Treatment of Left Ventricular Assist Device Thrombosis With Extended Catheter-Directed Intraventricular Thrombolytic Therapy
2013; Lippincott Williams & Wilkins; Volume: 6; Issue: 3 Linguagem: Inglês
10.1161/circheartfailure.113.000013
ISSN1941-3297
AutoresThenappan Thenappan, Allen S. Anderson, Valluvan Jeevanadham, Jonathan D. Rich, Atman P. Shah,
Tópico(s)Cardiac Arrest and Resuscitation
ResumoHomeCirculation: Heart FailureVol. 6, No. 3Treatment of Left Ventricular Assist Device Thrombosis With Extended Catheter-Directed Intraventricular Thrombolytic Therapy Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBTreatment of Left Ventricular Assist Device Thrombosis With Extended Catheter-Directed Intraventricular Thrombolytic Therapy Thenappan Thenappan, MD, Allen S. Anderson, MD, Valluvan Jeevanadham, MD, Jonathan D. Rich, MD and Atman P. Shah, MD Thenappan ThenappanThenappan Thenappan From the Section of Cardiology (T.T., A.S.A., J.D.R., A.P.S.) and Department of Cardiothoracic Surgery (V.J.), University of Chicago, Chicago, IL. , Allen S. AndersonAllen S. Anderson From the Section of Cardiology (T.T., A.S.A., J.D.R., A.P.S.) and Department of Cardiothoracic Surgery (V.J.), University of Chicago, Chicago, IL. , Valluvan JeevanadhamValluvan Jeevanadham From the Section of Cardiology (T.T., A.S.A., J.D.R., A.P.S.) and Department of Cardiothoracic Surgery (V.J.), University of Chicago, Chicago, IL. , Jonathan D. RichJonathan D. Rich From the Section of Cardiology (T.T., A.S.A., J.D.R., A.P.S.) and Department of Cardiothoracic Surgery (V.J.), University of Chicago, Chicago, IL. and Atman P. ShahAtman P. Shah From the Section of Cardiology (T.T., A.S.A., J.D.R., A.P.S.) and Department of Cardiothoracic Surgery (V.J.), University of Chicago, Chicago, IL. Originally published1 May 2013https://doi.org/10.1161/CIRCHEARTFAILURE.113.000013Circulation: Heart Failure. 2013;6:e27–e29IntroductionContinuous flow left ventricular assist devices (LVAD) are used in patients with advanced heart failure, either as bridge to transplant or as destination therapy.1 Because current generation continuous flow LVADs activate the coagulation system, anticoagulant therapy with warfarin is recommended to minimize the risk of device thrombosis.2 Occasionally, however, device thrombosis may still occur, which may necessitate surgical LVAD exchange. Because of the relatively high morbidity and mortality associated with a surgical LVAD exchange, alternative methods to abort LVAD thromboses short of surgical intervention would be attractive. Recently, resolution of device thrombosis with catheter-directed intraventricular administration of a single bolus dose of fibrinolytic therapy has been reported.3,4 Here, we report the successful resolution of 2 consecutive cases of LVAD thrombosis using continuous catheter-directed intraventricular administration of fibrinolytics for an extended period in patients who did not respond to the initial bolus dose of fibrinolytics without resorting to surgical LVAD exchange.Case 1A 45-year-old man with HeartMate II (Thoratec Corporation, Pleasanton, CA) LVAD as destination therapy for dilated cardiomyopathy presented with dark red urine 11 months after device implantation. Further evaluation revealed a subtherapeutic international normalized ratio (INR) (1.4), markedly elevated serum lactate dehydrogenase (LDH; 4010 U/L), low serum haptoglobin (<20 mg/dL), mild hyperbilirubinemia (1.2 mg/dL), and elevated plasma-free hemoglobin (15.4 mg/dL), consistent with hemolysis. Review of logged waveform files revealed no power or flow surges. A transthoracic echocardiogram revealed rightward deviation of the interventricular septum, regular opening of the aortic valve, and mild mitral regurgitation. With gradual increase of LVAD speed to a maximum of 11 200 rpm, the interventricular septum remained rightward and aortic valve opened with every cardiac cycle, suggesting the inability of the device to unload the left ventricle. Both the inflow cannula and the outflow graft seemed appropriately positioned. These findings coupled with his ongoing hemolysis were suggestive of likely device thrombosis. The patient was initially treated with intravenous heparin and eptifibatide