Background. Thromboembolic events (TEs) are common adverse events with continuous-flow left ventricular assist devices (LVADs). Left atrial appendage occlusion (LAAO) is commonly performed at the time of a cardiac operation. The effect of LAAO on TEs in LVAD patients remains unknown.Methods. All patients receiving a first LVAD implantation between January 2013 and January 2014 were reviewed. TEs included device thrombosis and ischemic cerebrovascular accidents. The incidence of TEs with respect to LAAO was evaluated using Kaplan-Meier and Cox proportional hazards analyses.Results. The analysis included 102 patients, 36 of whom received LAAO and 66 did not. LAAO patients were an average age of 60 years, and 69.4% were men. Non-LAAO patients were an average age of 59.3 years, and 71.2% were men. There were no significant differences in characteristics other than history of coronary artery bypass grafting (8.3% of LAAO vs 44% of non-LAAO, p [ 0.0005). Preoperative atrial fibrillation was present in 19 LAAO patients (52.7%) and in 36 non-LAAO patients (54.5%; p [ 1.0). Patients were monitored for a median of 306 days. TEs occurred in 3 LAAO patients (1 device thrombosis and 2 cerebrovascular accidents) compared with 15 non-LAAO patients (5 device thromboses and 11 cerebrovascular accidents, p [ 0.049). In a Cox hazards analysis including age, sex, hypertension, and atrial fibrillation, LAAO demonstrated a decreased risk of TE (hazard ratio, 0.27; 95% confidence interval, 0.08 to 0.95; p [ 0.04).Conclusions. In patients undergoing LVAD implantation, LAAO is associated with reduced TEs, and this effect may be independent of atrial fibrillation. A prospective randomized study to examine the efficacy LAAO in prevention of TE is needed to confirm these findings.
Anticoagulation therapy is used to prevent thromboembolic events in patients with left ventricular assist devices (LVADs). This study aims to determine the safety of low molecular weight heparin (enoxaparin) for bridging subtherapeutic international normalized ratio (INR) in LVAD patients. In this retrospective single-center study, all patients who underwent LVAD implantation were examined between January 1, 2013, and December 31, 2014. Patients were divided into two groups: enoxaparin bridge and no bridge, with identification of major bleeding episodes (MBEs) and thrombotic events (TEs). Major bleeding episode and TE incidence was compared between the two groups, with subanalysis of incidence in the enoxaparin group between the periods on and off treatment. One hundred eighteen patients were included in this analysis. Fifty-five patients received enoxaparin, whereas 63 patients did not receive enoxaparin, with no significant difference between groups in all baseline characteristics. For the study period, enoxaparin patients had no increased incidence of MBEs (0.53 vs. 0.35 MBE per year; p = 0.12). However, there was a fourfold increase in MBEs during the bridged period in the enoxaparin group (2.02 vs. 0.45 MBE per year; p = 0.03). Major bleeding episodes on versus off enoxaparin had no major difference in transfusion requirements (2.7 ± 2.9 vs. 2.5 ± 3.4 units; p = 0.57) or mortality (p = 0.11). The enoxaparin group trended to a higher incidence of TEs (0.20 vs. 0.11 events per year; p = 0.08). Enoxaparin bridging in patients with subtherapeutic INR is associated with a significantly increased risk of MBEs. Prospective studies are needed to confirm these findings; however, until then, caution should be used with enoxaparin for bridging in LVAD patients.
This study sought to determine the incidence, predictors, and outcomes of postoperative atrial fibrillation (POAF) in patients undergoing implantation of left ventricular assist devices (LVADs). A retrospective analysis of all patients who underwent LVAD implantation from 2013 to 2014 was conducted. Postoperative AF, survival, and thrombotic complications were evaluated after surgery. A total of 47 patients (mean age, 56.4 ± 12.5 years; 33 male) were included and followed for a median of 331 days. Within 30 days of surgery, 13 (28%) patients developed POAF at mean 7.9 ± 8.5 days. Obstructive lung disease was a predictor of POAF (p = 0.01). Postoperative AF was not associated with increased mortality, length of stay, or thrombotic complication within 30 days. Postoperative AF was predictive of recurrent new AF (24 vs. 5.5%) after 30 days of LVAD implantation. Also, POAF was associated with increased risk of ischemic stroke and device thrombosis during follow-up (p = 0.01). These results show that unlike in other cardiac surgery, POAF does not have a negative impact on early postoperative morbidity or mortality. However, POAF is a predictor for future AF, ischemic stroke, and device thrombosis.
Despite clinical advances in its treatment, heart failure (HF) is associated with significant adverse clinical outcomes and is among the greatest drivers of healthcare utilization. Outpatient management of HF remains suboptimal, with gaps in the provision of evidencebased therapies, and difficulties in predicting and managing clinical decompensation. Remote patient monitoring (RPM) has the potential to address these issues, and thus has been of increasing interest to HF clinicians and health systems. Economic incentives, including increasing RPM reimbursement and HF readmission penalties, are also spurring increased interest in RPM. This review establishes a framework for evaluating RPM based on its various components: 1) patient data collection, 2) data transmission, analysis, and presentation, and 3) care team review and clinical action. The existing evidence regarding RPM in HF management is also reviewed. Based on the data, we identify RPM features associated with clinical efficacy and describe emerging digital tools that have the promise of addressing current needs.
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