Medical Management of Pump-Related Thrombosis in Patients with Continuous-Flow Left Ventricular Assist Devices: A Systematic Review and Meta-Analysis

Abstract

Pump thrombosis is a dreaded complication of left ventricular assist device (LVADs). We completed a systematic review to evaluate the efficacy and complications associated with medical management of LVAD thrombosis. Databases were searched using the terms “vad*” or “ventricular assist device” or “heart assist device” and “thrombus” or “thrombosis” or “thromboembolism”. Of 2383 manuscripts, 49 articles met the inclusion criteria. The risk of partial or no resolution of LVAD thrombosis did not significantly differ between thrombolytic and non-thrombolytic regimens (OR 0.48; 95% CI 0.20–1.16). When response to therapy was evaluated based upon pump type, there were no significant differences in how patients with a HMII or HVAD responded to thrombolytic or non-thrombolytic treatment. Pooled risk of major bleeding in the thrombolytic group was 29% (95% CI 0.17–0.44) and 12% (95% CI 0.01–0.57) in the non-thrombolytic group. Odds of death did not differ between thrombolytic and non-thrombolytic regimens (OR 1.28; 95% CI 0.42–3.89). Although thrombolytic and non-thrombolytic treatment similarly resolved LVAD thrombosis, major hemorrhage may be increased with use of thrombolysis. Randomized clinical trials comparing thrombolytic and non-thrombolytic treatment of LVAD thrombosis are needed to establish the most effective and safe option for patients who are not surgical candidates.

Effective strategy of rescue treatment for acute pump thrombosis after left ventricular assist device implantation in patients with high risk of bleeding complications

“…This proposed innovative algorithm of thrombolytic treatment guided by the power consumption and flow curves was elaborated while facing dramatic LVAD dysfunction and emergent need of rescue strategy in patients with high risk of bleeding complications. tPA was chosen as the safest available thrombolytic agent [12] and due to the algorithm, it was administered in the smallest effective dose.…”

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

“…Given that LDH elevation may occur prior to symptoms of pump thrombosis, it is a valuable surveillance identifier for potential pump thrombus via serial sampling . 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 …”

“…12 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. 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.…”

Heart Transplantation in the Era of the Left Ventricular Assist Devices

“…The use of a combination of heparin and IIB/IIIA antagonists/direct thrombin inhibitors was associated with high rates of major bleeding (35%) and intracerebral hemorrhage (18%). Death was most commonly reported after thrombolytics (20%), and the rate of intracerebral hemorrhage was 17%, but only when thrombolytics were used in combination with IIB/IIIA antagonists/direct thrombin inhibitors [46].…”