scholarly journals Mechanical circulatory support: balancing bleeding and clotting in high-risk patients

Hematology ◽  
2015 ◽  
Vol 2015 (1) ◽  
pp. 61-68 ◽  
Author(s):  
Lisa Baumann Kreuziger ◽  
M. Patricia Massicotte
Keyword(s):  
High Risk ◽  
Heart Transplant ◽  
Continuous Flow ◽  
Antithrombotic Therapy ◽  
Mechanical Circulatory Support ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Acquired Von Willebrand Syndrome ◽  
Thrombotic Complications

Abstract Mechanical circulatory support (MCS) provides a bridge to heart transplant in children and adults with life-threatening heart failure and sustains patients ineligible for transplant. Extracorporeal membrane oxygenation (ECMO) provides temporary support for patients in cardiac or pulmonary failure through external gas exchange and continuous flow of blood. Because the median time to heart transplant exceeds event-free time on ECMO, pulsatile left ventricular assist devices (LVADs) are used to support infants and children. Continuous flow LVADs are preferred in adolescents and adults due to increased pump durability and improved overall survival. The shear stress created by the mechanical pumps cause changes in the hematologic system; acquired von Willebrand syndrome occurs in almost all patients treated with MCS. Despite the improvements in survival, major bleeding occurs in one-third of patients with a LVAD and ischemic stroke and LVAD thrombosis can affect 12% of adults and 29% of children. An antithrombotic strategy to mitigate LVAD bleeding and thrombotic complications has been tested in a randomized trial in children, but intensity of antithrombotic therapy in adults varies widely. Consensus guidelines for antithrombotic therapy during ECMO were created due to significant differences in management across centers. Because of the high risk for both bleeding and thrombotic complications, experts in hemostasis can significantly impact care of patients requiring mechanical circulatory support and are a necessary part of the management team.

scholarly journals Temporary mechanical circulatory support in heart transplant candidates

2018 ◽  
Vol 19 (4) ◽  
pp. 113-123
Author(s):  
V. N. Poptsov ◽  
E. A. Spirina ◽  
S. G. Ukhrenkov ◽  
D. M. Bondarenko ◽  
A. A. Dogonasheva ◽  
...  
Keyword(s):  
Heart Transplant ◽  
Mechanical Circulatory Support ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Organizational Conditions ◽  
Effi Ciency ◽  
Transplant Candidates

Implantable left ventricular assist devices (LVAD) have become the leading method of mechanical circulatory support (MCS) in heart transplant candidates. But the temporary MCS as a mechanical bridge to heart transplantation (HT) continues to use. The temporary MCS remains an effi ciency method of treatment of life-threatening heart failure (HF), when implantation of permanent LVAD or BiVAD is associated with high risk. The temporary MCS creates clinical and organizational conditions for the urgent HT. This approach allows not only to save life of heart transplant candidates, but also to improve the availability of the HT. The choice of the temporary MCS is determined by the type and severity of HF and the expected duration of its application. The review presents a characteristic, and discusses the effectiveness of various methods of temporary MCS at heart transplant candidates needed in urgent HT.

scholarly journals Fatal Flaw – Driveline Fracture as a Rare But Serious Complication Of Mechanical Circulatory Support With Left Ventricular Assist Devices

2017 ◽  
Author(s):  
Yuri Boyechko ◽  
Thomas Tribble ◽  
Maya Guglin
Keyword(s):  
Heart Transplant ◽  
Mechanical Circulatory Support ◽  
Rare Complication ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Assist Devices ◽  
Left Ventricular Assist

