Medicine and Health Sciences Commons^™

Thrombotic And Hemorrhagic Complications Following Left Ventricular Assist Device Placement: An Emphasis On Gastrointestinal Bleeding, Stroke, And Pump Thrombosis, Joseph Phan, Kareem Elgendi, Masi Javeed, Juan M. Aranda, Mustafa M. Ahmed, Juan Vilaro, Mohammad Al-Ani, Alex M. Parker

HPD Articles

The left ventricular assist device (LVAD) is a mechanical circulatory support device that supports the heart failure patient as a bridge to transplant (BTT) or as a destination therapy for those who have other medical comorbidities or complications that disqualify them from meeting transplant criteria. In patients with severe heart failure, LVAD use has extended survival and improved signs and symptoms of cardiac congestion and low cardiac output, such as dyspnea, fatigue, and exercise intolerance. However, these devices are associated with specific hematologic and thrombotic complications. In this manuscript, we review the common hematologic complications of LVADs.

Partial Support In Chronic Heart Failure, Bart Meyns, Walter Droogne, Steven Jacobs

The VAD Journal

Partial left ventricular assist device (LVAD) support offers several advantages in treating chronic heart failure. It also raises concerns about insufficient support, worsening symptoms, and impediment of myocardial recovery. The clinical trial results for the CircuLite device (Medtronic) have shown that close monitoring can ensure improved outcomes for partial support. Another study on the ovine model demonstrated that partial and full support have similar effects regarding reverse remodeling. Thus, patients receiving partial LVAD support need regular follow-up care. Clinical assessment of symptoms and organ function must be used alongside objective judgment of patients’ needs to ensure support levels are appropriately …

Standardizing Initial Inpatient Palliative Care Consultations For Patients Receiving Left Ventricular Assist Devices At A Large Urban Hospital, Deborah A. Szeto

Doctoral Projects

For patients with advanced heart failure (HF) ineligible for or awaiting heart transplantation, left ventricular assist device (LVAD) implantation can be considered. LVADs have helped to improve recipients’ survival rates and quality of life. However, LVAD patients are at risk for complications such as stroke, bleeding, infection, and right ventricular failure. Moreover, events such as end-stage malignancy or progression of a neurodegenerative disorder may occur. Such complications and repeated hospitalizations can pose questions about the acceptability of LVAD therapy. As such, both the Centers for Medicare and Medicaid Services and The Joint Commission require that palliative care (PC) be part …

A Unique Case Of Inflow Cannula Obstruction By A Tissue Membrane, Roopa A. Rao, Kashif Saleem, Bistees George, Maya Guglin

The VAD Journal

The use of a left ventricular assist device has increased and is a primary surgical treatment for heart failure. However, one major complication of left ventricular assist device support is an obstruction in the blood flow pathway. Pump thrombosis and outflow graft occlusion are some of the common causes of such obstructions. Here, we describe a unique case of HeartMate II (Abbott Laboratories) inflow cannula obstruction from a membranous structure without evidence of thrombus. The histology showed evidence of fibrous tissue and heart muscle tissue in the membrane. The patient underwent a successful device exchange with a HeartMate 3 (Abbott …

Cardiovascular Outcomes And Trends Of Transcatheter Vs. Surgical Aortic Valve Replacement Among Octogenarians With Heart Failure: A Propensity Matched National Cohort Analysis, Yasar Sattar, David Song, Talal Almas, Mohamed Zghouzi, Usama Talib, Abdul-Rahman M Suleiman, Bachar Ahmad, Junaid Arshad, Waqas Ullah, Muhammad Zia Khan, Christopher M Bianco, Rodrigo Bagur, Muhammad Rashid, Mamas A Mamas, M Chadi Alraies

Division of Cardiology Faculty Papers

Background: Heart failure (HF) is a complex clinical syndrome with symptoms and signs that result from any structural or functional impairment of ventricular filling or ejection of blood. Limited data is available regarding the in-hospital outcomes of TAVR compared to SAVR in the octogenarian population with HF.

Methods: The National Inpatient Sample (NIS) database was used to compare TAVR versus SAVR among octogenarians with HF. The primary outcome was in-hospital mortality. The secondary outcome included acute kidney injury (AKI), cerebrovascular accident (CVA), post-procedural stroke, major bleeding, blood transfusions, sudden cardiac arrest (SCA), cardiogenic shock (CS), and mechanical circulatory support (MCS). …

Recurrent Giant Cell Myocarditis After Heart Transplant: A Case Report, Eitan S. Frankel, Alexander G. Hajduczok, Indranee N. Rajapreyar, Yevgeniy Brailovsky

Division of Cardiology Faculty Papers

BACKGROUND: Giant cell myocarditis (GCM) is a rare but well-known cause of fulminant myocarditis. Despite optimal medical therapy, many patients progress to orthotopic heart transplant (OHT). We present a case of recurrent GCM following OHT, including complex considerations in patient management and infectious sequelae.

