Multi-targeted Antithrombotic Therapy for Total Artificial Heart Device Patients: a case series

Transcription

1 Multi-targeted Antithrombotic Therapy for Total Artificial Heart Device Patients: a case series Angeleah Ramirez BS 1 Jeff Riley CCP Lyle Joyce MD 1. Second year perfusion student - Midwestern University

2 Disclosures I have no disclosures

3 Purpose Outline adoption of a multi-targeted antithrombotic (MTA) therapy clinical procedure guideline (CPG) Heparin + AT Clopidogrel Texas Heart Inst J. 2010;37:149-58

4 Purpose Outline the results of MTA Procedure Guideline Present the results of 13 patient case series Review ability to follow the CPG Present the results for balancing thrombosis versus bleeding

5 Background La Pitié Hospital (Ann Thor Surg, 1999) Pavie, Szefner, Leger and Gandjbakhch Multi-institutional Review (Texas Heart Inst J, 2010) Ensor, Cahoon, Crouch, Katlaps, Hess, Cooke, Bunnerson and Kasirajan University of Arizona (ASAIO J, 2013) Copeland, Copeland, Nolan, Gustafson, Slepian and Smith Mayo Clinic Rochester, MN - Adopted protocol

6 Methods 13 Total Artificial Heart (TAH) patients Implanted April 2013 February 2015 Bleeding and Anticoagulation monitoring Thromboelastograph Heparinase + Kaolin (HTEG) Kaolin (KTEG) Light transmission aggregometry (LTA) Arachidonic acid (AA) Adenosine-5- diphosphate (ADP) Epinephrine (EPI) Collagen MTA Regimens Heparin, Warfarin, Aspirin, Dipyridamole, Pentoxifylline

7 Patient Demographics

8 Current Multi-Targeted Antithrombotic (MTA) Regimen Mayo Clinic Hospital Rochester MN Protocol [February 2014] Medication Start Regimen Monitoring Duration Heparin (Sodium Heparin) May start at surgeon discretion. POD 1-3 when CT output < 30 CC/HR x 4 HRS. Dose 2-5 U/KG/HR (lower than conventional starting dose) If HIT Positive, consider ultra low dose Bivalirudin ( MG/KG/HR Max 0.02 MG/KG/HR adjusted to Heparinase TEG normocoagulable (R 3-8, K 1-3, CI -3 to 3 range) Monitor Kaolin (K) and Kaolin + Heparinase (H) TEGs Goal: KTEG R > 12, AA < 50, CI -5 to -10 range; HTEG nomocoagulable with CI -3 to 3 range Labs: K and HTEG ( CI, R, G, AA, MA), PTT, PLT, Fibrinogen, d-dimer Until Warfarin therapeutic Coumadin (Sodium Warfarin) Start POD 1-7 when CT output stops INR (2.5 to 3.5) Goal is heparinase TEG mildly hypocoagulable or normocoagulable range (R 3-8, CI -3 to 0 range) Ongoing- Adjusted to INR and TEG R and CI Aspirin (ASA) Start POD 1 ( if PLT> 50K) Goal MG per 250K PLT Usually always start at full dose 325 MG Use LTA (light transmittance aggregometry) to guide therapy. Goal: AA: < 50%: 20% 40% ADP: < 50%: 20% 40% EPI: < 50%: 20% 40% -angle, MA and G low or below normal on Heparinase TEG indicates effect of antiplatelet function Ongoing-LTA adjusted Persantine (Dipyridamole) MG q8h per 100K PLT. May start when PLT > 50K If 300K PLT give 300 MG q8h LTA (light transmittance aggregometry) to guide therapy. Goal: AA: < 50%: 20% 40% ADP: < 50%: 20% 40% EPI: < 50%: 20% 40% Ongoing-LTA adjusted in conjunction with ASA Trental (Pentoxifylline) MG q8h to reduce hemolysis and blood viscosity though little evidence to support its use. Start when service determines need. Total Plasma Hemoglobin (< 50 MG/DL) As needed

9 Heparin Administration per aptt

10 sec Coagulation Lab Results Post-Implant Day The median value of patient values per post-implant day

11 Chest Tube Drainage and Estimated Blood Loss

12 Chest Tube Drainage and Estimated Blood Loss (ml/kg/day)

13 Lab Values 10 9 /L gm/dl Post-Implant Day The median value of patient values per post-implant day

14 Lab Values 10 9 /L mg/dl Post-Implant Day The median value of patient values per post-implant day

15 Lab Values mg/dl % About 40% of patients received AT supplement the first week Post-Implant Day The median value of patient values per post-implant day

16 TEG Parameters The median value of patient values per post-implant day

17 % TEG Parameters Coagulation Index (CI) Post-Implant Day The median value of patient values per post-implant day

18 LTA Platelet Agonist Inhibition The median value of patient values per post-implant day

19 Blood Donor Exposures

20 Patient Demographics

21 Conclusion MTA CPG adopted and followed CPB was successfully followed Literature findings Supports multi-targeted approach for TAH Results may be generalizable to ECMO and VADs Our goals Antiplatelet therapy Intrinsic and extrinsic pathways Inhibition of Vitamin K synthesis factors Successful bridge to transplantation

22 Acknowledgements Perfusion team and VAD specialists at Mayo Clinic Rochester, MN Cardiovascular Science faculty at Midwestern University Glendale, AZ AmSECT

23 Thank You

24 References 1. Copeland, J.G., 3rd, et al., The CardioWest total artificial heart bridge to transplantation: 1993 to 1996 national trial. The Annals of thoracic surgery, (5): p Copeland, J.G., et al., Total artificial heart bridge to transplantation: a 9-year experience with 62 patients. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, (7): p Copeland, J.G., et al., Correlation of clinical embolic events with coagulability in a patient with a total artificial heart. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, (5): p Copeland, J.G., et al., Total artificial hearts: bridge to transplantation. Cardiology clinics, (1): p Copeland, J., Copeland H, Nolan P, et al.. Results with an Anticoagulation Protocol in 99 SynCardia Total Artificial Heart Recipients. ASAIO Journal, : p Szefner, J., Control and treatment of hemostasis in cardiovascular surgery. The experience of La Pitie Hospital with patients on total artificial heart. The International journal of artificial organs, (10): p Pavie, A., et al., Clinical experience with a total artificial heart as a bridge for transplantation: the pitie experience. Journal of cardiac surgery, (5): p Copeland, J.G., et al., Cardiac replacement with a total artificial heart as a bridge to transplantation. The New England journal of medicine, (9): p Ensor, C.R., et al., Pharmacotherapy for mechanical circulatory support: a comprehensive review. The Annals of pharmacotherapy, (1): p Ensor, C.R., et al., Antithrombotic therapy for the CardioWest temporary total artificial heart. Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, (2): p