Medicine and Health Sciences Commons^™

Managing Intracranial Hemorrhage In Patients With A Durable Continuous Flow Left Ventricular Assist Device, Godly Jack, Phil Barker, Ryan Searcy, Jason N. Katz

The VAD Journal

Background: While intracranial hemorrhage (ICH) is a known complication of left ventricular assist device (LVAD) support, and is associated with high morbidity and mortality, optimal care pathways have neither been elucidated nor reported. We describe management of LVAD patients following ICH, with a focus on anticoagulation, operative interventions, care team designation, complications, and outcomes.

Methods: We retrospectively reviewed all durable continuous-flow LVAD implantations at our academic medical center from January 2007 to July 2018. Patients who experienced ICH after LVAD were identified. We defined baseline and ICH characteristics, medical and surgical interventions, care teams, and outcomes including death, device thrombosis, …

The Use Of Cardiomems In Dialysis Patients With Heart Failure, Karolina Viquez, Peggy Hardesty, Karim Fahmy, Amr Elhusseini, Mohamed Elyamny, Maya Guglin

The VAD Journal

In patients with chronic kidney disease (CKD) and heart failure (HF), volume overload is a major problem. Removal of fluid during the dialysis treatment, is the cornerstone management in these conditions but, assessing the amount of volume that should be removed is a challenge since physical exam findings are not accurate. Ambulatory pulmonary artery (PA) pressure measurement is a promising intervention in HF that potentially could be used as well in CKD population, predicting volume status changes and allowing a promptly intervention. We presented two cases of patient with CKD, HF and cardioMEMS

Refining Auscultation Of Left Ventricular Assist Devices: Insights From Phonocardiography, Faris Araj, Alpesh Amin, Julie Cox, Pradeep Mammen

The VAD Journal

No abstract provided.

Favorable Outcomes With Ventricular Assist Device Exchange, Megan Carroll, Meghan Tooman, Markian Bochan, Christopher Salerno, Ashwin Ravichandran

The VAD Journal

Left ventricular assist device (LVAD) therapy remains a vital therapeutic option for patients with end-stage heart failure. Unfortunately, adverse events can occur and progress to require consideration for device exchange once the failure of medical management becomes evident, especially when heart transplantation is not possible in a timely manner. The aim of this analysis is to describe the incidence and outcomes of LVAD exchanges at our institution. Between April 2008 and May 2017, 397 patients underwent LVAD implantation, with 32 of those patients subsequently receiving exchange upon the recommendation of our multidisciplinary team due to refractory infection (n=12), device malfunction …

Successful Extracorporeal Membrane Oxygenation In The Management Of Acute Respiratory Distress Syndrome And Cardiopulmonary Collapse Secondary To Amniotic Fluid Embolism, Sumon Roy, Nishit A. Biniwale, Venkata S. Pendela, Patricia Oates, Katrina Wojciechowski, Scott C. Feitell

The VAD Journal

Amniotic fluid embolism (AFE) is one of the most devastating complications of pregnancy that typically manifests as acute cardiopulmonary collapse during delivery or in the postpartum period. The potential role of extracorporeal membrane oxygenation (ECMO) as a management technique in severe cases of AFE remains largely unknown given the limited literature available. In this report, we present the first case, to our knowledge, of successful implementation of ECMO as a life-saving measure in a case of hemorrhagic shock due to postpartum bleeding complicated by severe AFE leading to acute respiratory distress syndrome (ARDS) ultimately requiring tracheostomy. Hemodynamic decompensation is often …

What Did We Learn About Vads In 2018?, Maya Guglin

The VAD Journal

No abstract provided.

Implantation Of Left Ventricular Assist Device In The Setting Of Heavily Calcified Left Ventricular Apex Using An Apex Preserving Technique, Ismael A. Salas De Armas, Mehmet H. Akay, Jayeshkumar A. Patel, Chandni Patel, Manish K. Patel, Bindu Akkanti, Biswajit Kar, Igor D. Gregoric

The VAD Journal

A heavily calcified ventricular apex represents a challenging, rare and unique situation in LVAD implantation. A 44-year-old male was admitted with myocardial infarction. Left heart catheterization was complicated by episodes of ventricular fibrillation. After an acute stabilization with veno-arterial extracorporeal membrane oxygenation (VA-ECMO), an LVAD implantation was approved. Pre-operative work-up had shown a heavily calcified ventricular apex and an intraventricular thrombus, which was confirmed intraoperatively. To retain a viable ventricular geometry, the decision was made to preserve the calcified apex rather than to excise the entire calcified left ventricular aneurysm. Sutures for the inlet cannula were placed around the calcific …

