Anticoagulation for Percutaneous Ventricular Assist Device-Supported Cardiogenic Shock

Vandenbriele, Christophe; Arachchillage, Deepa J.; Frederiks, Pascal; Giustino, Gennaro; Gorog, Diana A.; Gramegna, Mario; Janssens, Stefan; Meyns, Bart; Polzin, Amin; Scandroglio, Mara; Schrage, Benedikt; Stone, Gregg W.; Tavazzi, Guido; Vanassche, Thomas; Vranckx, Pascal; Westermann, Dirk; Price, Susanna; Chieffo, Alaide

doi:10.1016/j.jacc.2022.02.052

Cited by 56 publications

(51 citation statements)

References 47 publications

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“…The pump bearings are additionally protected by either heparinization or addition of low-dose sodium bicarbonate to the purge. On the other hand, to prevent thrombus formation on the catheter surface, a target level of systemic anticoagulation should be achieved 5 ( Figure 1A ). Inadequate anticoagulation leads to thrombus formation and device dysfunction ( Figure 1B ).…”

Section: Bleeding Thrombotic Complications and Haemolysis During Prot...mentioning

confidence: 99%

“…Conversely, excessive anticoagulation and the effect of dual antiplatelet therapy (DAPT) increase the risk of bleeding ( Figure 1C ). Moreover, the shear stress and the continuous flow may lead to proteolysis of the high molecular weight von Willebrand factor 5 resulting in an acquired von Willebrand syndrome (AVWS) within 24 h of starting the p-LVAD 5 further aggravating the bleeding risk 6 ( Figure 1A ). Most studies investigated bleeding risk focused on Impella ™ support during cardiogenic shock (CS).…”

Section: Bleeding Thrombotic Complications and Haemolysis During Prot...mentioning

confidence: 99%

“…Bleeding is associated with prolonged inotropic and ventilatory support and increases the risk of death. 5 , 10 Non-modifiable risk factors associated with increased p-LVAD-related vascular complications and major bleeding include older age, female gender, obesity, previous hypertension, and peripheral arterial disease. 8 , 11 As one or more of these factors is often present in patients with p-LVAD, standardized peri- and post-interventional management of anticoagulation is essential/critical.…”

Section: Bleeding Thrombotic Complications and Haemolysis During Prot...mentioning

confidence: 99%

“…Shear stress-induced acquired von Willebrand factor is measured via von Willebrand factor antigen and functional von Willebrand testing. Haemolysis is measured via plasma-free haemoglobin levels 5 and/or bilirubin. ( B ) Thrombus formation in the blood inlet area of the Impella ® devices.…”

Section: Bleeding Thrombotic Complications and Haemolysis During Prot...mentioning

confidence: 99%

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What is known in pre-, peri-, and post-procedural anticoagulation in micro-axial flow pump protected percutaneous coronary intervention?

Leick

Grottke

Oezkur³

et al. 2022

European Heart Journal Supplements

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Interest in the use of percutaneous left ventricular assist devices (p-LVADs) for patients undergoing high-risk percutaneous coronary intervention (PCI) is growing rapidly. The Impella™ (Abiomed Inc.) is a catheter-based continuous micro-axial flow pump that preserves haemodynamic support during high-risk PCI. Anticoagulation is required to counteract the activation of the coagulation system by the patient’s procoagulant state and the foreign-body surface of the pump. Excessive anticoagulation and the effect of dual antiplatelet therapy (DAPT) increase the risk of bleeding. Inadequate anticoagulation leads to thrombus formation and device dysfunction. The precarious balance between bleeding and thrombosis in patients with p-LVAD support is often the primary reason that patients’ outcomes are jeopardized. In this chapter, we will discuss anticoagulation strategies and anticoagulant management in the setting of protected PCI. This includes anticoagulant therapy with unfractionated heparin, direct thrombin inhibitors, DAPT, purge blockage prevention by bicarbonate-based purge solution, and monitoring by activated clotting time, partial thromboplastin time, as well as anti-factor Xa levels. Here, we provide a standardized approach to the management of peri-interventional anticoagulation in patients undergoing protected PCI.

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Section: Bleeding Thrombotic Complications and Haemolysis During Prot...mentioning

confidence: 99%

Section: Bleeding Thrombotic Complications and Haemolysis During Prot...mentioning

confidence: 99%

Section: Bleeding Thrombotic Complications and Haemolysis During Prot...mentioning

confidence: 99%

Section: Bleeding Thrombotic Complications and Haemolysis During Prot...mentioning

confidence: 99%

See 2 more Smart Citations

What is known in pre-, peri-, and post-procedural anticoagulation in micro-axial flow pump protected percutaneous coronary intervention?