for 5 days with no significant improvement and worsening serum LDH, bilirubin, and creatinine values. Due to lack of clinical response, a trial of intraventricular fibrinolytics was initiated in the cardiac catheterization laboratory. Twenty-five milligrams of alteplase was administered as a bolus dose via a pigtail catheter placed in the left ventricle using the transfemoral approach over 10 minutes. The sheath and the catheter were secured in place, and alteplase was infused continuously at 1 mg/h. An intravenous heparin infusion was used concomitantly with an activated partial thromboplastin time maintained between 50 and 60 seconds. Intraventricular alteplase infusion was continued until serum LDH and bilirubin (surrogate markers for LVAD thrombosis), and creatinine (used as a marker of end-organ perfusion) approached the patient's previous baseline values suggestive of device thrombosis resolution. Position of the pigtail catheter was confirmed daily by chest x-ray (Figure 1). During the course of 30 hours of alteplase infusion, there was normalization of his serum LDH, bilirubin levels, and creatinine (Figure 2). A repeat transthoracic echocardiogram confirmed an unloaded left ventricle with the interventricular septum in the midline, only trace mitral regurgitation, and intermittent opening of the aortic valve. The patient developed a groin hematoma around the arterial sheath site, which was controlled with manual compression.Download figureDownload PowerPointFigure 1. Chest x-ray showing the pigtail catheter and the left ventricular assist device inflow cannula in the left ventricular cavity.Download figureDownload PowerPointFigure 2. Comparison of serum lactate dehydrogenase (LDH), bilirubin, and creatinine pre- and postfibrinolytic therapy. AC indicates anticoagulation therapy (intravenous heparin); AP, antiplatelet therapy (intravenous eptifibatide), and TPA, tissue-type plasminogen activator (alteplase). Blue represents case 1 and red represents case 2.Case 2A 46-year-old man with HeartMate II LVAD for dilated cardiomyopathy presented with dark red urine 8 months after his LVAD implantation. On cardiac auscultation, he had abnormal LVAD tones. Further evaluation revealed a significantly elevated serum LDH (3237 U/L), low serum haptoglobin (<20 mg/dL), and elevated unconjugated bilirubin (2.2 mg/dL) consistent with hemolysis. His INR was subtherapeutic at 1.6. LVAD logged waveform files revealed recent intermittent power surges. A transthoracic echocardiogram revealed inadequate unloading of the left ventricle with shifting of the interventricular septum to the right and moderate mitral regurgitation, despite a gradual increase in his LVAD speed to 10600 rpm. Cardiac computed tomography excluded inflow cannula and outflow graft obstruction. On the basis of these findings, LVAD thrombosis was suspected, and he was initially treated with intravenous heparin and eptifibatide. Due to lack of clinical response, he was treated with catheter-directed alteplase infusion as described in case 1 for 96 hours until normalization of serum LDH, bilirubin, and creatinine values were achieved (Figure 2). A repeat transthoracic echocardiogram suggested an unloaded left ventricle with the interventricular septum in the midline and a reduction in the severity of the mitral regurgitation to mild. The patient tolerated the alteplase infusion well without any complications. The pigtail catheter position was stable in both of the patients throughout the duration of therapy and there was no evidence of infection.DiscussionThis case series illustrates the feasibility of aborting an evolving LVAD thrombosis with prolonged catheter-directed administration of intraventricular fibrinolytics. An LVAD thrombosis may result from the development of an in situ thrombosis on the impeller itself or by ingestion of an existing thrombus from the left atrium or the left ventricle. Device thrombosis was reported in 4% of patients with destination LVADs and in 1.5% of patients with LVADs as a bridge to cardiac transplant in the HeartMate II clinical trials.1,5 Although both of our patients in this case series presented with a subtherapeutic INR, LVAD thromboses may occur at any