LEFT VENTRICULAR ASSIST DEVICE COMPLICATIONS. Daniel Vargas, MD Section of Cardiothoracic Imaging University of Colorado Anschutz Medical Campus
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1 LEFT VENTRICULAR ASSIST DEVICE COMPLICATIONS Daniel Vargas, MD Section of Cardiothoracic Imaging University of Colorado Anschutz Medical Campus
2 OBJECTIVES Review the most common LVAD-related complications. Discuss the role of imaging in the evaluation of these complications
3 OUTLINE Continuous Flow LVADs Hemostatic Complications Infection Positioning/Implantation-Related Complications Take Home Points
4 CF-LVADs In the US > 2,000 CFLVADs per year CF-LVADs HeartMate II (Thoratec, Pleasanton, CA) HeartWare HVAD (HeartWare International, Inc., Framingham, MA) >40% of patients on Destination Therapy (DT) Kirklin JK, et al. Sixth INTERMACS annual report: A 10,000-patient database. J Heart Lung Transplant 2014;33:
5 CF-LVADs Survival: Kirklin JK, et al. Sixth INTERMACS annual report: A 10,000-patient database. J Heart Lung Transplant 2014;33:
6 HEMOSTATIC COMPLICATIONS Hemorrhagic: Acquired von Willebrand Syndrome Anticoagulation and antiplatelet therapy Thrombotic: Activated coagulation cascade and inflammatory response Kirklin JK, et al. Sixth INTERMACS annual report: A 10,000-patient database. J Heart Lung Transplant 2014;33:
7 GI BLEEDING Most common complication Multifactorial: Acquired von Willebrand (loss of high-molecular-weight von Willebran multimers) Anticoagulation Impaired platelet aggregation Continuous flow physiology promotes angiodysplasia Other: erosive gastritis, PUD, etc.
8 GI BLEEDING Guha A, et al. Methodist Debakey Cardiovasc J 2015 Jan-Mar;11(1):24-7
9 GI BLEEDING Factors Predisposing to GI bleeding: Lopilato AC, et al. Artif Organs Apr 24.
10 OTHER HEMORRHAGIC EVENTS Hemorrhagic Stroke (2.5%-6%) Other Bleeding (2.5%) Retroperitoneal bleeds Pump pocket hematoma Hemopericardium Akhter SA, et al. Ann Thorac Surg. 2015;100:884-9 Meyer AL, et al. J Am Coll Cardiol HF 2014;2:141-5
11 INTRACRANIAL HEMORRHAGE
12 PUMP POCKET HEMATOMA
13 HEMOPERICARDIUM
14 THROMBOTIC AND EMBOLIC COMPLICATIONS Flow Induced Device Thrombogenicity Hypersensitivity and inflammatory response. LVAD thrombosis is a devastating complication Asymptomatic to cardiogenic shock 94% free of pump exchange or death at 6 months
15 LVAD THROMBOSIS New signs and symptoms of HF (CXR useful) Change in functional capacity Increase in pump power Increase in LDH >1100 UI/L 100% sens, 92% spec Increase in plasma free hemoglobin Increase in BNP
16 LVAD THROMBOSIS Ramp Study Repeat tests at different pump speeds (RPM) LVEDD MR AV opening Blunted or absent reduction in LVEDD with RPM obstruction to flow in device.
17 LVAD THROMBOSIS
18 OTHER EMBOLIC/THROMBOTIC EVENTS
19 CF-LVADs
20 LVAD-SPECIFIC INFECTIONS Definitions: Percutaneous Driveline Infection: Superficial Deep Pocket Infection Pump and/or cannula infection (LVAD endocarditis) Feared complication High mortality Exchange pump Hannan MH, et al. Working formulation for the standardization of definitions of infections in patients using ventricular assist devices. J Heart Lung Transplant Apr;30(4):375-8
21 LVAD SPECIFIC INFECTIONS Common Complication Driveline Infection 12-50% of patients Pocket Infection: 0.5% to 7% Most common infectious agent: Staphylococcus MRSA Pseudomona aureginosa Klebsiella sp. Topkara VK, et al. Ann Thorac Surg 2010;90: Sharma V, et al. Ann Thorac Surg 2012;94: Koval CE, et al. J Heart Lung Transplant 2014;33: Toda K, et al. Gen Thorac Cardiovasc Surg 2015; 63:1-7.
22 LVAD SPECIFIC INFECTIONS
23 LVAD SPECIFIC INFECTIONS
24 LVAD SPECIFIC INFECTIONS
25 LVAD SPECIFIC INFECTIONS
26
27 LVAD SPECIFIC INFECTIONS
28 LVAD POSITIONING/ IMPLANTATION COMPLICATIONS Inflow cannula: Perpendicular to septum Directed towards mitral valve from body axis Pump in sufficiently deep pocket Outflow cannula Too short compression of RV Too long kinking (flow obstruction)
29 LVAD MALPOSITION
30 LVAD MALPOSITION
31 CANNULA KINKING
32 COLONIC PERFORATION
33 TAKE HOME POINTS
34 ACKNOWLEDGEMENTS Girish Shroff, MD Daniel Ocazionez, MD Kelsey Flint, MD Colleen McIlvennan, NP
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