CASE SUMMARY: A 33-year-old previously healthy male presented with 2 months of worsening shortness of breath. Transthoracic echocardiogram (TTE) demonstrated a left ventricular ejection fraction of 30-35%. After ruling out an ischaemic aetiology, he was discharged on guideline-directed medical therapy and later presented with productive cough, worsening dyspnoea on exertion, and diarrhoea. He was found to …

Fondaparinux As An Alternative Anticoagulant Treatment In Patients With Left Ventricular Assist Devices And Recurrent Gastrointestinal Bleeding: Case Series, Daniela Piani, Andrea Lechiancole, Massimo Maiani, Igor Vendramin, Sandro Sponga, Elisabetta Auci, Ugolino Livi

The VAD Journal

Gastrointestinal bleeding (GIB) can occur in patients after left ventricular assist device (LVAD) implantation. In cases of recurrent GIB, the management of anticoagulation treatment represents a challenging situation in which the risk of bleeding recurrence and the need for long-term anticoagulation must be balanced. This case series describes the successful management of anticoagulation in three patients with recurrent GIB using fondaparinux.

To our knowledge, these are the first reported cases of recurrent GIB in which a single dose of subcutaneous fondaparinux was used instead of oral anticoagulation. None of the patients presented with signs of pump thrombosis or arterial embolism. …

Heart And Kidney Transplant In A Patient On Total Artificial Heart Bridge Therapy For 318 Days, Sunny S. Cai, Heather L. Andrews, Christopher A. Molini

Journal of Community Hospital Internal Medicine Perspectives

There are few cases in the current literature that describe simultaneous heart and kidney transplant (HKTx) while on total artificial heart (TAH) bridge therapy. We present a case of successful HKTx after 318 days on TAH bridge therapy and renal replacement therapy. This case demonstrates that TAH placement is a unique and up-and-coming option for bridging patients with heart and kidney failure to HKTx. TAH is a promising bridging option for patients who do not qualify for left ventricular assist device placement. The survival rates to heart transplant and long-term outcomes after heart transplant on TAH bridge therapy are encouraging …

Thyroidectomy In Mechanical Circulatory Support - A Salvage Treatment For Thyrotoxicosis-Induced Cardiogenic Shock: Case Series, Rody G. Bou Chaaya, Lauren M. Saint, Onyedika J. Ilonze Md, Mph

The VAD Journal

Amiodarone is frequently used to treat arrhythmias in patients supported with left ventricular assist devices. Long term amiodarone use can cause hyperthyroidism ultimately leading to cardiomyopathy and sometimes thyrotoxicosis-induced cardiogenic shock (CS). We describe two cases of thyrotoxicosis-induced CS rescued by successful thyroidectomy under mechanical circulatory support (MCS) – one with a Heartmate III (Abbott Laboratories) and another supported with veno-arterial extracorporeal membrane oxygenation (V-A ECMO). In refractory CS, the initiation of V-A ECMO as a bridge to recovery is critical. In thyrotoxicosis-induced CS that is refractory to medical therapy requiring MCS, thyroidectomy is feasible, and a growing body of …

Caregiver Health-Related Quality Of Life, Burden, And Patient Outcomes In Ambulatory Advanced Heart Failure: A Report From Revival., Nisha A. Gilotra, Salpy V. Pamboukian, Maria Mountis, Shawn W. Robinson, Michelle Kittleson, Keyur B. Shah, Rhondalyn C. Forde-Mclean, Donald C. Haas, Douglas A. Horstmanshof, Ulrich P. Jorde, Stuart D. Russell, Wendy C. Taddei-Peters, Neal Jeffries, Shokoufeh Khalatbari, Catherine A. Spino, Blair Richards, Matheos Yosef, Douglas L. Mann, Garrick C. Stewart, Keith D. Aaronson, Kathleen L. Grady

Abington Jefferson Health Papers

Background

Heart failure (HF) imposes significant burden on patients and caregivers. Longitudinal data on caregiver health‐related quality of life (HRQOL) and burden in ambulatory advanced HF are limited.

