Heparin-Induced Thrombocytopenia under Mechanical Circulatory Support by Large Impella for Acute Cardiogenic Shock

Sugimura, Yukiharu; Bauer, Sebastian; Immohr, Moritz Benjamin; Hermsen, Derik; Westenfeld, Ralf; Boeken, Udo; Aubin, Hug; Tudorache, I.; Lichtenberg, Artur; Akhyari, Payam

doi:10.3390/jcdd8120161

Cited by 12 publications

(15 citation statements)

References 14 publications

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“…Additionally, the TTR reported in our study is nearly identical to the TTR observed with systemic heparin reported by Wood et al Major bleeding requiring either transfusion or vascular surgery has been reported in 9%–29% of patients treated with an Impella device and heparin‐based anticoagulation 24,26 . While difficult to draw direct comparisons between our cohort and with previously published data surrounding heparin‐based anticoagulation, it appears that the bleeding rates observed in our series are comparable to formerly published data 24,27 . Third, the use of tPA was at the discretion of the multi‐disciplinary team without pre‐specified triggers to initiate a tPA purge solution.…”

Section: Discussionsupporting

confidence: 87%

“…24,26 While difficult to draw direct comparisons between our cohort and with previously published data surrounding heparin-based anticoagulation, it appears that the bleeding rates observed in our series are comparable to formerly published data. 24,27 Third, the use of tPA was at the discretion of the multi-disciplinary team without pre-specified triggers to initiate a tPA purge solution. However, most of the tPA purge solution use only occurred after declines and rises in purge rates and pressures, respectively.…”

Section: Discussionmentioning

confidence: 99%

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Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5

et al. 2022

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Background: Impella 5.5 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation and sodium bicarbonatedextrose purge solution (SBPS) in IMP5.5. Methods: This single center, retrospective study included 34 patients supported on IMP5.5 with BIV based AC and SBPS between December 1st 2020 to December 1st 2021.The efficacy and safety end points were incidence of development of HIT, Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure as well as clinically significant bleeding. Results:The median duration of IMP5.5 support was 9.8 days (IQR: 6-15). Most patients were bridged to HTX (58%) followed by recovery (27%) and LVAD implantation (15%). Patients were therapeutic on bivalirudin for 64% of their IMP5.5 support. One patient (2.9%) suffered from ischemic stroke and 26.5% (9) patients developed clinically significant bleeding. tPA was administered to 7(21%) patients. One patient in the entire cohort developed HIT. Conclusions:Our experience supports the use of systemic BIV and SBPS as a method to avoid heparin exposure in a patient population predisposed to the development of HIT.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5

et al. 2022

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“…supported patients noted a 10.7% incidence of HIT; however, confirmatory functional assay results were not reported. 12 In our population, no patient developed functional assay/SRA-confirmed HIT despite many patients experiencing a platelet drop ≥50% of baseline and 6.4% of patients having a positive PF-4 ELISA.…”

Section: Discussionmentioning

confidence: 67%

Incidence and severity of thrombocytopenia associated with use of intravascular microaxial ventricular assist devices for treatment of cardiogenic shock

