Clinical and In Vitro Evidence That Subclinical Hemolysis Contributes to LVAD Thrombosis

Bartoli, Carlo; Zhang, David M.; Kang, Jooeun; Hennessy-Strahs, Samson; Restle, David; Howard, Jessica; Redline, Gretchen; Bermúdez, C.; Atluri, Pavan; Acker, Michael A.

doi:10.1016/j.athoracsur.2017.05.060

Cited by 41 publications

(31 citation statements)

References 35 publications

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“…Experimentally determined stress thresholds for hemolysis depend on exposure time, but are generally above 150 Pa . However, recent evidence suggests that even subclinical hemolysis, which may occur below the abovementioned thresholds, might contribute to thrombotic adverse events . Since viscous stresses in the HM3 are generally lower than 150 Pa throughout the investigated conditions, we expect negligible hemolysis, which fits clinical experience and in vitro experiments .…”

Section: Discussionsupporting

confidence: 76%

Fluid Dynamics in the HeartMate 3: Influence of the Artificial Pulse Feature and Residual Cardiac Pulsation

et al. 2018

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Ventricular assist devices (VADs), among which the HeartMate 3 (HM3) is the latest clinically approved representative, are often the therapy of choice for patients with end-stage heart failure. Despite advances in the prevention of pump thrombosis, rates of stroke and bleeding remain high. These complications are attributed to the flow field within the VAD, among other factors. One of the HM3's characteristic features is an artificial pulse that changes the rotor speed periodically by 4000 rpm, which is meant to reduce zones of recirculation and stasis. In this study, we investigated the effect of this speed modulation on the flow fields and stresses using high-resolution computational fluid dynamics. To this end, we compared Eulerian and Lagrangian features of the flow fields during constant pump operation, during operation with the artificial pulse feature, and with the effect of the residual native cardiac cycle. We observed good washout in all investigated situations, which may explain the low incidence rates of pump thrombosis. The artificial pulse had no additional benefit on scalar washout performance, but it induced rapid variations in the flow velocity and its gradients. This may be relevant for the removal of deposits in the pump. Overall, we found that viscous stresses in the HM3 were lower than in other current VADs. However, the artificial pulse substantially increased turbulence, and thereby also total stresses, which may contribute to clinically observed issues related to hemocompatibility.

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Section: Discussionsupporting

confidence: 76%

Fluid Dynamics in the HeartMate 3: Influence of the Artificial Pulse Feature and Residual Cardiac Pulsation

et al. 2018

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“…Serum LDH greater than three times the upper limit of normal is a finding highly suggestive of active pump thrombosis and should prompt consideration of in‐patient hospital admission, intensification of antithrombotic therapy and evaluation for potential surgical management . The source of LDH is hypothesized to be from erythrocyte hemolysis due to increased shear forces within the CF‐LVAD during pump thrombosis …”

Section: Lactate Dehydrogenase Isoenzymes and Hemolysis In Pump Thrommentioning

confidence: 99%

“…While signs of hemolysis are present during acute pump thrombosis episodes, patients with CF‐LVADs have been shown to have evidence of subclinical hemolysis at baseline . Early elevation of LDH post CF‐LVAD implantation, as well as an elevated baseline level of hemolysis, has a proven track‐record of being predictive of future thrombotic events …”

Section: Lactate Dehydrogenase Isoenzymes and Hemolysis In Pump Thrommentioning

confidence: 99%

“…26,28,42 The source of LDH is hypothesized to be from erythrocyte hemolysis due to increased shear forces within the CF-LVAD during pump thrombosis. 26,43 While signs of hemolysis are present during acute pump thrombosis episodes, patients with CF-LVADs have been shown to have evidence of subclinical hemolysis at baseline. [43][44][45] Early elevation of LDH post CF-LVAD implantation, as well as an elevated baseline level of hemolysis, has a proven track-record of being predictive of future thrombotic events.…”

Section: Isoenzymes and Hemolysis In Pump Thrombosismentioning

confidence: 99%

“…26,43 While signs of hemolysis are present during acute pump thrombosis episodes, patients with CF-LVADs have been shown to have evidence of subclinical hemolysis at baseline. [43][44][45] Early elevation of LDH post CF-LVAD implantation, as well as an elevated baseline level of hemolysis, has a proven track-record of being predictive of future thrombotic events. [43][44][45][46] Total serum LDH level elevation has long been used to indicate pump thrombosis but is a nonspecific finding and can be found in several inflammatory and pathologic states.…”

Section: Isoenzymes and Hemolysis In Pump Thrombosismentioning

confidence: 99%

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Clinical implications of LDH isoenzymes in hemolysis and continuous‐flow left ventricular assist device‐induced thrombosis

et al. 2019

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Pump‐induced thrombosis continues to be a major complication of continuous‐flow left ventricular assist devices (CF‐LVADs), which increases the risks of thromboembolic stroke, peripheral thromboembolism, reduced pump flow, pump failure, cardiogenic shock, and death. This is confounded by the fact that there is currently no direct measure for a proper diagnosis during pump support. Given the severity of this complication and its required treatment, the ability to accurately differentiate CF‐LVAD pump thrombosis from other complications is vital. Hemolysis measured by elevated lactate dehydrogenase (LDH) enzyme levels, when there is clinical suspicion of pump‐induced thrombosis, is currently accepted as an important metric used by clinicians for diagnosis; however, LDH is a relatively nonspecific finding. LDH exists as five isoenzymes in the body, each with a unique tissue distribution. CF‐LVAD pump thrombosis has been associated with elevated serum LDH‐1 and LDH‐2, as well as decreased LDH‐4 and LDH‐5. Herein, we review the various isoenzymes of LDH and their utility in differentiating hemolysis seen in CF‐LVAD pump thrombosis from other physiologic and pathologic conditions as reported in the literature.

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LVAD‐Associated Acquired von Willebrand Syndrome and Gastrointestinal Bleeding: Pathophysiology, Etiologies, and Management

Ramdeen,

Bartoli

2023

Textbook of Transplantation and Mechanical Support for End‐Stage Heart and Lung Disease

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Clinical and In Vitro Evidence That Subclinical Hemolysis Contributes to LVAD Thrombosis

Cited by 41 publications

References 35 publications

Fluid Dynamics in the HeartMate 3: Influence of the Artificial Pulse Feature and Residual Cardiac Pulsation

Fluid Dynamics in the HeartMate 3: Influence of the Artificial Pulse Feature and Residual Cardiac Pulsation

Clinical implications of LDH isoenzymes in hemolysis and continuous‐flow left ventricular assist device‐induced thrombosis

LVAD‐Associated Acquired von Willebrand Syndrome and Gastrointestinal Bleeding: Pathophysiology, Etiologies, and Management

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