cardiac Surgery University of Pittsburgh Medical Center Pittsburgh PA
| |
Collapse
|
38
|
Taylor C, Bittner K, Bartell N, Aranez J, Alexis JD, Carlson B, Chen L, McNitt S, Kothari T, Kaul V, Kothari S. Outcomes of gastrointestinal bleeding in patients with left ventricular assist devices: a tertiary care experience. Endosc Int Open 2020; 8:E301-E309. [PMID: 32140555 PMCID: PMC7055617 DOI: 10.1055/a-1090-7200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/28/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Left ventricular assist device (LVAD) placement is a therapeutic modality for patients with end-stage heart failure. Gastrointestinal bleeding is a common complication following LVAD implantation. The aim of this study was to report our experience in management and outcomes of gastrointestinal bleeding in a large cohort of patients with LVADs. Patients and methods We performed a retrospective review of all patients who underwent LVAD implantation at the University of Rochester Medical Center from January 2008 to June 2017. Data were collected on patient characteristics, clinical aspects of gastrointestinal bleeding events, and procedural interventions. A Cox proportional hazard model was utilized to identify potential risk factors for a gastrointestinal bleeding event. Results During the study period, 345 patients underwent LVAD implantation. Of these, 125 patients (36.2 %) experienced 297 gastrointestinal bleeding events resulting in 533 endoscopic procedures. The diagnostic yield of endoscopy in determining a bleeding source was 49.5 %. If required, therapeutic interventions were successful in achieving homeostasis in 96.2 % of procedures. Our 30-day overall post-procedure adverse event (AE) rate was 6.6 %. Procedure-related (bleeding, infection, and perforation) AEs were very minimal (2.8 %). A Cox proportional hazard model indicated that older age at implant, female sex, African-American race, diabetes mellitus, and pulmonary hypertension were statistically significant predictors of a gastrointestinal bleeding event following LVAD implantation. Conclusions LVAD patients have a high risk of gastrointestinal bleeding. Endoscopy was able to safely locate a bleeding lesion in approximately half of our patients and was successful in treating bleeding lesions in a majority of the cases.
Collapse
Affiliation(s)
- Caren Taylor
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Krystle Bittner
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Nicholas Bartell
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Jose Aranez
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Jeffrey D Alexis
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Beth Carlson
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Leway Chen
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Scott McNitt
- Division of Cardiology, University of Rochester Medical Center, Rochester New York, United States
| | - Truptesh Kothari
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Vivek Kaul
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| | - Shivangi Kothari
- Center for Advanced Therapeutic Endoscopy, Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester New York, United States
| |
Collapse
|
39
|
Kutyifa V, Naqvi SY, Vidula H, Thomas S, Sherazi S, Mcnitt S, Alexis JD. Clinical Significance of Early Hospital Readmission in Continuous-Flow Left Ventricular Assist Device Patients. ASAIO J 2020; 66:760-5. [DOI: 10.1097/mat.0000000000001065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|