Goetz

O’Brien

Bream-Rouwenhorst

et al. 2022

Cathet Cardio Intervent

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Introduction The use of temporary mechanical circulatory support (MCS) for patients with refractory cardiogenic shock has increased over the past decade. Impella devices (intravascular microaxial ventricular assist devices [VADs]) have become common MCS options but reportedly cause thrombocytopenia. Limited published data regarding the incidence or severity of microaxial VAD‐associated thrombocytopenia exists. Objectives The goal of this study was to determine the incidence, timing, and severity of thrombocytopenia in a microaxial VAD population. Methods A retrospective multicenter review of electronic medical records identified all patients implanted with microaxial VAD at three US academic teaching hospitals between June 2015 and August 2017. Patients were excluded for short‐term procedural microaxial VAD use during percutaneous coronary intervention. Results Sixty‐four patients underwent microaxial VAD insertion (95% for left‐sided support) during the observed time period. Support was in place for a median duration of 5.2 (interquartile range [IQR]: 2.4–10.0) days. Within 7 days postinsertion, 98.5% of patients developed thrombocytopenia (platelet count <150,000/μl) and 81.3% of patients experienced a >50% platelet decrease. Average platelet count nadir was 68,200/μl or 63.9% from baseline occurring on median day 3.8 (IQR: 2.4–5.4). Twenty‐four patients (38.1%) were tested for heparin‐induced thrombocytopenia by the heparin‐dependent antibody (HDA) test. All HDAs were either negative or had serotonin release assay negative confirmation. Postdevice removal, platelet counts returned to baseline or >150,000/μl in 63% of patients by Day 5. Conclusion Microaxial VAD‐associated thrombocytopenia is common. Practitioners should consider this when evaluating supported patients for other causes of thrombocytopenia. Platelet counts return to preimplantation levels within days of device removal.

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“…Postoperative management after Impella 5+ follows as we described before ( 9 , 10 ). Briefly, all parameters displayed in Impella monitor, e.g., Impella setting, Impella flow, purge pressure, purge flow rate, and placement signal, were documented every 3 h. All patients underwent chest X-ray evaluation every day to examine the position of the Impella pump.…”

Section: Methodsmentioning

confidence: 99%

“…However, both anticoagulation agents were regulated appropriately in case of significant bleeding, i.e., major bleeding. In the case of heparin-induced thrombocytopeniaII, argatroban was administrated instead of heparin ( 10 ). For the evaluation of whole organs, blood gas analysis was routinely performed several times per day.…”

Section: Methodsmentioning

confidence: 99%

Outcome of Patients Supported by Large Impella Systems After Re-implantation Due to Continued or Recurrent Need of Temporary Mechanical Circulatory Support

Sugimura

Bauer²,

Immohr³

et al. 2022

Front. Cardiovasc. Med.

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Despite the growing utilization of a large microaxial pump, i. e., Impella 5.0 or 5.5 (Abiomed Inc., Danvers, MA, USA) (Impella 5+) for patients with cardiogenic shock (CS), adverse events including the necessity of re-implantation have not been well discussed. In all 67 patients, in-hospital mortality was 52.2% (n = 35). Explantation of Impella 5+ was performed in 39 patients (58.2%), 22 of whom (32.8%) recovered under Impella 5+, and ten further patients (14.9%) survived after a successful transition to permanent mechanical circulatory support. Embolic events were considerable complications in each access. They occurred in the right arm after the removal of Impella 5+ via a subclavian artery (SA) (n = 3, 9.1%) or in the form of leg ischemia in patients with Impella 5+ via femoral artery (FA) (n = 2, 33.3%). Re-implantation was necessary for 10 patients (14.9%) due to 1) recurrent CS (n = 3), 2) pump thrombosis (n = 5), or 3) pump dislocation (n = 2), all of which were successfully performed via the same access route. In univariate analysis, FA access was a significant risk factor for Impella dysfunction compared to SA access (FA vs. SA, 42.9% vs. 9.8%, p < 0.05, odds ratio 6.88). No statistical difference of overall mortality was observed in patients with Impella 5+ re-implantation (n = 10) compared to patients with primary Impella 5+ support (n = 57) (80.0% (n = 8/10) vs. 47.4% (n = 27/57), p = 0.09). Our results suggested the acceptable clinical outcome of Impella 5+ despite a 15% re-implantation rate. Our observational data may merit further analysis of anticoagulation strategies, including risk stratification for embolic events.

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Heparin-Induced Thrombocytopenia under Mechanical Circulatory Support by Large Impella for Acute Cardiogenic Shock

Cited by 12 publications

References 14 publications

Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5

Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5

Incidence and severity of thrombocytopenia associated with use of intravascular microaxial ventricular assist devices for treatment of cardiogenic shock

Outcome of Patients Supported by Large Impella Systems After Re-implantation Due to Continued or Recurrent Need of Temporary Mechanical Circulatory Support

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