Background Patients with advanced heart failure have seen decreased mortality and improved quality of life due to mechanical circulatory support with left ventricular assist devices (LVAD). Regardless of such outcomes, many complications still exist and remain a significant cause of morbidity and mortality. Our purpose is to study the prevalence, clinical course, and outcomes specifically of patients with LVAD driveline (DL) fractures. Methods This single-center, retrospective review included all patients at our institution who had continuous flow LVADs and experienced DL fracture/injury from January 2012 - December 2015. Results Thirteen of 110 LVAD patients (11.8%) had DL fractures (Table 1). Time from implant to time of fracture was 23+/-16.5 months. The majority of fractures were external (62%), due to trauma (i.e. cut during dressing change). Internal injury, proximal to the cutaneous exit site, occurred in 38% of patients, usually due to unknown causes. Only one patient (7.6%) survived on LVAD support. One survived LVAD explant, two underwent pump exchange, and four others underwent heart transplantation. The remaining 5 expired. All patients with untreated internal fractures died (60%). Conclusions Driveline fracture is a rare complication of LVAD and is often lethal when it occurs. Only one patient in our cohort survived without the need for heart transplant, LVAD exchange, or explant. Internal driveline fractures portend a very high mortality. Driveline fracture, especially one that cannot be promptly repaired or if internal fracture is suspected, requires immediate pump exchange or listing for heart transplant.

scholarly journals Tolerance of Sustained Ventricular Fibrillation During Continuous-Flow Left Ventricular Assist Device Support

2017 ◽  
Vol 44 (5) ◽  
pp. 357-360 ◽  
Author(s):  
Andrew C.W. Baldwin ◽  
Courtney J. Gemmato ◽  
Elena Sandoval ◽  
William E. Cohn ◽  
Jeffrey A. Morgan ◽  
...  
Keyword(s):  
Ventricular Fibrillation ◽  
Continuous Flow ◽  
Mechanical Circulatory Support ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Assist Devices ◽  
Left Ventricular Assist

The widespread use of continuous-flow left ventricular assist devices for mechanical circulatory support has shown that long-term hemodynamic support is possible, even when a clinical “pulse” cannot be detected. We present the incidental discovery of ventricular fibrillation in 6 alert, hemodynamically stable patients supported only by a continuous-flow device (HeartMate II, n=5; Jarvik 2000, n=1). Ventricular fibrillation was found in 3 patients during routine outpatient follow-up visits and in 3 awaiting discharge from the hospital after device placement. Diagnosis was confirmed by electrocardiographic and echocardiographic studies. The average duration of mechanical circulatory support before ventricular fibrillation occurred was 221 ± 362 days (range, 5–864 d). All patients were conscious and ambulatory at the time of the arrhythmia. Three patients reported symptoms—primarily fatigue, nausea, and exertional dyspnea—that prompted evaluation. Serum chemistry analysis of blood drawn immediately after diagnosis showed no changes that suggested end-organ dysfunction. Three patients died of unrelated complications an average of 3.9 yr (range, 360–2,270 d) after the event. Two of the remaining 3 patients eventually underwent successful pump explantation, and one is on ongoing support. Our experience shows that it is possible for patients with continuous-flow left ventricular assist devices to remain hemodynamically stable while in ventricular fibrillation. Additional investigation is needed to determine whether defibrillator settings for these patients should be adjusted to limit delivery of shock therapy.

scholarly journals Endocrine Challenges in Patients with Continuous-Flow Left Ventricular Assist Devices

Nutrients ◽  
2021 ◽  
Vol 13 (3) ◽  
pp. 861
Author(s):  
Gennaro Martucci ◽  
Federico Pappalardo ◽  
Harikesh Subramanian ◽  
Giulia Ingoglia ◽  
Elena Conoscenti ◽  
...  
Keyword(s):  
Continuous Flow ◽  
Left Ventricular ◽  
Endocrine Function ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Endocrine Dysfunction ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Assist Devices ◽  
Left Ventricular Assist

Heart failure (HF) remains a leading cause of morbidity, hospitalization, and mortality worldwide. Advancement of mechanical circulatory support technology has led to the use of continuous-flow left ventricular assist devices (LVADs), reducing hospitalizations, and improving quality of life and outcomes in advanced HF. Recent studies have highlighted how metabolic and endocrine dysfunction may be a consequence of, or associated with, HF, and may represent a novel (still neglected) therapeutic target in the treatment of HF. On the other hand, it is not clear whether LVAD support, may impact the outcome by also improving organ perfusion as well as improving the neuro-hormonal state of the patients, reducing the endocrine dysfunction. Moreover, endocrine function is likely a major determinant of human homeostasis, and is a key issue in the recovery from critical illness. Care of the endocrine function may contribute to improving cardiac contractility, immune function, as well as infection control, and rehabilitation during and after a LVAD placement. In this review, data on endocrine challenges in patients carrying an LVAD are gathered to highlight pathophysiological states relevant to this setting of patients, and to summarize the current therapeutic suggestions in the treatment of thyroid dysfunction, and vitamin D, erythropoietin and testosterone administration.

scholarly journals Can mechanical circulatory support be an effective treatment for HFpEF patients?

