Long-term Follow-up of Continuous Flow Left Ventricular Assist Devices: Complications and Predisposing Risk Factors

2017 ◽  
Vol 40 (11) ◽  
pp. 622-628 ◽  
Author(s):  
Tolulope A. Adesiyun ◽  
Rhondalyn C. McLean ◽  
Ryan J. Tedford ◽  
Glenn J.R. Whitman ◽  
Chris M. Sciortino ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Platelet Count ◽  
Continuous Flow ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Early Complications ◽  
Factors Associated

Purpose To assess LVAD complications and their overall effect on mortality and determine factors associated with development of early and long-term complications. Methods A retrospective cohort study of patients who underwent continuous flow LVAD placement between January 1, 2000 and November 30, 2013 was performed. The incidence of complications (sepsis or bacteremia, driveline infections, gastrointestinal bleeding, pump thrombosis, cerebrovascular accidents and anemia requiring transfusion) was collected and logistic regression and Cox proportional hazards analyses were performed. Results 108 patients met our inclusion criteria. Median length of follow-up was 2.2 years. In univariable logistic regression analysis, higher blood urea nitrogen (BUN), creatinine clearance <60, no prior inotrope use, higher INTERMACS class and lower platelet count were associated with early complications. On multivariable analysis, factors associated with early complications included higher BUN (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.001-1.06 per mg/dL BUN), no prior inotrope use (OR 4.92, 95% CI 1.64- 14.7) and lower platelet count (OR 4.29, 95% CI 1.45-12.7 <200 10(3) cu mm); 24% of patients developed early complications and 18.5% developed an early and late complication. Early complications were significantly associated with death (p = 0.017). The presence of 2 or more complications was associated with a 2.7-fold increase in the odds of death (p = 0.016) and odds of death increased by 20% with each subsequent complication (p = 0.004). Conclusions LVADs are associated with significant long-term complications including stroke and sepsis and minimizing time on LVADs may decrease the risk of complications and subsequent morbidity and mortality.

Abstract 18178: Cardiac Index Declines During Long-term LVAD Support

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Rohan J Kalathiya ◽  
Jordan M Chaisson ◽  
Gerin R Stevens ◽  
Christopher M Sciortino ◽  
Ashish S Shah ◽  
...  
Keyword(s):  
Cardiac Index ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Valvular Regurgitation ◽  
Left Ventricular Assist Devices ◽  
Heartmate Ii ◽  
Pump Speed ◽  
Lvad Support

Background: It is increasingly common for patients to be supported by left ventricular assist devices (LVADs) for an extended period of time. At our institution, we have anecdotally noticed a decline in functional status during the course of prolonged LVAD therapy. Our objective was to analyze hemodynamic and echocardiographic data of patients with at least 2 years of ongoing LVAD support. Methods: We retrospectively reviewed all patients who underwent HeartMate II implantation between 2005 and 2012. Of the 131 patients reviewed, we identified 20 patients who were supported by LVADs for at least 2 years and had right heart catheterization (RHC) in both the initial postoperative period and at 2-3 year follow-up. No patients were on inotropic therapy at the time of RHC. Results: The mean times of initial and follow-up post-LVAD RHCs were 59 ± 41 days and 889 ± 160 days, respectively. Cardiac index (CI) declined by an average of 0.4 L/min/m2 over the study period (p=0.04). Other than a reduction in transpulmonary gradient, no other hemodynamic differences were observed. There was a statistically significant worsening of aortic insufficiency (AI) at follow-up. However, when dichotomized by the median change in CI (-0.4 L/min/m2), there is no difference in AI between groups (p =0.60). In fact, 2 of the 3 patients with moderate AI had an increase in CI. There were no differences in pump speed, mean pressure, aortic valve opening, or lactate dehydrogenase between initial and follow up periods (Table 1). Conclusion: In the first study to report long term hemodynamic follow up in patients supported by HeartMate II LVADs, cardiac index significantly declined over time. The decline was not the result of worsening right ventricular function or valvular regurgitation nor a difference in pump speed or blood pressure. This is a potentially worrisome finding, especially for destination therapy patients. Further studies are needed to understand what factors may contribute to this decline.

