High Right Atrial Pressure and Low Pulse Pressure Predict Gastrointestinal Bleeding in Patients With Left Ventricular Assist Device

The “double whammy” of a continuous-flow left ventricular assist device on von Willebrand factor

“…A retrospective analysis of 108 LVAD recipients revealed several independent factors associated with GIB, including pulse pressure, age, mean arterial blood pressure, right atrial blood pressure, and previous GIB. 7 Furthermore, by stratifying this cohort on the basis of a pulse pressure cutoff value of 35 mm Hg, significant insight into the potential role of pulsatility was provided: Within 9 months of implantation, the high pulsatility group experienced only 8 GIB events (83% unaffected), whereas the low pulsatility group experienced 47 GIB events (69% unaffected). In another retrospective study, Patel and colleagues 4 observed 88 GIB events (75% unaffected) within 12 months of CF-LVAD support.…”

“…Indeed, a plethora of observational evidence, from our institute and others, points to a potential causal link between pulsatility and nonsurgical bleeding events in CF-LVADs. [4][5][6][7] Building on this, there is an emerging body of evidence elucidating how the potential mechanisms by which reduced arterial pulsatility and high pump shear stress result in the impairment of peripheral cardiovascular and clotting function. [1][2][3][4]8 Specifically, in vitro studies have documented a shared mechano-transduction pathway in endothelial cells for the secretion of clotting factors and the production of the vasodilator nitric oxide (NO), a key vasodilator that has been recognized to be attenuated in CF-LVAD recipients.…”

Clinical characteristics and outcomes of patients requiring prolonged inotropes after left ventricular assist device implantation

“…The data were collected from medical records; nevertheless, clinical decisions were made based on these data at the time they were produced and thus offer real-world applicability. 21 It represents a single-center experience, and the duration of inotrope use after LVAD implantation was based on the discretion of treating physicians with no standardized criteria. Most patients did not have invasive hemodynamic monitoring at 14 days to directly measure right-sided filling pressures, so we were unable to directly correlate inotrope use with RAP measurements and a proportion of these patients may not have had primary RVF.…”

Prognostic implications of serial outpatient blood pressure measurements in patients with an axial continuous-flow left ventricular assist device

“…endothelial dysfunction makes the vasculature more susceptible to damage with each incremental rise in SBP. 18 Mechanistic and histologic studies are warranted to assess the interaction of BP and reduced pulsatility in the pathogenesis of microvascular damage, not only in the cerebral but also in the gastrointestinal circulation, 19 in CF-LVAD patients. While awaiting stronger evidence to confirm or dismiss our findings, it may be reasonable to target an SBP <101 mm Hg in patients with reduced pulsatility (PP <22 mm Hg), particularly when considering that our results are in line with older studies that demonstrated an association between low PP and poor outcomes in HF patients.…”