Leick

Grottke

Oezkur³

et al. 2022

European Heart Journal Supplements

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“…Although hemodilution during CPB can lower AT-III levels, it is also connected to dilution of procoagulant chemicals, therefore heparin resistance is rarely seen. The most prevalent cause of heparin resistance in cardiac surgery patients is AT-III depletion or dysfunction, which is caused by prior heparin administration 6 . AT III activity reduction (sometimes accompanied by heparin resistance) is more common in certain patient groups.…”

Section: Introductionmentioning

confidence: 99%

Incidence of Heparin resistance after preoperative heparin therapy in patients undergoing open heart surgery

Naeem¹,

Niazi²,

Muneeb³

et al. 2022

PJMHS

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Aim: Incidence of Heparin Resistance after preoperative heparin therapy in patients undergoing open heart surgery. Methods: The Prospective Observational study included 124 patients of different heart diseases undergoing open heart surgery, at cardiac surgery department of Punjab Institute of Cardiology; Lahore Pakistan was performed between 5th October 2013 to 16 March 2014. Both genders age 18-75 were included. All those patients who present with diseases other than heart diseases, age <18 and > 75 were excluded in the study. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 16.0. P-value ≤ 0.05 were considered significant. Results: Our results showed that out of 124 patients, 87(70.16%) were male while 37(29.84%) were females. Clinical characteristics i.e. (hypertension, diabetes mellitus, emergency bypass, smoking, alcohol intake, hyperlipidemias, obesity and family history) were insignificantly associated with heparin resistance. The clinical characteristics i.e. (baseline activated clotting time, albumin and cross clamp time) were significantly associated with the development of heparin resistance as (p-value <0.05 .015, .041 and .025 respectively). Conclusion: The results indicate that the incidence of heparin resistance after preoperative heparin therapy was 8.06%.

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Caution With Conclusions and Context of Mechanical Circulatory Devices

2023

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To the Editor In a recent article, Dr Miller and colleagues 1 reported an increased risk of 1-year mortality and bleeding among patients supported by an intravascular microaxial left ventricular assist device (LVAD) vs an intra-aortic balloon pump (IABP) who had all experienced an acute myocardial infarction complicated by cardiogenic shock (CS) and were undergoing percutaneous coronary intervention. This retrospective, propensity-matched analysis was performed in more than 800 patients. Similar conclusions (ie, increased mortality and major bleeding in the LVAD vs the IABP group) were previously reported by 2 large retrospective studies across the US involving 3360 propensity-matched patients with CS and mechanical circulatory support (MCS) 2 and more than 48 300 patients undergoing percutaneous coronary intervention supported by MCS. 3 Although these findings 1 are important, we must strongly emphasize that the focus on outcome among this critically ill population should be shifted from device-stratified outcome to outcome according to patient selection and case management. Because this study population was highly heterogeneous-including stratification of severity, phenotypes and related pathophysiology, complication rates, and intensive care unit management-throughout different institutions, we agree with the authors that all of the findings should be cautiously contextualized by the retrospective nature of the analyses. Indeed, no information was provided on the shock stage classification 4 of patients with CS for the LVAD vs IABP groups nor on the device selection. 1 Because LVAD allows a higher level of support, it may likely have been used in patients with more severe CS and worse organ function, or more severe CS levels may have been associated with intrinsic or congestionrelated coagulation dysfunction.The importance of a standardized heparin anticoagulation strategy-based on parallel activated partial thromboplastin time and anti-Xa assay measurements-in microaxial flow pumpsupported patients to avoid (major) bleeding complications and hemolysis has recently been emphasized. 5 In none of 3 the above-mentioned retrospective analyses was information provided on the anticoagulant drug used, the tests for monitoring the anticoagulant, nor the anticoagulation target. Moreover, major bleeding was not defined. Therefore, we believe that a detailed pathophysiological assessment-including organ function, CS severity, and a more standardized approach toward managing these devices in patients in the intensive care unitis mandatory before any firm conclusions can be drawn regarding complications associated with the device itself.

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Anticoagulation for Percutaneous Ventricular Assist Device-Supported Cardiogenic Shock

Cited by 56 publications

References 47 publications

What is known in pre-, peri-, and post-procedural anticoagulation in micro-axial flow pump protected percutaneous coronary intervention?

What is known in pre-, peri-, and post-procedural anticoagulation in micro-axial flow pump protected percutaneous coronary intervention?

Incidence of Heparin resistance after preoperative heparin therapy in patients undergoing open heart surgery

Caution With Conclusions and Context of Mechanical Circulatory Devices

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