The Role of Serial Testing for Heparin/PF4 Antibodies in Evolving HITT: A Unique Phenomenon of Delayed Seroconversion with Thrombosis.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 1309-1309
Author(s):  
Indu Sabnani ◽  
Marc Cohen ◽  
David A. Baran ◽  
Patricia Tsang ◽  
Luis H. Arroyo ◽  
...  
Keyword(s):  
Platelet Count ◽  
Clinical Setting ◽  
Elisa Test ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Platelet Recovery ◽  
Elisa Testing ◽  
Heparin Exposure

Abstract In the appropriate clinical setting, a negative ELISA test for Hep/PF4 antibodies (Ab) has traditionally been considered sufficient to rule out HIT/HITT. We describe a series of 20 cases of HIT/HITT in which the ELISA at the onset of thrombocytopenia was negative despite high (6/8) “4T’s” scores (Thrombocytopenia, Timing of thrombocytopenia in relation to heparin exposure, Thrombosis, and no oTher explanation of thrombocytopenia) but showed strong seroconversion subsequently. This suggests that the negative predictive value of the ELISA test may be too low to definitively exclude HITT. We retrospectively reviewed 494 consecutive Hep/PF4 ELISA assays (sensitivity >90%) performed on 395 patients (pts). Of the 292 pts who tested negative, 73 pts underwent repeat ELISA testing due to the development of a new thrombotic event or the persistence of strong clinical suspicion of HIT/HITT. Twenty of the 73 pts (27%) were observed to have initial negative Hep/PF4 titers (mean = 0.13) at the time of thrombocytopenia but a positive assay (mean = 1.5) on follow-up testing (figure 1 right panel). All 20 pts presented with high “4T’s” scores (6 of 8) at the time of the negative ELISA and had a history of recent heparin exposure. The M:F ratio was 11:9. Eleven pts had prior cardiopulmonary bypass while six had left ventricular assist devices. Fifteen pts (75%) had >50% drop in platelet count (figure 1 left panel). Mean platelet count at the time of negative ELISA was 71x109/l (vs. baseline mean platelet count of 171x109/l) (figure 2). Fourteen of 15 pts (for which data was available) had thrombotic events (9 arterial, 5 venous). Strong seroconversion was seen in all pts (mean = 8 days after initial test) and surprisingly, it accompanied platelet recovery in 15 of 20 pts (figure 1 left panel), with mean platelet count of 136x109/l at the time of the positive ELISA (figure 2). Argatroban was used as a direct thrombin inhibitor (DTI) in 16/20 pts. The prognosis was poor: 10 pts (50%) succumbed with multi-system organ failure. Conclusion: We have described 20 cases of HIT/HITT with initial negative Hep/PF4 Ab titers at the time of thrombocytopenia, followed by delayed seroconversion. This observation suggests that in the proper clinical setting one isolated negative ELISA result cannot exclude evolving HIT/HITT. Follow-up testing may be informative even as the platelet count begins to recover. As HIT/HITT may have potentially fatal outcome, clinicians should maintain a high degree of suspicion despite a negative serology by ELISA, especially in pts with “4T’s” scores ≥ six. Empiric treatment with DTI’s may be warranted until two consecutive ELISA tests are negative. Figure Figure Figure Figure

Aortic regurgitation in continuous flow left ventricular assist devices for long-term use: a diagnostic and therapeutic challenge

2020 ◽  
Vol 73 (6) ◽  
pp. 508-510
Author(s):  
Amaia Martínez León ◽  
Beatriz Díaz Molina ◽  
José Alonso Domínguez ◽  
Jacobo Silva Guisasola ◽  
Jose Luis Lambert Rodríguez ◽  
...  
Keyword(s):  
Aortic Regurgitation ◽  
Continuous Flow ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Therapeutic Challenge ◽  
Assist Devices ◽  
Left Ventricular Assist