INR, including supratherapeutic INR. Resolution of device thrombosis with catheter-directed administration of a bolus dose of fibrinolytic therapy has been reported.3,4 However, the patients in the current case series did not respond to the initial bolus fibrinolytic injection, perhaps attributable to the slower, chronically developing in situ thrombosis. The eventual complete resolution of the LVAD thrombosis in response to prolonged, catheter-directed fibrinolytic therapy in both patients (30 and 96 hours, respectively) suggests that a longer duration of fibrinolytic infusion could be considered in patients with lack of an immediate response to bolus fibrinolytics before resorting to surgical device exchange.Prolonged catheter-directed administration of fibrinolytics could be associated with serious bleeding complications, especially given the inherent bleeding risks associated with continuous flow LVADs. Another potential concern would be dislodgement of the pigtail catheter into the LVAD inflow cannula. Meticulous efforts must be taken to ensure that the pigtail catheter is well secured and in a proper position. Thus, despite our successful outcomes, further studies using prolonged catheter-directed fibrinolytic therapy are warranted to determine the feasibility, safety, and efficacy more completely of this novel technique in cases of refractory VAD thrombosis.DisclosuresV. Jeevanandam is a scientific advisor for Thoratec and HeartWare. The other authors have no conflicts to report.FootnotesCorrespondence to Atman P. Shah, MD, FACC, FSCAI, Section of Cardiology, The University of Chicago, 5847 S Maryland Ave, Chicago, IL 60637. E-mail [email protected]References1. Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, Sun B, Tatooles AJ, Delgado RM, Long JW, Wozniak TC, Ghumman W, Farrar DJ, Frazier OH; HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device.N Engl J Med. 2009; 361:2241–2251.CrossrefMedlineGoogle Scholar2. Slaughter MS, Pagani FD, Rogers JG, Miller LW, Sun B, Russell SD, Starling RC, Chen L, Boyle AJ, Chillcott S, Adamson RM, Blood MS, Camacho MT, Idrissi KA, Petty M, Sobieski M, Wright S, Myers TJ, Farrar DJ; HeartMate II Clinical Investigators. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure.J Heart Lung Transplant. 2010; 29:S1–39.CrossrefMedlineGoogle Scholar3. Kiernan MS, Pham DT, DeNofrio D, Kapur NK. Management of HeartWare left ventricular assist device thrombosis using intracavitary thrombolytics.J Thorac Cardiovasc Surg. 2011; 142:712–714.CrossrefMedlineGoogle Scholar4. Kamouh A, John R, Eckman P. Successful treatment of early thrombosis of HeartWare left ventricular assist device with intraventricular thrombolytics.Ann Thorac Surg. 2012; 94:281–283.CrossrefMedlineGoogle Scholar5. Pagani FD, Miller LW, Russell SD, Aaronson KD, John R, Boyle AJ, Conte JV, Bogaev RC, MacGillivray TE, Naka Y, Mancini D, Massey HT, Chen L, Klodell CT, Aranda JM, Moazami N, Ewald GA, Farrar DJ, Frazier OH; HeartMate II Investigators. Extended mechanical circulatory support with a continuous-flow rotary left ventricular assist device.J Am Coll Cardiol. 2009; 54:312–321.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Whitaker-Lea W, Toms B, Toms J, Shah K, Quader M, Tang D, Kasirajan V, Rivet D and Reavey-Cantwell J (2020) Neurologic Complications in Patients with Left Ventricular Assist Devices: Single Institution Retrospective Review, World Neurosurgery, 10.1016/j.wneu.2020.04.064, 139, (e635-e642), Online publication date: 1-Jul-2020. Kim J, Loi M, Stone M and VanderPluym C (2020) Medical and Invasive Management of Cardiac Thrombosis in Children with Congenital and Acquired Heart Disease, Current Treatment Options in Pediatrics, 10.1007/s40746-020-00214-3, 6:4, (283-298), Online publication date: 1-Dec-2020. Kirklin J, Pagani F, Goldstein D, John R, Rogers J, Atluri P, Arabia F, Cheung A, Holman W, Hoopes C, Jeevanandam V, John R, Jorde U, Milano C, Moazami N, Naka Y, Netuka I, Pagani F, Pamboukian S, Pinney S, Rogers J, Selzman C, Silverstry S, Slaughter M, Stulak J, Teuteberg J, Vierecke J, Schueler S and D'Alessandro D (2020) American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2019.12.021, 159:3, (865-896), Online publication date: 