scholarly journals Anticoagulation with VADs and ECMO: walking the tightrope

Hematology ◽  
2017 ◽  
Vol 2017 (1) ◽  
pp. 674-680 ◽  
Author(s):  
Leslie Raffini
Keyword(s):  
Thrombus Formation ◽  
Ventricular Assist Devices ◽  
Quality Data ◽  
Critically Ill Children ◽  
Circulatory Support ◽  
Ventricular Assist ◽  
Blood Flows ◽  
Patients With Heart Failure ◽  
Normal Hemostasis ◽  
Design And Manufacture

Abstract The evolution of devices for mechanical circulatory support (MCS), including ventricular assist devices (VADs) for patients with heart failure and extracorporeal membrane oxygenation (ECMO) for patients with acute cardiac or respiratory failure, has improved survival for subsets of critically ill children and adults. The devices are intricate and complex, allowing blood to bypass the heart or lungs (or both). As blood flows through these artificial devices, normal hemostasis is disrupted, coagulation is promoted, and in the absence of anticoagulation, a thrombus may form in the device, resulting in device failure or embolic stroke. Therefore, anticoagulation is necessary to prevent thrombus formation and maintain device function. However, patients on MCS also have very high bleeding rates. Titrating anticoagulation to prevent hemorrhagic complications and thrombotic events can be a challenge, and hematologists may be consulted in complex cases. Substantial variability remains in the approach to anticoagulant and antiplatelet therapy for patients on MCS, largely because of the lack of high-quality data. Improvements in the design and manufacture of these devices, as well as in the individualized titration of antithrombotic intensity, are expected to enhance outcomes. Several factors pertaining to both the device and the patient (adult and children) should be considered when attempting to optimize this delicate balance.

Design Optimization of a Mechanical Heart Valve for Reducing Valve Thrombogenicity: A Case Study With ATS Valve

2010 ◽  
Author(s):  
Gaurav Girdhar ◽  
Yared Alemu ◽  
Michalis Xenos ◽  
Jawaad Sheriff ◽  
Jolyon Jesty ◽  
...  
Keyword(s):  
Heart Valves ◽  
Thrombus Formation ◽  
Anticoagulation Therapy ◽  
Mechanical Heart Valve ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Ventricular Assist ◽  
Mechanical Circulatory Support Devices ◽  
Artificial Hearts

Flow past mechanical heart valves (MHV) in mechanical circulatory support devices including total artificial hearts and ventricular assist devices, is primarily implicated in thromboembolism due to non-physiological flow conditions where the elevated stresses and exposure times are sufficiently high to cause platelet activation and thrombus formation. Mitigation of this risk requires lifelong anticoagulation therapy and less thrombogenic MHV designs should therefore be developed by device manufacturers [1].

In Vitro Evaluation of Shear-Induced Platelet Activation in the MicroMed DeBakey Ventricular Assist Device With Antiplatelet Therapy

2013 ◽  
Author(s):  
Jawaad Sheriff ◽  
Gaurav Girdhar ◽  
Sheela George ◽  
Wei-Che Chiu ◽  
Bryan E. Lynch ◽  
...  
Keyword(s):  
Platelet Activation ◽  
Thrombus Formation ◽  
Optimization Techniques ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Ventricular Assist ◽  
Bridge To Transplant ◽  
Thrombotic Complications ◽  
End Stage

Mechanical circulatory support (MCS) devices, which include ventricular assist devices (VADs), offer an attractive solution to approximately 35,000 end-stage heart failure patients eligible for transplants, of which only 2,000–2,300 are performed annually [1]. These devices are employed to augment the function of the ailing left and/or right ventricle and serve as bridge-to-transplant or destination therapy, but are often accompanied by thrombotic complications. Pathologic flow patterns are characteristic of VADs and increase susceptibility to shear-induced platelet activation, which leads to thrombus formation [2]. Patients implanted with such devices are routinely prescribed antiplatelets to tackle these complications. Despite this concurrent therapy, thromboembolic incident rates of 0.9–13% are reported for the widely-implanted Thoratec HeartMate II and MicroMed DeBakey VADs [3, 4]. This has spurred the development of design optimization techniques to lower or eliminate the incidence of thrombosis and reduce the dependence on pharmacotherapy management.

scholarly journals Pediatric Palliative Care in the Heart Failure, Ventricular Assist Device and Transplant Populations: Supporting Patients, Families and Their Clinical Teams

Children ◽  
2021 ◽  
Vol 8 (6) ◽  
pp. 468
Author(s):  
Kyle D. Hope ◽  
Priya N. Bhat ◽  
William J. Dreyer ◽  
Barbara A. Elias ◽  
Jaime L. Jump ◽  
...  
Keyword(s):  
Heart Failure ◽  
Palliative Care ◽  
Heart Transplantation ◽  
Ventricular Assist Device ◽  
Mechanical Circulatory Support ◽  
Pediatric Palliative Care ◽  
Circulatory Support ◽  
Assist Device ◽  
Ventricular Assist ◽  
Patients With Heart Failure

Heart failure is a life-changing diagnosis for a child and their family. Pediatric patients with heart failure experience significant morbidity and frequent hospitalizations, and many require advanced therapies such as mechanical circulatory support and/or heart transplantation. Pediatric palliative care is an integral resource for the care of patients with heart failure along its continuum. This includes support during the grief of a new diagnosis in a child critically ill with decompensated heart failure, discussion of goals of care and the complexities of mechanical circulatory support, the pensive wait for heart transplantation, and symptom management and psychosocial support throughout the journey. In this article, we discuss the scope of pediatric palliative care in the realm of pediatric heart failure, ventricular assist device (VAD) support, and heart transplantation. We review the limited, albeit growing, literature in this field, with an added focus on difficult conversation and decision support surrounding re-transplantation, HF in young adults with congenital heart disease, the possibility of destination therapy VAD, and the grimmest decision of VAD de-activation.

