The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
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J. Heart Lung Transplant. · Jan 2014
EditorialThe vexing problem of thrombosis in long-term mechanical circulatory support.
Durable left ventricular assist devices (LVADs) have not only enhanced longevity but also conferred sustained improvements in quality of life, symptom control, and functional capacity in patients with medically refractory advanced heart failure. Problems with device-related infection, bleeding, neurologic events, right-sided heart failure, and device malfunction have dominated the clinical care of patients living on mechanical support. ⋯ By 2012, the problem of thrombosis in LVADs began to consume most of the scientific direction as centers and collaborative groups began to dissect this nascent phenomenon. In this perspective, we describe the magnitude and implications of pump thrombosis, discuss secular and management trends in this unique population, attempt to dissect the problem at its root, offer guidance on surveillance and therapeutic principles, and outline issues that deserve our immediate and collaborative attention.
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J. Heart Lung Transplant. · Jan 2014
Device thrombosis in HeartMate II continuous-flow left ventricular assist devices: a multifactorial phenomenon.
Continuous-flow left ventricular assist devices (CF-LVADs) are increasingly used to support patients with advanced heart failure (HF). Device thrombosis is a serious complication of CF-LVADs, but its precise prevalence and etiology remains uncertain. ⋯ Device thrombosis is a multifactorial phenomenon, and differentiation of mechanical and non-mechanical causes is an essential step for individual diagnosis and treatment plans. Larger studies excluding patients with obvious mechanical etiology are needed to investigate biologic and/or management-related risk factors for device thrombosis. Our findings suggest that LDH may be an early risk marker. Due to the difficulty in treating late-stage device thrombosis, we suggest early use of simple tests to rule out both causes of thrombosis, such as X-rays and closer LDH monitoring (bi-weekly).
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J. Heart Lung Transplant. · Jan 2014
The use of eptifibatide for suspected pump thrombus or thrombosis in patients with left ventricular assist devices.
Pump thrombosis in patients with left ventricular assist devices (LVADs) continues to present treatment challenges. Anti-coagulation strategies used to treat this complication are empiric and without firm data for guidance. The addition of a platelet glycoprotein IIb/IIIa inhibitor to intravenous anti-coagulation has been suggested by several case series and recent guidelines. The aim of this study was to evaluate our use of eptifibatide for the treatment of suspected pump thrombus/thrombosis. ⋯ Our limited experience indicates the risk of using eptifibatide outweighs the proposed benefit of salvaging the existing LVAD in the setting of suspected pump thrombus/thrombosis at our institution.
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J. Heart Lung Transplant. · Jan 2014
Hemolysis in left ventricular assist device: a retrospective analysis of outcomes.
Hemolysis is becoming increasingly recognized as a major complication of left ventricular assist device (LVAD) support. Data regarding risk factors, prevalence, and outcomes are limited. To better define the characteristics and prognosis of hemolysis, we present a retrospective case-control study of LVAD patients in our institution. ⋯ These findings demonstrate that hemolysis is associated with high mortality, likely serving as a marker of pump thrombosis. Elevated lactate dehydrogenase and bilirubin levels are important indicators for hemolysis, and lower international normalized ratio may pre-dispose for this worrisome condition. Diagnosis should prompt clinicians to consider pump exchange or explant, listing for transplantation, or intensifying anti-coagulation.
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J. Heart Lung Transplant. · Jan 2014
Comparative StudyAmbient hemolysis and activation of coagulation is different between HeartMate II and HeartWare left ventricular assist devices.
Thromboembolic and bleeding events in patients with a left ventricular assist device (LVAD) are still a major cause of complications. Therefore, the balance between anti-coagulant and pro-coagulant factors needs to be tightly controlled. The principle hypothesis of this study is that different pump designs may have an effect on hemolysis and activation of the coagulation system. Referring to this, the HeartMate II (HMII; Thoratec Corp, Pleasanton, CA) and the HeartWare HVAD (HeartWare International Inc, Framingham, MA) were investigated. ⋯ Our results support the finding that all patients with rotary blood pumps suffered from von Willebrand syndrome. In addition, a distinct footprint of effects on hemolysis and the coagulation system can be attributed to different devices. As a consequence, the individual status of the coagulation system needs to be controlled in long-term patients.