Methods and Results

Ambulatory patients with advanced HF (n=400) and their participating caregivers (n=95) enrolled in REVIVAL (Registry Evaluation of Vital Information for VADs [Ventricular Assist Devices] in Ambulatory Life) were followed up for 24 months, or until patient death, left ventricular assist device implantation, heart transplantation, or loss to follow‐up. Caregiver HRQOL (EuroQol Visual Analog Scale) and burden (Oberst Caregiving Burden Scale) did not change significantly from baseline to follow‐up. At …

Left Ventricular Assist Device Thrombosis Treated With Intravenous Tissue Plasminogen Activator In A Patient With Covid-19 Infection, Simone A. Jarrett, Jafar Alzubi, Savalan Babapoor-Farrokhran, Zaid Ammari, Mohammad Al-Sarie, Zachary Port, Farhan Hasni, Behnam Bozorgnia, Raphael Bonita

The VAD Journal

Left ventricular assist device (LVAD) implantation is an established treatment for patients with end-stage, systolic heart failure as a bridge to heart transplantation or destination therapy. LVAD pump thrombosis is a life-threatening complication than can be triggered by prothrombotic conditions such as infection. Management of pump thrombosis presents as both a diagnostic and therapeutic challenge that is associated with a high morbidity and mortality. We report a case of pump thrombosis in a patient with a HeartMate II (Abbott Laboratories, Chicago, IL) and coronavirus (COVID-19) infection that was treated successfully with an intravenous thrombolytic, tissue plasminogen activator.

Advantages Of Bridging To Durable Left Ventricular Assist Device With The Impella 5.0, Manish K. Patel

The VAD Journal

The mainstay therapy for patients in critical cardiogenic shock (CS) is temporary mechanical circulatory support. Although there is a trend toward use of durable left ventricular assist devices (LVAD) in patients that are less ill, we present our experience with using the Impella 5.0 (Abiomed) to illustrate the potential benefits of supporting patients with critical CS before durable LVAD implantation. Since 2012, our use of the Impella has increased from 5 to 38 per year. Mortality is highest early after LVAD implantation, but our long-term survival is better than data reported to the INTERMACS registry. Use of an Impella 5.0 …

A "Blinking" Left Ventricular Assist Device, Maya Guglin, Roopa Rao

The VAD Journal

A 61-year-old male with history of coronary artery disease and end stage ischemic cardiomyopathy underwent a successful implantation of a HeartMate 3 device with an uneventful recovery. However, after 6 months, he complained of increased fatigue, intermittent dizziness, and weakness after minor exertion. The pulsatility index was increased to 8, but the left ventricular assist device (LVAD) was otherwise functioning properly. No major changes in either medications or laboratory results were noted. The patient started getting low flow alarms seven months after the procedure and the dizziness increased. On the controller, a continuously changing (“blinking”) speed was noted (Supplemental Video …

Evaluation Of Outpatient Anticoagulation Bridging After Left Ventricular Assist Device Implantation, Rebecca A. Rainess, Lauren Alderman, Teresa Cicci, Monty Yoder, Barbara Pisani, Thomas O’Neill, Diego Malaver

The VAD Journal

Objective: The aim of this study is to evaluate the safety of outpatient anticoagulation bridging following left ventricular assist device (LVAD) implantation.

Methods: This study is a retrospective, single-center cohort of adult patients who underwent LVAD implantation (HeartMate II™ or HeartMate 3™) and received warfarin and at least one dose of therapeutic enoxaparin or fondaparinux for outpatient anticoagulation bridging. The primary endpoint was the incidence of bleeding complications within one week of completing the bridging episode. Secondary endpoints included the incidence of new hemolysis or thrombosis within 30 days, INR at the time of bridge initiation, duration of anticoagulation bridge, …

Effects Of Left Ventricular Assist Device On Pulmonary Functions And Pulmonary Hemodynamics: A Meta-Analysis, Waqas Ullah, Casey Meizinger, Zain Ali, Ankur Panchal, Rehan Saeed, Donald C. Haas, Eduardo Rame

Abington Jefferson Health Papers

BACKGROUND: Given current evidence, the effect of left ventricular assist device (LVAD) implantation on pulmonary function tests remains controversial.

AIM: To better understand the factors contributing to the changes seen on pulmonary function testing and the correlation with pulmonary hemodynamics after LVAD implantation.

METHODS: Electronic databases were queried to identify relevant articles. The summary effect size was estimated as a difference of overall means and standard deviation on a random-effects model.