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 Temporary Mechanical Circulatory Support: A Review of the Options, Indications, and Outcomes

2014 ◽  
Vol 8s1 ◽  
pp. CMC.S15718 ◽  
Author(s):  
Nisha A. Gilotra ◽  
Gerin R. Stevens
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Mechanical Circulatory Support ◽  
Clinical Applications ◽  
Ventricular Assist Devices ◽  
Blood Pump ◽  
Circulatory Support ◽  
Disease Entity ◽  
Significant Morbidity ◽  
Ventricular Assist ◽  
Acute Setting

Cardiogenic shock remains a challenging disease entity and is associated with significant morbidity and mortality. Temporary mechanical circulatory support (MCS) can be implemented in an acute setting to stabilize acutely ill patients with cardiomyopathy in a variety of clinical situations. Currently, several options exist for temporary MCS. We review the indications, contraindications, clinical applications, and evidences for a variety of temporary circulatory support options, including the intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), CentriMag blood pump, and percutaneous ventricular assist devices (pVADs), specifically the TandemHeart and Impella.

Development of Mechanical Circulatory Support Devices: 55 Years and Counting

2021 ◽  
Vol 32 (4) ◽  
pp. 424-433
Author(s):  
Emalie Petersen
Keyword(s):  
Mechanical Circulatory Support ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Assist Devices ◽  
Left Ventricular Assist ◽  
Mechanical Circulatory Support Devices ◽  
Support Devices

Heart failure is a leading cause of morbidity and mortality in the United States. Treatment of this condition increasingly involves mechanical circulatory support devices. Even with optimal medical therapy and use of simple cardiac devices, heart failure often leads to reduced quality of life and a shortened life span, prompting exploration of more advanced treatment approaches. Left ventricular assist devices constitute an effective alternative to cardiac transplantation. These devices are not without complications, however, and their use requires careful cooperative management by the patient’s cardiology team and primary care provider. Left ventricular assist devices have undergone many technological advancements since they were first introduced, and they will continue to evolve. This article reviews the history of different types of left ventricular assist devices, appropriate patient selection, and common complications in order to increase health professionals’ familiarity with these treatment options.

Cerebrovascular Events in Patients with Centrifugal-Flow Left Ventricular Assist Devices: A Propensity Score Matched Analysis from the Intermacs Registry

Circulation ◽  
2021 ◽  
Author(s):  
Sung-Min Cho ◽  
J. Hunter Mehaffey ◽  
Susan L. Myers ◽  
Ryan S. Cantor ◽  
Randall C. Starling ◽  
...  
Keyword(s):  
Risk Factors ◽  
Propensity Score ◽  
Secondary Analysis ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Assist Devices ◽  
Left Ventricular Assist

Background: Ischemic and hemorrhagic cerebrovascular accidents (ICVA and HCVA, respectively) remain common among patients with centrifugal-flow left ventricular assist devices (CF-LVADs), despite improvements in survival and device longevity. Therefore, the incidence of neurological adverse events (NAEs) associated with two contemporary CF-LVADs, the Abbott HeartMate3 ® (HM3) and the Medtronic HeartWare ™ HVAD ® (HVAD), were compared. Methods: Using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs), we collected data on adult patients who received a CF-LVAD as a primary isolated implant between 1/1/2017 and 9/30/2019. Major NAEs were defined as transient ischemic attack (TIA), ICVA, and HCVA. The association of HVAD with risk of NAE in the first year post implant was evaluated using propensity score matching to balance for pre-implant risk factors. After matching, freedom from first major NAE in the HM3 and HVAD cohorts was compared with Kaplan-Meier curves. A secondary analysis using multivariable multiphase hazard models was used to identify predictors of NAE, which uses a data driven parametric fit of the early declining and constant phase hazards and the associations of risk factor with either phase. Results: Of 6,205 included patients, 3,076 (49.6%) received the HM3 and 3,129 (50.4%) received the HVAD. Median follow-up was 9 and 12 months (HM3 and HVAD). HVAD patients had more major NAEs (16.4% vs. 6.4%, p <0.001), as well as each subtype (TIA: 3.3% vs. 1.0%, p <0.001; ICVA: 7.7% vs. 3.4%, p <0.001; and HCVA: 7.2% vs. 2.0%, p <0.001), than did HM3 patients. A propensity-matched cohort balanced for pre-implant risk factors showed that HVAD was associated with higher probabilities of major NAEs (% freedom from NAE: 82% vs. 92%, p <0.001). Device type was not significantly associated with NAEs in the early hazard phase, but HVAD was associated with higher incidence of major NAEs during the constant hazard phase (hazard ratio: 5.71, confidence interval: 3.90-8.36). Conclusions: HM3 is associated with lower hazard of major NAEs than is HVAD beyond the early post-implantation period and during the constant hazard phase. Defining the explanation for this observation will inform device selection for individual patients.

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