Hemodynamic, Therapeutic, And Clinical Outcomes Of Ambulatory Pressure-Guided Heart Failure Management, Jacob Abraham, Lian Wang, Rebecca Lewis, Katherine Callis, Joshua Remick, Kateri J. Spinelli

The VAD Journal

Background: Heart failure (HF) management guided by CardioMEMS™ pulmonary artery pressure (PAP) monitoring reduces PAP and HF hospitalizations. The objective of this project was to characterize the relationship between medication adjustments, PAP change, and outcomes for all patients at an advanced HF center.

Methods: We retrospectively analyzed medication changes and hospitalizations for 32 consecutive patients implanted with the CardioMEMS™ sensor at a single HF center and related these outcomes to PAP data from the Merlin.net (Abbott) database. Absolute change in PAP from baseline was estimated using area under the curve normalized to days monitored.

Results: Patients had an average change …

Implanted Hemodynamic Monitoring In Management Of Significant Right Heart Failure Before And After Lvad Implantation: Creation And Maintenance Of Fontan Physiology In Severe Rv Dysfunction, Kevin Yei, Casey Kaisi, Rajeev Mohan, Ajay Srivastava, J Thomas Heywood

The VAD Journal

In the left ventricular assist device (LVAD) population, right ventricular (RV) failure represents a significant cause of morbidity and mortality. It is unclear whether hemodynamic monitoring with the implantable CardioMEMS system can improve outcomes within this population. This case report highlights two patients in our clinic who had CardioMEMS implanted after LVAD, enabling us to modify their medical regimens remotely and more frequently in the management of their RV failure.

Restoration Of Left Ventricular Function Following Lvad Implantation – Remission Or Recovery? A Case Series., Shiksha Joshi, Mariah Barlow, Maya Guglin

The VAD Journal

Background

A wide range of left ventricular (LV) recovery rates on left ventricular assist device (LVAD) support have been reported. In this case series, we summarize our experience with LVAD explantation for presumed LV recovery.

Case series

Out of 240 patients who received an LVAD implant in our program since its inception, we explanted/inactivated the pump for presumed LV recovery in only three patients. All three of these patients had relapse of cardiomyopathy within 6 months of explantation.

Conclusion

Our experience does not support the existence of LV recovery following LVAD implantation as a common phenomenon. Improvement in LV function …

De-Airing Method Of An Axial Flow Left Ventricular Assist Device Influences Post-Operative Lactate Dehydrogenase Levels: A Possible Explanation For Some Episodes Of Pump Thrombosis, Daizo Tanaka, Saif Rizvi, Andrew Boyle, Md, John W..C. Entwistle

The VAD Journal

Background

Pump thrombosis (PT) is a relatively uncommon but serious complication of a left ventricular assist device (LVAD). We believe that de-airing of the HeartMate II (HMII) with the pump turned on and a clamp across the outflow graft may lead to early thrombus formation due to heat generation on the bearings.

Methods

Patients who underwent HMII implantation from November 2012 to February 2016 were retrospectively reviewed. Patients were separated into two groups depending on the timing of removing the clamp from the outflow graft. Patients in Group 1 underwent de-airing by turning on the pump with the vascular clamp …

A Modified Access Technique Of Impella 5.0 Axillary Artery Insertion, Abdallah Alameddine, Brian J. Binnall, Eric Dibiasio-White, Khaled Alameddine

The VAD Journal

The conventional method for the axillary artery insertion of Impella 5.0 is a non-tunneling route of the side-graft. We present an alternative technique in order to facilitate device insertion and to ensure protection from potential wound contamination. The technique consists of exiting the graft separately and away from the main incision with an intact skin and subcutaneous fat between the two sites. By proper isolation of the main wound, the risk of infection can thus be largely mitigated. Furthermore, this technique allows a better landing entry angle of graft insertion; the resulting smoother curve trajectory leads to facile device insertion, …

Effects Of Beta Blockers And Ace Inhibitors After Left Ventricular Assist Device Implantation, Gaurang Vaidya, Emma Birks, Jessica Pillarella, Benjamin Salgado, Rajakrishnan Vijayakrishnan, Andrew Lenneman, Mark Slaughter, Dmitry Abramov

