Outcomes of Various Treatment Strategies for Patients with Continuous-Flow Ventricular Assist Device Thrombosis: A Retrospective Analysis

Abstract

Pump thrombosis is associated with high morbidity and mortality in patients with a continuous-flow left ventricular assist device. Although it has been defined clearly, the diagnosis and treatment of this complication still remain controversial. Between 2010 and 2014, 163 consecutive patients (mean age: 50.7 ± 13 years, 84% males, median duration of support: 277 (2-1077) days) were implanted a continuous-flow left ventricular assist device. Prospectively collected data of all patients who had at least one pump thrombosis event have been analyzed, retrospectively. Twenty-one pump thrombosis events were observed in 15 patients (9.2%, 0.137 events/patient-year). Median duration of support at the time of first pump thrombosis event was 259 (8-585) days. Overall mortality was 40% (6/15), and overall procedural success was 71.4% (15/21) in our entire cohort. The cause of mortality was hemorrhagic stroke in those who had medical treatment (n = 5), and sepsis and right ventricular failure in the other who had pump exchange. Pump exchange was performed in five patients, of which four survived. Glycoprotein IIb/IIIa antagonists are not beneficial in medical treatment of pump thrombosis. Medical treatment methods including unfractionated heparin and thrombolytics may completely resolve the thrombus and save some patients from pump exchange. In patients where medical treatment does not result in complete thrombus resolution within a reasonable period, and a donor heart is not available, pump exchange is the ultimate solution. Further studies are needed for optimal dosing of thrombolytics to decrease the rate of side effects.

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

“…Retrospective cohort studies comprised 18% (9/49) of the included studies (Table 3). 4,15–18,20–23 None of the these studies were controlled trials and thus were deemed of moderate quality. The most reported devices included HVAD (120/216, 56%), HeartMate II (76/216, 35%) and MicroMed DeBakey (14/216, 6%).…”

“…No minor bleeding events occurred while major bleeding events were reported in 10% (3/31) of patients. 4,20–23,25–31 IV UFH was used in combination with a GPIIb/IIIa inhibitor and/or a direct thrombin inhibitor in the management of 51 events resulting in complete resolution in 49% (25/51) of the cases and no or partial resolution in 51% (26/51) cases. Major bleeding events were noted in 35% (18/51) cases.…”

“…Major bleeding events were noted in 35% (18/51) cases. 4,17,20–23,26,32–39 GPIIb/IIIa inhibitor or direct thrombin inhibitor therapy alone (goal PTT of 50– 75 sec) was used in 39 patients with pump thrombosis resulting in complete thrombus resolution in 49% (19/39) of patients. Major bleeding events were noted in 10% (4/39) of patients and there was one reported death.…”

“…There were 20 reported deaths in this group of patients. 4,15,20–23,26,27,42–62 Thrombolytics were used as a triple or a quadruple drug therapy (i.e. in combination with IV UFH and either GPIIb/IIIa inhibitor and/or direct thrombin inhibitor) in 18 patients resulting in a complete resolution in 56% (10/18) of patients.…”

“…There were 6 major bleeding events and 1 minor bleeding event. 4,20,22,42,44,63,64 Overall, 16% (37/238) of reported patients died among all the medical regimens.…”