Complications of Left Ventricular Assist Device Chronic Support. Dr. Tal Hasin RMC, Beilinson, Petach-Tiqva, Israel
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1 Complications of Left Ventricular Assist Device Chronic Support. Dr. Tal Hasin RMC, Beilinson, Petach-Tiqva, Israel
2 No disclosures
3 Probability of survival Survival (%) Survival with LVAD Destination Bridge to transplant Pulsatile-flow LVAD Continuous-flow LVAD P=0.008 by the log-rank test Months since randomization No. at risk Months No. at risk Slaughter, N Engl J Med 361:23, 2009 Miller, N Engl J Med 357:9, 2007
4 LVAD in the Treatment of Heart Failure Kirklin, JHLT 32; 2, 2013
5 Despite an overall improved survival and QOL, most LVAD patients will have an adverse event Kirklin, JHLT 32; 2, 2013
6 Causes for Readmissions after LVAD Forest, The Annals of Thoracic Surgery 95; 4, 2013
7 Causes for Readmissions after LVAD Hasin, JACC 15;61(2), 2013
8 HF with LVAD Readmissions (BTT, DT) Patients (BTT, DT) Cardiac 50 (11, 39) 35 (7, 28) readmissions Heart failure 21 (6, 15) 19 (4, 15) Arrhythmia 27 (5, 22) 19 (4, 15) Ventricular 24 (4, 20) 17 (3, 14) arrhythmia Chest pain 2 2 Rogers, JACC 55;17, 2010
9 Arrhythmias Ventricular arrhythmias Etiology: scar, cannula, electrolytes, ischemia Clinical: well tolerated; RV dysfunction Treatment: ICD for all?, medications, pump adjustment, ablation (post-op, intra-op)
10 Heart Failure with LVAD RV dysfunction Fluid overload (renal dysfunction) Pump problems (thrombosis, cannula obstruction, graft kink) Pump speed adjustment Aortic regurgitation
11 Resolution of the HF syndrome may take time Post-opertative NTproBNP trends among 72 LVAD recipients. Hasin, IHS meeting 2012
12 It s not always just the RV Elevated (>15mmHg) filling pressures among patients on LVAD support Patients with HF symptoms (n=27) Asymptomatic (n=23) Hasin, ISHLT meeting 2013
13 Bleeding Most late bleeds are GI, 57% UGI (erosions, ulcers, angiodysplasia) Risk factors include previous GI bleed, high INR, low platelets Re-bleeding is common (50%), usually from same site Hydes syndrome may partly explain the pathophysiology Aggarwal, Annals of Thoracic Surgery 93; 5, 2012
14 Proportion with no GI bleed Bleeding GI bleed usually will occur within the first 6 months Pulsatile 0.6 Non-Pulsatile No. at risk Time from device implant (mo) Crow, The Journal of Thoracic and Cardiovascular Surgery, 137; 1, 2009
15 GI Bleeding- Treatment Stopping anticoagulation Endoscopy (upper, lower), double balloon, capsule. Treatment: local, anti-acid (?Danazol,?Octreotide) Pereira, Interactive CardioVascular and Thoracic Surgery 11 ;4, 2010
16 Bleeding All cause bleed was 5 th cause of death (3%) in the HMII DT trial Aggarwal, Annals of Thoracic Surgery 93; 5, 2012
17 Infections Hannan, JHLT 30; 4, 2011
18 Driveline infections are more common and occur throughout support Kirklin, JHLT 32; 2, 2013
19 Bloodstream infections Bloodstream infections in LVAD patients are associated with neurological complications Kato, JHLT 31; 1, 2012 Especially hemorrhagic stroke Aggarwal, ASAIO J 58; 5, 2012
20 Neurological complications ICH CVA Kirklin, JHLT 32; 2, 2013
21 Neurological complications Patients Readmissions (BTT, DT) (BTT, DT) Major neurologic events 13 (3, 10) 13 (3, 10) CVA 6 6 Intracranial bleed 7 (2 trauma) 7 Leading cause of death (7% in HMII DT trial)
22 Intracranial Hemmorhage 36 ICH /330 LVADS. Traumatic 18/36, spontaneous intraparenchymal 17/36 Intraparenchymal- worse prognosis GCS<11, no survival Wilson,J. Neurosurgery 32; 2, 2013
23 Thrombosis Symptoms: HF, thrombo-emboli, hemolytic anemia Pump parameters: increased power Lab: Intravascular hemolysis (LDH, anemia, plasma free hemoglobin, hemoglobinuria, bilirubin)
24 LVAD Thrombosis, echocardiography Uriel, JACC 60;18, 2012 Fine, JACC Imaging, accepted
25 Treatment Pump change-out Augment anticoagulation Add antiplatelet agent (clopidogrel, IIbIIIa inhibitor) Thrombolysis? Recurrences are common Pump change-out/ transplantation Hasin, ASAIO J, accepted
26 Conclusions Medical complications commonly occur in patients chronically supported by LVAD These are unique to this patient population The attending physician should be familiar with the diagnosis and treatment
27 Thank you
28 Jul06 Jan07 Jul07 Jan08 Jul08 Jan09 Jul09 Jan10 Jul10 Jan11 Jul11 Activated hospitals Implants per year LVAD in the Treatment of Heart Failure Hospital and Patient Accrual June 2006-June 2011 Primary Implant Enrollment: n= Year 1 New pts: 346 Year 2 New pts: 460 Protocol amendment 2.2 Year 3 New pts: 984 Protocol amendment 2.3 HeartMate II BTT approval (4/21/08) Month Year 4 New pts: 1312 Hospital Patient Year 5 New pts: HeartMate II DT approval (1/21/10) Patient accrual Continuous Flow Intracorporeal LVAD Pump Pulsatile Flow Intracorporeal TAH Pulsatile Flow Intracorporeal LVAD Pump Pulsatile Flow Para corporeal LVAD Pump Cont Intra Pump Puls Intra TAH Puls Intra Pump Puls Para Pump (Jan-Jun) Kirklin, JHLT : 31(2), 2012
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