The VAD Journal

Purpose: While Beta blockers(BB) and Angiotensin system blockers(ACEinh/ARB) are important components in advanced heart failure therapy, their use after left ventricular assist device (LVAD) implantation remains controversial. Concern has been raised about possible adverse effects of BB on right ventricular(RV) function while tolerance and efficacy/outcome data for ACEinh are lacking. This study aimed to characterize the use of medical therapy post-LVAD implantation and to evaluate its safety and efficacy. Methods: Demographic, clinical and echocardiographic variables of patients implanted with a continuous-flow LVAD between 2012 and 2015 at a single center were retrospectively reviewed. Mortality and heart failure(CHF) hospitalizations were followed …

Electrocardiographic Characteristics, Antiarrhythmic Utilization, And Outcomes In Patients With Left Ventricular Assist Devices, Scott Lundgren, Elizabeth Lyden, Douglas Stoller, Marshall Hyden, Adam Burdorf, Ronald Zolty, John Um, Brian Lowes

The VAD Journal

Background: Left ventricular assist devices (LVAD) are an increasingly used therapy for patients with advanced heart failure. Arrhythmias are common complications following LVAD implantation requiring admission, initiation, and escalation of medical therapy. Despite their frequent use in the treatment of arrhythmias, little has been reported regarding electrocardiographic changes, antiarrhythmic utilization, and outcomes post-LVAD.

Methods: A total of 309 patients who received a LVAD underwent retrospective chart review pre- and post-LVAD. Kaplan-Meier curves were calculated and compared using the log-rank test. Cox regression model was used for univariate analysis and those with a p

Results: There was a significant reduction in …

Safety And Efficacy Of Routine Bridging Anticoagulation For Subtherapeutic Anticoagulation In Outpatients With A Left Ventricular Assist Device, David C. Shisler, Gaurang N. Vaidya, Lori Muncy, Rajakrishnan Vijayakrishnan, Mark S. Slaughter, Emma J. Birks, Dmitry Abramov

The VAD Journal

Background

Anticoagulation with vitamin K antagonists is vital to prevent pump thrombosis in patients with left ventricular assist devices (LVADs). However, the safety and efficacy of bridging anticoagulation for the routine management of subtherapeutic international normalized ratio (INR) in stable outpatients remains poorly characterized.

Methods

In this retrospective study, a total of 60 LVAD outpatients had 110 episodes of subtherapeutic INR noted on routine testing. 34 of these episodes were managed with parenteral bridging anticoagulation and 76 were managed with only an adjusted dose of warfarin. The rates of bleeding and thromboembolic adverse events following these episodes of subtherapeutic INR …

Exploring The “Weekend Effect” On The Care Of Patients With Left Ventricular Assist Devices, Gbolahan O. Ogunbayo, Le Dung Ha, Naoki Misumida, Ayman Elbadawi, Qamar Ahmad, Remi Okwechime, Deborah Akanya, Andrew Kolodziej, Claude S. Elayi, Maya E. Guglin

The VAD Journal

Many studies have described differences in in-hospital outcomes and length of stay between patients treated for major cardiac conditions on weekdays versus weekends.¹ Our study aimed to explore the “weekend effect” on in-hospital care among patients with left ventricular assist devices.

Using data from the National Inpatient Sample (NIS) database, with a weighted estimate of more than 35 million admissions per year.² We identified patients 18 years or older with an ICD code signifying presence of a LVAD. Characteristics, comorbidities and clinical outcomes were compared between patients admitted on a weekend versus patients admitted on a weekday. The …

Reversal Of Fixed Pulmonary Hypertension With Transcatheter Valve Replacement For Aortic Insufficiency On Ventricular Assist Device Support, Faraz S. Ahmad, Mark J. Ricciardi, Laura J. Davidson, Allen S. Anderson, Kambiz Ghafourian, Ike Okwuosa, Esther Vorovich, Jane E. Wilcox, Daniel D. Holloway, Duc T. Pham, Jonathan D. Rich

The VAD Journal

We present a 43-year-old woman with a nonischemic cardiomyopathy implanted with a ventricular assist device (VAD) as bridge to transplant due to severe, “fixed” pulmonary hypertension (PH). Within three months of VAD implant, her “fixed” PH had resolved entirely. Nearly two years later, still supported with a VAD because of severe HLA allosensitization, she developed dyspnea and “moderate” aortic insufficiency (AI) by standard criteria. Invasive hemodynamics revealed recurrence of severe PH in the setting of elevated left-sided filling pressures. We concluded the AI was indeed severe and the cause of her symptoms and recurrent PH. Despite her minimally calcified aortic …

What Did We Learn About Vads In 2017?, Maya Guglin

The VAD Journal

No abstract provided.