2021 ◽  
Author(s):  
Einar Gude ◽  
Arnt E. Fiane
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Mechanical Circulatory Support ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Left Ventricular Cavity ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
Mechanical Pressure ◽  
Entry Points

AbstractHeart failure with preserved ejection fraction (HFpEF) is increasing in prevalence and represents approximately 50% of all heart failure (HF) patients. Patients with this complex clinical scenario, characterized by high filling pressures, and reduced cardiac output (CO) associated with progressive multi-organ involvement, have so far not experienced any significant improvement in quality of life or survival with traditional HF treatment. Left ventricular assist devices (LVAD) have offered a new treatment alternative in terminal heart failure patients with reduced ejection fraction (HFrEF), providing a unique combination of significant pressure and volume unloading together with an increase in CO. The small left ventricular cavity in HFpEF patients challenges left-sided pressure unloading, and new anatomical entry points need to be explored for mechanical pressure and volume unloading. Optimized and pressure/volume-adjusted mechanical circulatory support (MCS) devices for HFrEF patients may conceivably be customized for HFpEF anatomy and hemodynamics. We have developed a long-term MCS device for HFpEF patients with atrial unloading in a pulsed algorithm, leading to a significant reduction of filling pressure, maintenance of pulse pressure, and increase in CO demonstrated in animal testing. In this article, we will discuss HFpEF pathology, hemodynamics, and the principles behind our novel MCS device that may improve symptoms and prognosis in HFpEF patients. Data from mock-loop hemolysis studies, acute, and chronic animal studies will be presented.

Mechanical circulatory support with the Impella 5.0 and the Impella Left Direct pumps for postcardiotomy cardiogenic shock at La Pitié-Salpêtrière Hospital

2019 ◽  
Vol 57 (1) ◽  
pp. 183-188 ◽  
Author(s):  
Charles-Henri David ◽  
Astrid Quessard ◽  
Ciro Mastroianni ◽  
Guillaume Hekimian ◽  
Julien Amour ◽  
...  
Keyword(s):  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Heart Function ◽  
Left Ventricular ◽  
Survival Outcome ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
The Mean ◽  
Postcardiotomy Cardiogenic Shock

Abstract OBJECTIVES Postcardiotomy cardiogenic shock (PCCS) is associated with high mortality rates of 50–80%. Although veno-arterial extracorporeal membrane oxygenation has been used as mechanical circulatory support in patients with PCCS, it is associated with a high rate of complications and poor quality of life. The Impella 5.0 and Impella Left Direct (LD) (Impella 5.0/LD) are minimally invasive left ventricular assist devices that provide effective haemodynamic support resulting in left ventricular unloading and systemic perfusion. Our goal was to describe the outcome of patients with PCCS supported with the Impella 5.0/LD at La Pitié-Salpêtrière Hospital. METHODS We retrospectively reviewed consecutive patients supported with the Impella 5.0/LD for PCCS between December 2010 and June 2015. Survival outcome and in-hospital complications were assessed. RESULTS A total of 29 patients (63 ± 14 years, 17% women) with PCCS were supported with the Impella 5.0/LD. At baseline, 69% experienced chronic heart failure, 66% had dilated cardiomyopathy and 57% had valvular disease. The mean EuroSCORE II was 22 ± 17 and the ejection fraction was 28 ± 11%. Most of the patients underwent isolated valve surgery (45%) or isolated coronary artery bypass grafting (38%). The mean duration of Impella support was 9 ± 7 days. Weaning from the Impella was successful in 72.4%, and 58.6% survived to discharge. Recovery of native heart function was observed in 100% of discharged patients. Survival to 30 days and to 1 year from Impella implant was 58.6% and 51.7%, respectively. CONCLUSIONS The Impella 5.0 and the Impella LD represent an excellent treatment option for critically ill patients with PCCS and are associated with favourable survival outcome and native heart recovery.

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