RESULTS: A total of four studies comprising 219 patients were included. The overall mean forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity …

Extended Cable For Left Ventricular Assist Devices For Monitoring Isolated Patients During The Covid-19 Pandemic, Neal A. Waxali, James M. Kenward, Laurie P. Loza, Yasser Varona, Arvind Bhimaraj

The VAD Journal

We present a method to create an extended cable for patients who are supported by left ventricular assist devices (LVADs) while infected with SARS-CoV-2. The arrangement described facilitates the LVAD monitor console’s positioning outside of the patient’s room to minimize exposure of the mechanical circulatory support team to the novel coronavirus.

Angiotensin Inhibition And Gastrointestinal Bleeding Prevention In Patients With Left Ventricular Assist Devices, Phillip A. Weeks

The VAD Journal

Gastrointestinal bleeding remains a common complication in advanced heart failure patients following implantation of continuous-flow left ventricular assist devices. While the cause is likely multifactorial, development of arterial venous malformations in the gastrointestinal mucosa are a key factor. Inhibition of angiotensin II activity has been postulated to disrupt the signaling that promotes angiogenesis in these patients. We aim to review the theoretical basis for angiotensin receptor blockade, which has been proposed and explore the published evidence regarding this therapy and gastrointestinal bleeding in LVAD patients.

Unusual Case Of Pump Thrombosis In Lvad Patient With Covid-19 — Diagnostic Challenges, William H. Frick Md, Ryan D. Mallory, Maya Guglin, Eve Anderson, Erin N. Lushin, Rey P. Vivo, Kashif Saleem, Roopa A. Rao

The VAD Journal

We present the first reported case of left ventricular assist device (LVAD) pump thrombosis in the setting of the coronavirus pandemic. We describe the clinical features of the case which helped to differentiate coronavirus disease 19 (COVID-19) from LVAD pump thrombosis. The patient is 56-year-old female supported by destination LVAD therapy. She was originally implanted with a HeartMate II device in 2015 and underwent two pump exchanges in 2017 and 2019 for pump thrombosis, despite medication adherence. Shortly after routine lab work revealed near doubling of her lactate dehydrogenase (LDH) levels, she tested positive for COVID-19. She then developed power …

Perioperative Management Of Pheochromocytoma Resection In A Patient With A Continuous Flow Left Ventricular Assist Device, Arif Albulushi Md, Ronald Zolty Md Phd, Brian Lowes Md, Phd, Amy L. Duhacheck-Stapleman Md, Tal Sandler Md, James N. Sullivan Md, Douglas Stoller Md Phd

Journal of the Saudi Heart Association

Current generation LVADs provide continuous blood flow which has been shown to increase sympathetic tone. Pheochromocytoma is a rare neuroendocrine tumor which classically presents with episodic hypertension, palpitations and headaches. Careful perioperative management with alpha blockade is required to prevent cardiovascular complications, specifically hypertensive crisis. Here we present a description of perioperative management of pheochromocytoma in a patient with a continuous flow LVAD. Traditional assessment of sympathetic tone is challenging in LVAD patients due to the presence of continuous circulatory flow. Invasive management via an arterial line was useful in perioperative management, allowing for accurate circulatory monitoring and hemodynamic control. …

What Is A Vad Social Worker? A National Perspective, Pamela Combs, William Cohen, Umar Siddiqi, Valluvan Jeevanandam

The VAD Journal

Ventricular Assist Device Social Workers (VAD SWs) are mandated members of VAD care teams and contribute to the psychosocial aspect of patient care within the United States. However, the contributions and methods of the VAD SW are relatively undefined. This article reports the results of two national surveys regarding VAD SWs. One survey ascertains the VAD SW’s views of their work and their role in the VAD care team. The other survey assesses the VAD SWs involvement with care, through the perspective of the VAD team. Our results indicate that SWs are not only routinely involved in VAD patient selection …

What Did We Learn About Vads In 2019?, Maya Guglin

The VAD Journal

This is our 6th annual literature review on mechanical circulatory support (MCS) devices.

Our previous reports for 2014, 2015, 2016, 2017, 2018 were published as open access articles and were well received by the readers. In this paper, we summarize the most interesting and important, from our standpoint, publications from 2019. As we have done for the past two years, a section on extracorporeal membrane oxygenation (ECMO) is included and primarily addresses new developments in veno-arterial ECMO use.

