The Biological Basis of Thrombosis and Bleeding in Patients with Ventricular Assist Devices

Lee, Sang-Jin

doi:10.1007/s12265-008-9072-7

Cited by 48 publications

(34 citation statements)

References 53 publications

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“…However, nonocular bleeding complications with both the traditional pulsatile LVAD and the newer continuous-flow LVAD have been reported. 6,7 Angiodysplasia and AVMs are common sources of GI bleeding, which had previously occurred in our patient as well.…”

Section: Discussionsupporting

confidence: 62%

“…The ocular bleed in this patient likely resulted from the change in systemic immunologic and thrombostatic function from direct contact of the blood circulation with the LVAD biomaterial. 7 Though the mildly elevated INR may have contributed to the intraocular bleed, at least one study showed that INR was not predictive of bleeding events after LVAD implantation. 11 Another study indicated that older age (>65), lower preoperative hematocrit (≤31), ischemic cardiomyopathy, and female sex were risk factors for bleeding with the LVAD.…”

Section: Discussionmentioning

confidence: 99%

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Spontaneous hyphema and pupillary block in a patient with a left ventricular assist device

Kavoussi

Liu

2015

Digit J Ophthalmol

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SummaryThe left ventricular assist device (LVAD) has been a standard of care for the management of patients with advanced heart failure since the 1990s. An increased risk of spontaneous bleeding related to the device has been noted, ranging from minor epistaxis to major thoracic and mediastinal hemorrhages. To our knowledge, intraocular hemorrhage has not been previously reported. We report a 72-year-old patient with an LVAD who subsequently developed a spontaneous intraocular hemorrhage that manifested as hyphema, pupillary block, and acute intraocular pressure elevation. Case ReportA 72-year-old man with a history of ischemic cardiomyopathy with prior 5-vessel coronary artery bypass and a continuous-flow left ventricular assist device (LVAD) placed 6 months prior awoke with 10/10 pain and loss of vision in the right eye. Recent medical history included an ischemic stroke suffered 1 week after the LVAD procedure and 2 episodes of gastrointestinal (GI) bleeding with arteriovenous malformations (AVMs) found on endoscopy. Ocular history included uneventful bilateral cataract extraction and intraocular lens (IOL) implantation approximately 10 years prior and non-exudative, age-related macular degeneration in both eyes. There was no recent trauma. His medicines included 2 mg warfarin daily with a goal international normalized ratio (INR) of 1.8-2.5, which had been reduced to 1.8-2.2 after the GI bleeds.On initial evaluation, visual acuity in the right eye was light perception; intraocular pressure (IOP) in the right eye by Tono-Pen (Reichert Technologies, Depew, NY) was 87 mm Hg. The anterior chamber was deep with a 1.5 mm crescent-shaped layering hyphema. The iris was flat, without neovascularization, and the angle was open, with a deep chamber by Van Herick slit-lamp examination. The pupil was unreactive, and the entire pupillary aperture was filled with a blood clot obstructing the view to the posterior segment (Figure 1). B-mode ultrasonography revealed a vitreous opacity consistent with blood in the anterior vitreous. The left eye was unremarkable, with an open angle. The IOP dropped to 46 mm Hg 1 hour after administration of oral acetazolamide 500 mg and topical timolol 0.5%, 1 drop times 2 doses every 5 minutes. Two hours later, IOP was 17 mm Hg; the patient's pain abated with additional oral acetazolamide and topical brimonidine 0.2%, timolol 0.5%, latanoprost 0.005%, prednisolone, and atropine solutions. INR on admission was found to be elevated at 1.7, slightly below the goal therapeutic range for the LVAD. Prothrombin time was 14.9. In collaboration with cardiology, warfarin was stopped because of the ocular bleed. Computed tomography imaging was negative for intracranial hemorrhage. The patient was admitted to the coronary care unit and monitored closely for signs and symptoms of thrombosis.Twelve hours later, the patient's 10/10 eye pain returned. The IOP measured 58 mm Hg, with a shallow anterior chamber and 360 degrees of anterior iris bowing. Repeat B-scan was unchanged. An acute angle closure second...

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Section: Discussionsupporting

confidence: 62%

Section: Discussionmentioning

confidence: 99%

Spontaneous hyphema and pupillary block in a patient with a left ventricular assist device

Kavoussi

Liu

2015

Digit J Ophthalmol

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“…1 There are multiple emerging theories as to why this is the case, including reduced arterial pulse pressure promoting AVM formation, as well as the development of an acquired von Willebrand syndrome. 2 The lowered pulse pressure secondary to continuous-flow device therapy is akin to patients with severe aortic stenosis (AS). Heyde first described this association with AS in 1958.…”

Section: Discussionmentioning

confidence: 99%

Octreotide for Left Ventricular Assist Device–Related Gastrointestinal Hemorrhage

Rennyson

Shah²,

Tang³

et al. 2013

ASAIO Journal

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“…These factors include interaction of the blood with artifi cial surfaces, mechanical effects on coagulation factors, and high fl ow rates through small gaps, such as those within continuous fl ow devices, that may lead to high shear forces on the blood. 36,37 Excessive shear can lead to platelet degradation and dysfunction as well as destructi on of other blood factors, such as von Willebrand factor. 36 Antiplatelet therapy may be more important to use with these devices than anticoagulation therapy, but it is not yet clear at which point these shear stress-induced abnormalities develop, or what the optimal management strategies should be.…”

Section: Cannula Obstructionmentioning

confidence: 99%

Ventricular Assist Devices

O’Shea

2012

AACN Advanced Critical Care

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Patients with advanced heart failure have limited treatment options despite advances in medical management. Ventricular assist devices represent a surgical option that offers improved end-organ function, survival, and quality of life. Postoperative nursing management involves the most complicated aspects of care following cardiac surgery as well as issues unique to advanced heart failure and mechanical circulatory support. Despite growing numbers of ventricular assist device implants, literature about the challenging care of patients following ventricular assist device implantation is limited. This article focuses on the physiological basis for postoperative nursing management strategies and the most important complications of which critical care nurses need to be aware.

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The Biological Basis of Thrombosis and Bleeding in Patients with Ventricular Assist Devices

Cited by 48 publications

References 53 publications

Spontaneous hyphema and pupillary block in a patient with a left ventricular assist device

Spontaneous hyphema and pupillary block in a patient with a left ventricular assist device

Octreotide for Left Ventricular Assist Device–Related Gastrointestinal Hemorrhage

Ventricular Assist Devices

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