Management Of Aortic Insufficiency In Patients With Left Ventricular Assist Device ̶ A Retrospective Analysis, Hartmuth B. Bittner

The VAD Journal

Background: Aortic insufficiency is increasingly recognized as a complication of left ventricular assist device (LVAD) support and may lead to clinical decompensation requiring correction. This article describes experiences in managing patients presenting with concomitant aortic insufficiency and with de novo aortic insufficiency following left ventricular assist device implantations.

Methods: All patients undergoing LVAD implantation between 2012 and 2014 were included in this retrospective analysis if aortic valve insufficiency was present on implantation or newly developed (de novo) after implantation. Moderate to severe aortic valve insufficiency was corrected at implantation.

Results: The data of 39 patients were included. At the time …

Approach To Unresponsive Patient With Lvad, Maya Guglin

The VAD Journal

No abstract provided.

Unresponsive Patient With Lvad: A Case Series, Ameer Z. Musa, Julia Akhtarekhavari

The VAD Journal

Mechanical circulatory support (MCS) for patients with advanced heart failure (HF) is becoming more commonplace as technology has progressed and reliability of these systems has improved. We report our experience with three patients with cardiopulmonary arrest in the hospital and propose a protocol for the prompt assessment and treatment of an unresponsive patient with a LVAD in place. We presented three cases of unresponsive patients on LVAD support with low flow or no flow through the LVAD. Although all three of them were alive after resuscitation, none survived to discharge. In all three cases, there were no flaws in LVAD …

Capsule Endoscopy In Left Ventricular Assist Device Patients: Retrospective Review Of Efficacy And Necessity, Gaurang N. Vaidya, Michael Krease, Ali Dahhan, Rajakrishnan Vijayakrishnan, Thomas Abell, Emma Birks, Dmitry Abramov

The VAD Journal

Introduction: Capsule endoscopy (CE) is mainstream in the evaluation of obscure gastrointestinal bleeding (GIB) in the general population. However, the diagnostic and therapeutic impact of CE in LVAD patients susceptible to transient bleeding remains largely unexplored. This study aimed to assess the benefits of CE in the evaluation of LVAD associated GIB.

Methods: Retrospective review of patients implanted with a continuous flow LVAD who underwent inpatient capsule endoscopy (CE) between January 2014 and May 2017 at our center. Identification of lesions with high bleeding potential or presence of frank blood were considered abnormal findings on CE study.

Result: Twenty-five inpatients …

Anticoagulation Monitoring In Left Ventricular Assist Device (Lvad) Patients, Adam Sieg, Jennifer Gass, Phillip Weeks, Indranee Rajapreyar, Igor Gregoric

The VAD Journal

The use of left ventricular assist devices (LVAD) provides a treatment strategy for advanced heart failure patients to prolong life and serve as a mediator (bridge to transplant) until an organ becomes available in patients considered suitable candidates for heart transplantation. The use of LVAD therapy is complicated by the constant risk of bleeding and thrombotic events. We reviewed and analyzed the effectiveness of our current heparin protocol with respect to overall anticoagulation and time in therapeutic range (TTR). Our analysis demonstrated that patients did not achieve therapeutic anticoagulation for at least 24 hours following initiation of heparin and that …

Right Ventricle Chest Compressions: Do We Need A New Paradigm For Lvad Patients Needing Resuscitation? A Case Report., Arvind Bhimaraj, Erik E. Suarez, Jerry D. Estep

The VAD Journal

The use of chest compressions in patients with left ventricular assist devices (LVAD) have been viewed to cause a potential damage to the outflow graft and hence have been a topic of controversy. We report a case of a LVAD patient who needed chest compressions during resuscitation for severe right ventricular failure. With the presence of trans-esophageal echocardiogram we noticed that the chest compressions did not need to be full ACLS compressions but modified to gentle right ventricular (RV) compressions in order to move blood into a normally functioning LVAD. We report this as a call for the LVAD medical …