Predicting Bleeding And Thrombosis Complications In Patients With Continuous Flow Left Ventricular Assist Devices, Kyle Zacholski, William Kuan, Justin Mccann Mccann, Aric Schadler, Aaron Cook, Sara Parli, Adam Sieg

The VAD Journal

Background: Left ventricular assist device (LVAD) therapy has been proven to relieve heart failure symptoms and improve survival, but is not devoid of bleeding and/or thrombotic complications. Risk stratification tools have been utilized in other cardiovascular disease populations to estimate the risk of bleeding and thrombosis with and without anticoagulation, including the HAS-BLED, HEMORR₂HAGES, CHADS₂ and CHA₂DS₂-VASc models. The study objective was to evaluate the predictive value of available risk models for bleeding and thrombotic complications in patients with an LVAD within one year of implantation.

Methods: This was a retrospective, single-center analysis …

Device Related Concerns Pertaining To Primary Caregivers Of Lvad Patients, Nicole Smith, Carissa Smith

DNP Projects

Abstract

PURPOSE: The purpose of this project was to focus on caregiver education with an emphasis on caregiver concerns regarding the LVAD; additionally, evaluating the efficacy of an educational video acknowledging those device-related concerns identified by caregivers. The goal of this project is to improve caregiver knowledge and decrease the rate of device related concerns among the primary caregivers.

METHODS: This project is a single center cross-sectional, pre-post-test implementation design to determine the efficacy of device related concerns education on primary caregivers’ knowledge and concerns. A 16-point device related concerns scale was designed to appraise primary caregiver concerns. The scale …

Effects Of Stem Cell Therapy On 6-Minute Walk Test Distance And Left Ventricular Ejection Fraction In Patients With Nonischemic Cardiomyopathy, Kayleigh Hunt, Alexa Maziuk

Physician Assistant Capstones, 2016 to 2019

Objective

To assess the efficacy of stem cells in the improvement of functional capacity and quality of life in the setting of nonischemic dilated cardiomyopathy.

Design

Systematic literature review

Methods

A literature search of PubMed was conducted utilizing the following search terms: “stem,” “cell,” “nonischemic,” and “cardiomyopathy.” The following limits were used: “2015-2018,” nonischemic cardiomyopathy, results of LVEF and 6MWT, randomized controlled trials, pilot studies, and sample size >22.

Results

Butler et al. found that within the itMSC group, 6MWD increased by an average of 27.40 m (95% CI 0.28–54.52; P=0.05), but it decreased by an average of 10.83 m …

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

The VAD Journal

No abstract provided.

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

The VAD Journal

No abstract provided.

Changes In Pulmonary Artery Pressure Before And After Left Ventricular Assist Device Implantation In Patients Utilizing Remote Haemodynamic Monitoring, A. Kilic, J. N. Katz, S. M. Joseph, M. A. Brisco-Bacik, N. Uriel, B. Lima, R. Agarwal, R. Bharmi, D. J. Farrar, S. Lee

Journal Articles

No abstract provided.

Cardiac Prostheses‐Related Hemolytic Anemia, Mohamad Alkhouli, Ali Farooq, Ronald S. Go, Sudarshan Balla, Chalak Berzingi

Faculty & Staff Scholarship

Hemolysis is an unintended sequel of temporary or permanent intracardiac devices. However, limited data exist on the characteristics and treatment of hemolysis in patients with cardiac prostheses. This entity, albeit uncommon, often poses significant diagnostic and management challenges to the clinical cardiologist. In this article, we aim to provide a contemporary overview of the incidence, mechanisms, diagnosis, and management of cardiac prosthesis-related hemolysis.

Frailty In Patients Undergoing Left Ventricular Assist Device Implantation, Candice Falls

Theses and Dissertations--Nursing

Heart failure is a progressive condition that affects over 5.7 million Americans and costs associated with heart failure account for 2-3 % of the national health care budget. The high rates of morbidity and mortality along with increased costs from readmissions associated with advanced heart failure have led to the exploration of advanced treatments such as left ventricular assist devices (LVADs). LVADS have demonstrated morbidity and mortality benefit but cost remains extensive with costs per quality-adjusted years > $400,000. With this in mind, it is important to identify those who are most likely to benefit from an LVAD to avoid unfavorable …

Advanced Heart Failure Treatment Options Among The Elderly, German Guzman-Gutierrez, Yang Shi, Matthew Rappelt, Arshad Jahangir, Vinay Thohan

Aurora Heart Failure / Transplant Faculty

The aging human population has emerged as a critically important factor in health care, not only due to the unique physiologic and pathologic processes associated with aging but also because of the evolution of medical and surgical therapies that have increased quality and quantity of life. Heart failure is a disease found most commonly among older populations in whom it is associated with high morbidity and mortality. Heart failure disproportionately affects the elderly, and it stands to reason that the most terminal stage, known as advanced heart failure (AHF), is more common among the elderly. Despite limited data, treatment options …