Predictors and Long-Term Impact of De Novo Aortic Regurgitation in Continuous Flow Left Ventricular Assist Devices Using Vena Contracta

ASAIO Journal ◽  
2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Jeong Rang Park ◽  
Peter A. Brady ◽  
Alfredo L. Clavell ◽  
Joseph J. Maleszewski ◽  
Vuyisile T. Nkomo ◽  
...  
Keyword(s):  
Continuous Flow ◽  
De Novo ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Vena Contracta ◽  
Left Ventricular Assist ◽  
Long Term Impact

Abstract 374: Characteristics and Clinical Outcomes of Patients with Long-term Left Ventricular Assist Devices in Quebec Compared with the INTERMACS Registry

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Laurie J Lambert ◽  
Georgeta Sas ◽  
Leila Azzi ◽  
Anique Ducharme ◽  
Michel Carrier ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Destination Therapy ◽  
Left Ventricular Assist Devices ◽  
Ventricular Assist ◽  
Left Ventricular Assist ◽  
Lvad Support

Background: After a review of the evidence, our publicly funded cardiology evaluation unit recommended to the Quebec Ministry of Health that use of long-term left ventricular assist devices (LVAD) should be carefully monitored and not limited to bridge-to-transplant patients. Herein, we describe use and clinical outcomes of LVAD in Quebec during the latest 5-year period in comparison with results reported by the INTERMACS registry. Methods: A retrospective review of all pertinent hospital data sources of all LVAD-implanted patients in 2010-14 was performed with follow-up of major clinical outcomes to January 2015. Results: In Quebec’s 3 LVAD centers, 83 LVADs were implanted during 2010-14. Annual center patient volume varied from 0 to 24. Patients were mostly male (80%). Median age was 56 years (interquartile range, IQR: 45-62). The proportion of patients ≥ 60 years was 35% versus 49.5% in INTERMACS. For INTERMACS profiles that include inotrope dependence, the proportions of Quebec patients were very similar to INTERMACS for profile 1 (critical cardiogenic shock; 13% vs 15%, respectively) and profile 2 (progressive decline; 36% vs 36%) but higher for profile 3 (stable but inotrope dependent; 40% vs 30%). The proportion of patients who were not on the transplant list at the time of implantation was lower in Quebec (53%; 44/83) than in INTERMACS (78%) and destination therapy was much less frequent (11% [9/83] vs 43%). For patients implanted during 2010-13 (n=65), 1-year major clinical outcomes in Québec were very similar to INTERMACS (2006-2013): deaths, 17% vs 18%; cardiac transplantation, 22% vs 20%; LVAD removal because of myocardial recovery, 3% vs 1%; alive with LVAD support, 58% vs 61%. Clinical results at 1 year were similar for Quebec patients on and not on the transplant list at the time of implant (p=0.11). Two-thirds of the cohort had 2-year follow-up: 21% (12/56) died; 43% (24/56) had transplantation; 5% recovered and had LVAD removal; and 30% (17/56) were alive with LVAD. For patients implanted during 2014 (n=18), the median duration of follow-up was about 5 months and 5.6% had died on LVAD support. Among all Quebec patients (2010-2014), most recent follow-up indicates that 26% (9/32) of patients transplanted after LVAD support have died. Conclusions: In comparison with INTERMACS, Quebec LVAD patients were younger, more likely to be inotrope-dependent and less likely to be implanted as destination therapy. Despite relatively low center volumes, clinical outcomes for Quebec were very similar to INTERMACS. Results according to transplant list status at time of implant support the recommendation that transplant eligibility should not be an essential criterion for selection of patients for LVAD. Continued independent monitoring of LVAD patients, even after explant or transplant, will be important to optimize the value and quality of care of end-stage heart failure patients.

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