Left Ventricular Assist Device Is A Viable Therapy In End Stage Hypertrophic Cardiomyopathy, Mirnela Byku, Michael Nassif, Eric Novak, Akinobu Itoh, Greg Ewald, Shane J. Larue

The VAD Journal

Left Ventricular Assist Device (LVAD) therapy use is increasing rapidly in advanced heart failure (HF). Little data exists on the application of this therapy in patients with advanced HF due to Hypertrophic Cardiomyopathy (HCM). Altered ventricular geometry, thickened septum and reduced LV end-diastolic diameter (LVEDD) in HCM may lead to increased suction events, arrhythmias and inflow cannula malfunction.

We hypothesized that patients with end stage HCM benefit from LVAD therapy and have a similar rate of complications to those with ischemic or dilated CM.

Between 2009 and 2014, 5 patients with end stage HCM (HCM and EF

We conclude that …

Paranormal Activity: Para-Esophageal/Gastric Hemorrhage In A Patient With A Heartmate Ii Lvad, Anna Stone, Ashwin Ravichandran

The VAD Journal

In this report we present an unusual case of non-traumatic, spontaneous para-esophageal/para-gastric hemorrhage requiring multiple units of red blood cells in a female patient with a continuous flow left ventricular assist device. She presented with dysphagia and atypical chest pain 18 months post implantation, on the recommended anticoagulation regimen for HeartMate II support of ASA 81mg and international normalized ratio goal (INR) of 2-3 and was successfully managed with conservation support, volume resuscitation and multiple transfusions. Non-traumatic causes of acute bleeding, including acquired platelet dysfunction are considered.

Fatal Flaw - Driveline Fracture As A Rare But Serious Complication Of Mechanical Circulatory Support With Left Ventricular Assist Devices, Yuri Boyechko, Thomas Tribble, Maya Guglin

The VAD Journal

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). …

Reversible Mitral Regurgitation As A Complication Of Impella® 5.0, Katrina A. Bidwell, Andrew R. Kolodziej, Maya E. Guglin

The VAD Journal

The Impella® is a ventricular assist device used for temporary left ventricular support and has been approved for use since 2008. In this report we present a case of a patient who experienced mitral regurgitation as a complication shortly after placement of an Impella® as well as a brief literature review. To our knowledge this is the first such case demonstrating resolution of iatrogenic mitral regurgitation with removal of the device as opposed to permanent damage.

Does Left Ventricular Assist Device Implantation Affect Driving Patterns In Patients With End-Stage Heart Failure?, Mamatha Pinninti, Christina Sauld, Vinay Thohan, Omar Cheema, T. Edward Hastings, John Crouch, Frank Downey, Nasir Z. Sulemanjee

The VAD Journal

Background

In 2012, the Canadian Society of Cardiology indicated that patients supported with left ventricular assist device (LVAD) may drive a private vehicle 2 months after implantation, provided they are deemed clinically stable. Objective evidence supporting this recommendation is limited. We sought to compare data regarding driving habits in our patients following LVAD implantation.

Methods

A standard questionnaire addressing driving patterns before and after LVAD implantation was sent to all living patients who had received an LVAD between January 2010 and January 2014. Ninety-four of 124 patients responded (average age 58 years, 69.2% men, 77.7% bridge to transplant).

Results

Prior …

Venoarterial Extracorporeal Membrane Oxygenation For Cardiogenic Shock: A Retrospective Analysis Based On The Etiology Of Shock, Andrew Burchett, Thomas Tribble, Richard Charnigo, Susan Smyth, Maya Guglin

The VAD Journal

Abstract:

Background: We performed a retrospective analysis to evaluate the efficacy of VA-ECMO support in cardiogenic shock based on various etiologies.

Methods: We retrospectively analyzed 99 patients supported with VA-ECMO from January 1, 2012 to January 1, 2015. Outcomes included survival to discontinuation of VA-ECMO support and survival to hospital discharge. The etiologies of cardiogenic shock included cardiac arrest (CPR), acute myocardial infarction (AMI), decompensated congestive heart failure (CHF), pulmonary embolism (PE), right ventricular failure (RVF) not secondary to an acute pulmonary embolism, and post-cardiotomy syndrome (PCS). The PCS group was used as a reference group; odds ratios were estimated …