1-Mar-2020. Kirklin J, Pagani F, Goldstein D, John R, Rogers J, Atluri P, Arabia F, Cheung A, Holman W, Hoopes C, Jeevanandam V, John R, Jorde U, Milano C, Moazami N, Naka Y, Netuka I, Pagani F, Pamboukian S, Pinney S, Rogers J, Selzman C, Silverstry S, Slaughter M, Stulak J, Teuteberg J, Vierecke J, Schueler S and D'Alessandro D (2020) American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support, The Journal of Heart and Lung Transplantation, 10.1016/j.healun.2020.01.1329, 39:3, (187-219), Online publication date: 1-Mar-2020. Dang G, Epperla N, Muppidi V, Sahr N, Pan A, Simpson P and Baumann Kreuziger L (2017) Medical Management of Pump-Related Thrombosis in Patients with Continuous-Flow Left Ventricular Assist Devices: A Systematic Review and Meta-Analysis, ASAIO Journal, 10.1097/MAT.0000000000000497, 63:4, (373-385), Online publication date: 1-Jul-2017. Rimsans J, Sylvester K and Connors J (2016) Direct Thrombin Inhibitor for LVAD Thrombosis: A Closer Look, Clinical and Applied Thrombosis/Hemostasis, 10.1177/1076029616672583, 23:5, (405-409), Online publication date: 1-Jul-2017. Doligalski C and Jennings D (2015) Device-Related Thrombosis in Continuous-Flow Left Ventricular Assist Device Support, Journal of Pharmacy Practice, 10.1177/0897190015615894, 29:1, (58-66), Online publication date: 1-Feb-2016. Consolo F, Dimasi A, Rasponi M, Valerio L, Pappalardo F, Bluestein D, Slepian M, Fiore G and Redaelli A (2016) Microfluidic Approaches for the Assessment of Blood Cell Trauma: A Focus on Thrombotic Risk in Mechanical Circulatory Support Devices, The International Journal of Artificial Organs, 10.5301/ijao.5000485, 39:4, (184-193), Online publication date: 1-Apr-2016. Grinstein J, Estrada J, Sayer G, Kim G, Sarswat N, Adatya S, Nathan S, Paul J, Blair J, Jeevanandam V, Lang R, Uriel N and Shah A (2016) Left Ventricular Assist Device Deactivation via Percutaneous Closure of the Outflow Graft, Journal of Cardiac Failure, 10.1016/j.cardfail.2016.04.022, 22:8, (653-655), Online publication date: 1-Aug-2016. Nair N, Schmitt A, Rau E, Anders S, Sandler D and Icenogle T (2016) Thrombolytics in VAD management — A single-center experience, IJC Heart & Vasculature, 10.1016/j.ijcha.2016.03.006, 11, (49-54), Online publication date: 1-Jun-2016. Rosenthal J and Starling R (2015) Coagulopathy in Mechanical Circulatory Support: A Fine Balance, Current Cardiology Reports, 10.1007/s11886-015-0670-0, 17:12, Online publication date: 1-Dec-2015. Godown J, Dodd D, Doyle T, Smith A, Janssen D and Mettler B (2015) Tissue plasminogen activator treatment of bilateral pulmonary emboli in a pediatric patient supported with a ventricular assist device, Pediatric Transplantation, 10.1111/petr.12568, 19:7, (E160-E164), Online publication date: 1-Nov-2015. Toeg H, Ruel M and Haddad H (2015) Anticoagulation strategies for left ventricular assist devices, Current Opinion in Cardiology, 10.1097/HCO.0000000000000143, 30:2, (192-196), Online publication date: 1-Mar-2015. Jennings D and Weeks P (2014) Thrombosis in Continuous-Flow Left Ventricular Assist Devices: Pathophysiology, Prevention, and Pharmacologic Management, Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 10.1002/phar.1501, 35:1, (79-98), Online publication date: 1-Jan-2015. Retzer E, Tannenbaum S, Fedson S, Kim G, Sayer G, Paul J, Nathan S, Jeevanandam V, Friant J, Uriel N and Shah A (2015) Successful percutaneous trans‐catheter treatment of left ventricular assist device outflow graft stenosis with a covered stent, ESC Heart Failure, 10.1002/ehf2.12030, 2:2, (100-102), Online publication date: 1-Jun-2015. Bartoli C, Ailawadi G and Kern J (2013) Diagnosis, Nonsurgical Management, and Prevention of LVAD Thrombosis, Journal of Cardiac Surgery, 10.1111/jocs.12238, 29:1, (83-94), Online publication date: 1-Jan-2014. May 2013Vol 6, Issue 3 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.113.000013PMID: 23694774 Manuscript receivedJanuary 9, 2013Manuscript acceptedMarch 15, 2013Originally publishedMay 1, 2013 Keywordscatheterthrombosis, ventricular assist deviceheart failurethrombolysisPDF download Advertisement SubjectsCardiovascular SurgeryHeart FailureThrombosis
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