The effect of transfusion of blood products on ventricular assist device support outcomes

Shore, Supriya; Hanff, Thomas C.; Mazurek, Jeremy A.; Seigerman, Matthew; Zhang, Robert; Grandin, E. Wilson; Vorovich, Esther; Mather, Paul; Olt, Caroline; Howard, Jessica; Wald, Joyce; Acker, Michael A.; Goldberg, Lee R.; Atluri, Pavan; Margulies, Kenneth B.; Rame, J. Eduardo; Birati, Edo Y.

doi:10.1002/ehf2.12780

Cited by 15 publications

(13 citation statements)

References 21 publications

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“…Excessive blood and blood product usage increase the chance of RV dysfunction and failure. Apart from pre-operative correction of anaemia, intra-operative strategies to minimize blood loss should be considered [ 16 ]. This includes paying meticulous attention to haemostasis and maintenance of normothermia during CPB to reduce coagulopathy, using blood-conserving strategies such as avoidance of excessive haemodilution, use of closed extracorporeal circuit, and autologous priming of the CPB circuit.…”

Section: Rv Dysfunction and Failure-specific Situations And Managementmentioning

confidence: 99%

Perioperative right ventricular function and dysfunction in adult cardiac surgery—focused review (part 2—management of right ventricular failure)

Varma

Srimurugan

Jose

et al. 2021

Indian J Thorac Cardiovasc Surg

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Section: Rv Dysfunction and Failure-specific Situations And Managementmentioning

confidence: 99%

Perioperative right ventricular function and dysfunction in adult cardiac surgery—focused review (part 2—management of right ventricular failure)

Varma

Srimurugan

Jose

et al. 2021

Indian J Thorac Cardiovasc Surg

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“…However, bleeding, thromboembolism, and infections after surgery still cause considerable morbidity and mortality in this patient population (1,(3)(4)(5). Early bleeding is a common complication after LVAD implantation, requiring transfusion of blood products resulting in increased all-cause mortality (6) and acute RV failure (7). LVAD candidates are often on anticoagulants and antiplatelet drugs before LVAD implantation according to the underlying etiology of terminal heart failure.…”

Section: Introductionmentioning

confidence: 99%

A Prospective Observational Study on Multiplate®-, ROTEM®- and Thrombin Generation Examinations Before and Early After Implantation of a Left Ventricular Assist Device (LVAD)

et al. 2022

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BackgroundHeart failure patients are frequently on coagulation-active medications before LVAD implantation and perioperative bleeding is a frequent complication after left ventricular assist device (LVAD) implantation. The role of point-of-care coagulation tests in assessing bleeding risk for LVAD implantation and the early postoperative time course of these tests is not well established.MethodsWe prospectively enrolled 25 patients with terminal heart failure undergoing LVAD implantation. Study related TRAP-, ASPI- and ADP- tests of Multiplate® platelet aggregometry, ROTEM® rotational thromboelastometry (INTEM, EXTEM, FIBTEM), thrombin generation assay and conventional laboratory studies were measured at 11 predefined time-points during the first 21 postoperative days. We examined if preoperative TRAP-, ASPI-, ADP- and ROTEM values are correlated with estimated total blood loss (primary outcome parameter) during the first 21 days after LVAD implantation and compared the baseline values of these measurements between patients with a bleeding event to those without. We performed Spearman's correlation and non-parametric tests for paired and non-paired comparisons.Results7 out of 25 (28%) patients experienced a bleeding event of which 4 required surgical revision. Of the preoperatively performed measurements the TRAP test [Spearman's Rho (ρ) = −0.5, p = 0.01], INTEM CFT (ρ = 0.72, p < 0.001), INTEM alpha (−0.7, p < 0.001), EXTEM MCF (ρ = −0.63; p < 0.001), EXTEM alpha (ρ = −0.67; p < 0.001), FIBTEM MCF (ρ = −0.41; p = 0.042), Fibrinogen (Clauss) (ρ = −0.5; p = 0.011), Anti-thrombin activity (ρ = −0.49; p = 0.013) and platelet count (ρ = −0.42; p = 0.034) were significantly correlated to total blood loss. Patients undergoing a surgical bleeding revision had significantly reduced values in TRAP—[31.5 IQR (17.25–43.5U) vs. 69 IQR (52.5–87U); p = 0.004], ASPI—[16.5 IQR (5.5–35.7U) vs. 39 IQR (24.5–62.5U); p = 0.038], ADP—[30 IQR (22–69U) vs. 12.5 IQR (8.7–21.5U); p = 0.01], EXTEM MCF—[63 IQR (57.7–63.7) vs. 67 IQR (65–75.5); p = 0.019] and EXTEM alpha [74 IQR (68.75–74) vs. 79 IQR (78–80.5); p = 0.002] values before LVAD implantation.ConclusionMultiplate® and ROTEM® measurements before LVAD implantation may identify LVAD candidates with platelet dysfunction and alterations of the primary hemostasis and could guide anesthetists and intensive care practitioners in bleeding risk stratification and in the perioperative clinical management.

