Gastrointestinal bleeding rates in recipients of nonpulsatile and pulsatile left ventricular assist devices

Crow, Sheri; John, Ranjit; Boyle, Andrew; Shumway, Sara J.; Liao, Kenneth; Colvin-Adams, Monica; Toninato, C.; Missov, Emil; Pritzker, Marc; Martin, Cindy M.; Garry, Daniel J.; Thomas, William; Joyce, Lyle D.

doi:10.1016/j.jtcvs.2008.07.032

Cited by 447 publications

(346 citation statements)

References 19 publications

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“…Crow et al 31 showed increased rates of bleeding in patients supported with CF-LVADs compared with patients not requiring anticoagulation on pulsatile-flow LVADs (63 events/100 patient-years versus 6.8 events/100 years). However, the incidence of bleeding complications was higher than what would be expected based on systemic anticoagulation use alone.…”

Section: Discussionmentioning

confidence: 99%

Pulsatility and the Risk of Nonsurgical Bleeding in Patients Supported With the Continuous-Flow Left Ventricular Assist Device HeartMate II

Wever-Pinzon

Selzman

Drakos

et al. 2013

Circ: Heart Failure

211

111

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Background— Bleeding is an important cause of morbidity and mortality in patients with continuous-flow left ventricular assist devices (LVADs). Reduced pulsatility has been implicated as a contributing cause. The aim of this study was to assess the effects of different degrees of pulsatility on the incidence of nonsurgical bleeding. Methods and Results— The Utah Transplantation Affiliated Hospitals (U.T.A.H.) heart failure and transplant program databases were queried for patients with end-stage heart failure who required support with the continuous-flow LVAD HeartMate II (Thoratec Corp, Pleasanton, CA) between 2004 and 2012. Pulsatility was evaluated by means of the LVAD parameter pulsatility index (PI) and by the echocardiographic assessment of aortic valve opening during the first 3 months of LVAD support. PI was analyzed as a continuous variable and also stratified according to tertiles of all the PI measurements during the study period (low PI: <4.6, intermediate PI: 4.6–5.2, and high PI: >5.2). Major nonsurgical bleeding associated with a decrease in hemoglobin ≥2 g/dL (in the absence of hemolysis) was the primary end point. A total of 134 patients (median age of 60 [interquartile range: 49–68] years, 78% men) were included. Major bleeding occurred in 33 (25%) patients (70% gastrointestinal, 21% epistaxis, 3% genitourinary, and 6% intracranial). In multivariable analysis, PI examined either as a categorical variable, low versus high PI (hazard ratio, 4.06; 95% confidence interval, 1.35–12.21; P =0.04), or as a continuous variable (hazard ratio, 0.60; 95% confidence interval, 0.40–0.92; P =0.02) was associated with an increased risk of bleeding. Conclusions— Reduced pulsatility in patients supported with the continuous-flow LVAD HeartMate II is associated with an increased risk of nonsurgical bleeding, as evaluated by PI.

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Section: Discussionmentioning

confidence: 99%

Pulsatility and the Risk of Nonsurgical Bleeding in Patients Supported With the Continuous-Flow Left Ventricular Assist Device HeartMate II

Wever-Pinzon

Selzman

Drakos

et al. 2013

Circ: Heart Failure

211

111

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“…The abdominal aorta was chosen for the measurements because patients with PVADs typically do not suffer from gastrointestinal bleeding, whereas patients on continuous-flow VADs show a high incidence of such complication (8,11,22). Consequently, abdominal WI patterns under PVAD support should yield insight into what type of hemodynamic disturbance is acceptable in that region.…”

Section: Discussionmentioning

confidence: 99%

“…The impact of VADs on the hemodynamics and on the mechanical unloading of the heart has been analyzed previously (3,7,12,16,26). In cases where the duration of VAD support is in the order of years, its impact on the peripheral circulation and potentially induced structural changes (8,11,22) needs more research.Wave intensity analysis (WIA) is a relatively new method to evaluate arterial wave transmission phenomena. WIA has received increased attention because arterial waves are seen as possible independent mediators of cardiovascular risks (10).…”

mentioning

confidence: 99%

Effects of Thoratec pulsatile ventricular assist device timing on the abdominal aortic wave intensity pattern

