Complications of Left Ventricular Assist Device Chronic Support. Dr. Tal Hasin RMC, Beilinson, Petach-Tiqva, Israel

Complications of Left Ventricular Assist Device Chronic Support. Dr. Tal Hasin RMC, Beilinson, Petach-Tiqva, Israel

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Probability of survival Survival (%) Survival with LVAD Destination Bridge to transplant 1.0 0.8 0.6 0.4 Pulsatile-flow LVAD Continuous-flow LVAD 100 80 60 40 0.2 0.0 P=0.008 by the log-rank test 0 6 12 18 24 Months since randomization No. at risk 133 95 82 69 62 59 32 19 5 2 20 0 0 2 4 6 8 10 12 Months No. at risk 133 96 68 48 35 26 17 Slaughter, N Engl J Med 361:23, 2009 Miller, N Engl J Med 357:9, 2007

LVAD in the Treatment of Heart Failure Kirklin, JHLT 32; 2, 2013

Despite an overall improved survival and QOL, most LVAD patients will have an adverse event Kirklin, JHLT 32; 2, 2013

Causes for Readmissions after LVAD Forest, The Annals of Thoracic Surgery 95; 4, 2013

Causes for Readmissions after LVAD Hasin, JACC 15;61(2), 2013

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

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)

Heart Failure with LVAD RV dysfunction Fluid overload (renal dysfunction) Pump problems (thrombosis, cannula obstruction, graft kink) Pump speed adjustment Aortic regurgitation

Resolution of the HF syndrome may take time Post-opertative NTproBNP trends among 72 LVAD recipients. Hasin, IHS meeting 2012

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

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

Proportion with no GI bleed Bleeding GI bleed usually will occur within the first 6 months 1.0 0.8 Pulsatile 0.6 Non-Pulsatile 0.4 0.2 No. at risk 0.0 0 6 12 18 24 30 36 42 48 Time from device implant (mo) 46 40 28 12 55 23 6 2 Crow, The Journal of Thoracic and Cardiovascular Surgery, 137; 1, 2009

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

Bleeding All cause bleed was 5 th cause of death (3%) in the HMII DT trial Aggarwal, Annals of Thoracic Surgery 93; 5, 2012

Infections Hannan, JHLT 30; 4, 2011

Driveline infections are more common and occur throughout support Kirklin, JHLT 32; 2, 2013

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

Neurological complications ICH CVA Kirklin, JHLT 32; 2, 2013

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)

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

Thrombosis Symptoms: HF, thrombo-emboli, hemolytic anemia Pump parameters: increased power Lab: Intravascular hemolysis (LDH, anemia, plasma free hemoglobin, hemoglobinuria, bilirubin)

LVAD Thrombosis, echocardiography Uriel, JACC 60;18, 2012 Fine, JACC Imaging, accepted

Treatment Pump change-out Augment anticoagulation Add antiplatelet agent (clopidogrel, IIbIIIa inhibitor) Thrombolysis? Recurrences are common Pump change-out/ transplantation Hasin, ASAIO J, accepted

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

Thank you hasintal@gmail.com

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=4366 140 130 120 110 100 90 80 70 60 50 40 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: 1509 5000 4500 4000 3500 3000 HeartMate II DT approval (1/21/10) 2500 2000 1500 1000 500 0 1600 1400 Patient accrual 1200 1000 800 600 400 200 0 Continuous Flow Intracorporeal LVAD Pump Pulsatile Flow Intracorporeal TAH Pulsatile Flow Intracorporeal LVAD Pump Pulsatile Flow Para corporeal LVAD Pump 2006 2007 2008 2009 2010 2011 Cont Intra Pump 1 1 458 808 1445 692 Puls Intra TAH 2 22 22 22 27 4 Puls Intra Pump 71 219 154 36 6 1 Puls Para Pump 18 61 74 71 35 32 (Jan-Jun) Kirklin, JHLT : 31(2), 2012