Incidence and Risk Factor Analysis for Gastrointestinal Bleeding and Pump Thrombosis in Left Ventricular Assist Device Recipients

Abstract

Left ventricular assist devices (LVADs) are associated with hemostatic complications. We describe the incidence and risk factors for gastrointestinal bleeding (GIB) and pump thrombosis (PT) to optimize patient selection/management. An IRB-approved retrospective review of first LVAD implants between October 1, 2011 and September 30, 2013 at a single center was conducted. Endpoints included epidemiological and risk factor analyses for GIB and PT. Descriptive statistics, chi-squared, and t-tests were used. Sixty-four patients received continuous-flow LVADs. The 12-month incidence of GIB and PT was 23.4% and 12.5%. Time to first GIB was 72.6 days (9-160). The 1-, 3-, and 6-month rate of PT was 1.6%, 6.25%, and 12.5%, respectively. All PT required pump exchange. Females (50% vs. 16%, P = 0.026) and patients without antiplatelet therapy (12.5% vs. 50%, P = 0.046) were at increased risk of PT. No pre-implant comorbidities were associated with PT. Infection was not identified as a risk factor in our cohort (25% vs. 51.8%, P = 0.156). Mean INR preceding event was not different from nonevent patients (2.1 vs. 2.24, P = 0.24). Regarding biomarkers preceding event, elevated plasma free hemoglobin (pfHg) did not reach significance (75% vs. 58%, P = 0.383) while lactate dehydrogenase was elevated significantly (744 vs. 298, P < 0.001). Receiver operating characteristic (ROC) analysis demonstrated that an LDH of >500 was highly sensitive and specific for PT. No pre-implant factors were associated with GIB. Post-implant risk factors for GIB included infection (80% vs. 38.8%, P = 0.005) and infrequent elevations in pfHg (13.3% vs. 63.3%, P < 0.001). Increased pump speed as a GIB risk factor was confirmed (HeartMate II 9560 rpm vs. 9490 rpm, P < 0.001; HeartWare 2949 rpm vs. 2710 rpm, P < 0.001). Anticoagulation/antiplatelet therapy did not affect GIB: mean INR preceding event was not different from nonevent patients (2.21 vs. 2.27, P = 0.67) and antiplatelet use was not different (46.7% vs. 46.9%, P = 0.985). LVADs are associated with early hemostatic-related morbidity. Few pre-implantation risk factors were elucidated; however, post-implantation factors including antiplatelet therapy, infection, and pump speed were identified.

High-speed visualization of disturbed pathlines in axial flow ventricular assist device under pulsatile conditions

“…29 Finally, one of the most disconcerting complications seen in continuous flow LVAD recipients is chronic gastrointestinal bleeding, which often results in withholding anticoagulation. 30 This practice may also have implications for pump thrombosis under circumstances where flow patterns across the pump bearing are not optimized.…”

Pharmacotherapeutic Management of Gastrointestinal Bleeding in Patients with Continuous‐Flow Left Ventricular Assist Devices

“…A diversity of information has been published surrounding the association between international normalized ratio (INR) values and CF‐LVAD–related GIB. Researchers found no significant difference in INR values between patients who developed GIB and those who did not (INR 2.21 vs 2.27, respectively; p=0.67) in 64 patients with CF‐LVADs. A multivariate analysis evaluating major bleeding in patients with the Heartmate II (HMII; Thoratec, Pleasanton, CA) device (a CF‐LVAD) demonstrated that INR was not predictive of the development of GIB .…”

“…A multivariate regression analysis showed that the odds of GIB were 20.5 times greater in patients aged > 65 years compared to their younger counterparts . In a single‐center evaluation, patients who developed GIB had slightly higher pump speeds, lower creatinine clearance, and increased frequency of infection . One group noted that elevated pulmonary artery pressures and total bilirubin levels were also predictive of developing bleeding events.…”

“…26 In a single-center evaluation, patients who developed GIB had slightly higher pump speeds, lower creatinine clearance, and increased frequency of infection. 27 One group 28 noted that elevated pulmonary artery pressures and total bilirubin levels were also predictive of developing bleeding events. Other factors, including smoking status and elevated creatinine concentration, have been previously identified as strong independent risk factors for GIB.…”

Intensivbehandlung von Kranken mit Linksherzersatz

“…PumpenthrombusAnzeichen einer suboptimalen Antikoagulation und möglichen Bildung eines Pumpenthrombus sind v. a. ein Anstieg der Laktatdehydrogenase (LDH;[16]) als Marker für den Zelluntergang und eine Zunahme des freien Hämoglobins als Zeichen einer Hämolyse. Freies Hämoglo-bin tritt im Plasma auf, wenn die Haptoglobinbindungskapazität erschöpft ist.…”