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“…Acute RVF complicates 20%‐40% of LVAD implantations and has been associated with increased morbidity and mortality 2‐4 . With device initiation, changes in RV pumping efficiency and geometry are dynamic and may be aggravated by an acute increase in RV preload with evidence suggesting excessive fluid administration and blood product transfusion may increase the incidence of RVF and mortality 5‐8 …”

Section: Introductionmentioning

confidence: 99%

“…RV preload with evidence suggesting excessive fluid administration and blood product transfusion may increase the incidence of RVF and mortality. [5][6][7][8] Unfortunately, minimizing transfusion during LVAD implantation is challenging with transfusion rates as high as 90% in this population owing to both the frequency of underlying coagulopathy and surgical factors related to procedural complexity. [8][9][10] One potential method for replacing clotting factors while reducing volume administration is transfusion of plasma at the end of cardiopulmonary bypass (CPB) combined with ultrafiltration of an equivalent volume from the venous reservoir.…”

mentioning

confidence: 99%

“…[5][6][7][8] Unfortunately, minimizing transfusion during LVAD implantation is challenging with transfusion rates as high as 90% in this population owing to both the frequency of underlying coagulopathy and surgical factors related to procedural complexity. [8][9][10] One potential method for replacing clotting factors while reducing volume administration is transfusion of plasma at the end of cardiopulmonary bypass (CPB) combined with ultrafiltration of an equivalent volume from the venous reservoir. This offers the benefit of less consumption of clotting factors compared to priming the bypass machine with plasma while allowing volume removal through ultrafiltration which is not possible when plasma is transfused after the termination of CPB.…”

mentioning

confidence: 99%

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Use of plasma late on cardiopulmonary bypass in patients undergoing left ventricular assist device implantation

et al. 2021

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Coagulopathy is common during left ventricular assist device (LVAD) implantation, treatment of which can be challenging given the often‐limited ability for the right ventricle to accommodate volume transfusion after device initiation with 20% to 40% of patients developing right ventricular failure (RVF). Transfusion of plasma late on cardiopulmonary bypass (CPB) combined with ultrafiltration may replace clotting factors while reducing volume administration. We compared outcomes in patients undergoing LVAD implantation receiving plasma on CPB and ultrafiltration with traditional transfusion practices. Co‐primary outcomes needed for blood product transfusion in the first 6 and 24 hours after CPB. Secondary outcomes included metrics of morbidity and mortality. 396 patients were analyzed (59 plasma on CPB). Patients receiving plasma on CPB had a greater volume of blood products transfused (3764 vs. 2741 mL first 6 hours; 6059 vs. 4305 mL first 24 hours) in unadjusted analysis. In adjusted analysis, plasma transfusion on CPB with ultrafiltration had no significant effect on the primary outcomes of blood products given in the first 6 hours (estimated effect size 982 [−428, 2392] mL, P = .17) and 24 hours (estimated effect size 1076 [−904, 3057] mL, P = .29). Patients receiving plasma on CPB were more likely on either vasopressors or inotropes at 24 hours after ICU admission (P = .01), however, indices of coagulopathy and RVF were similar between groups. While prospective studies would be necessary to definitively evaluate the clinical utility of this strategy, no signal for benefit was observed suggesting plasma should not be used for this purpose.

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The effect of transfusion of blood products on ventricular assist device support outcomes

Cited by 15 publications

References 21 publications

Perioperative right ventricular function and dysfunction in adult cardiac surgery—focused review (part 2—management of right ventricular failure)

Perioperative right ventricular function and dysfunction in adult cardiac surgery—focused review (part 2—management of right ventricular failure)

A Prospective Observational Study on Multiplate®-, ROTEM®- and Thrombin Generation Examinations Before and Early After Implantation of a Left Ventricular Assist Device (LVAD)

Use of plasma late on cardiopulmonary bypass in patients undergoing left ventricular assist device implantation

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