Jahren

Amacher

Weber

et al. 2014

American Journal of Physiology-Heart and Circulatory Physiology

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Jahren SE, Amacher R, Weber A, Most H, Flammer SA, Traupe T, Stoller M, de Marchi S, Vandenberghe S. Effects of Thoratec pulsatile ventricular assist device timing on the abdominal aortic wave intensity pattern. Am J Physiol Heart Circ Physiol 307: H1243-H1251, 2014. First published August 22, 2014; doi:10.1152/ajpheart.00085.2014.-Arterial waves are seen as possible independent mediators of cardiovascular risks, and the wave intensity analysis (WIA) has therefore been proposed as a method for patient selection for ventricular assist device (VAD) implantation. Interpreting measured wave intensity (WI) is challenging, and complexity is increased by the implantation of a VAD. The waves generated by the VAD interact with the waves generated by the native heart, and this interaction varies with changing VAD settings. Eight sheep were implanted with a pulsatile VAD (PVAD) through ventriculoaortic cannulation. The start of PVAD ejection was synchronized to the native R wave and delayed between 0 and 90% of the cardiac cycle in 10% steps or phase shifts (PS). Pressure and velocity signals were registered, with the use of a combined Doppler and pressure wire positioned in the abdominal aorta, and used to calculate the WI. Depending on the PS, different wave interference phenomena occurred. Maximum unloading of the left ventricle (LV) coincided with constructive interference and maximum blood flow pulsatility, and maximum loading of the LV coincided with destructive interference and minimum blood flow pulsatility. We believe that noninvasive WIA could potentially be used clinically to assess the mechanical load of the LV and to monitor the peripheral hemodynamics such as blood flow pulsatility and risk of intestinal bleeding.arterial wave interference; heart-ventricular assist device interaction; pulsatility; ventricular assist device; wave intensity analysis VENTRICULAR ASSIST DEVICES (VADs) are clinically used blood pumps to treat end-stage heart failure (28). In addition to being used as a bridge-to-transplantation, the use of VADs as a bridge-to-recovery and as an alternative to heart transplantation is becoming increasingly important (14). The impact of VADs on the hemodynamics and on the mechanical unloading of the heart has been analyzed previously (3,7,12,16,26). In cases where the duration of VAD support is in the order of years, its impact on the peripheral circulation and potentially induced structural changes (8,11,22) needs more research.Wave intensity analysis (WIA) is a relatively new method to evaluate arterial wave transmission phenomena. WIA has received increased attention because arterial waves are seen as possible independent mediators of cardiovascular risks (10). WIA is based on conservation of mass and momentum in elastic vessels and uses the simultaneous measurement of arterial pressure and blood flow velocity (20, 31). Previously, WIA has been used to analyze the performance of intra-aortic balloon pumps (IABPs) (4, 5, 15, 17), para-aortic counterpulsation devices (18), or pusher-plate pulsatil...

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“…Bleeding rates in LVAD patients are higher than in patients treated with anticoagulation and anti-platelet agents for other indications [8]. Other factors possibly associated with CF-LVAD bleeding, include changes in the vWF multimer pattern, platelet function, and GI tract vasculature.…”

Section: Anticoagulation Management Of Left Ventricular Assist Devicesmentioning

confidence: 99%

Anticoagulation management of left ventricular assist devices

Connors

2014

American J Hematol

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Gastrointestinal bleeding rates in recipients of nonpulsatile and pulsatile left ventricular assist devices

Cited by 447 publications

References 19 publications

Pulsatility and the Risk of Nonsurgical Bleeding in Patients Supported With the Continuous-Flow Left Ventricular Assist Device HeartMate II

Pulsatility and the Risk of Nonsurgical Bleeding in Patients Supported With the Continuous-Flow Left Ventricular Assist Device HeartMate II

Effects of Thoratec pulsatile ventricular assist device timing on the abdominal aortic wave intensity pattern

Anticoagulation management of left ventricular assist devices

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