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Early Anticoagulation Bridging to Therapeutic International Normalized Ratio after Left Ventricular Assist Device Implantation is Not Associated with Thromboembolic and Bleeding Complications: A Systematic Review and Meta-Analysis
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The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
453
454
Early Anticoagulation Bridging to Therapeutic International Normalized Ratio after Left Ventricular Assist Device Implantation is Not Associated with Thromboembolic and Bleeding Complications: A Systematic Review and Meta-Analysis V. Kittipibul,1 N. Angsubhakorn,2 J. Kewchareon,3 N. Prasitlumkum,3 and P. Rattanawong.3 1Department of Internal Medicine, University of Miami Miller School of Medicine, Miami, FL; 2Department of Internal Medicine, University of Minnesota, Minneapolis, MN; and the 3Department of Internal Medicine, University of Hawaii, Honolulu, HI.
Thalidomide Use Reduces Risk of Refractory Gastrointestinal Bleeding in Patients with Continuous Flow Left Ventricular Assist Devices P. Namdaran,1 T.A. Zikos,2 J.Y. Pan,2 and D. Banerjee.3 1Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT; 2Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA; and the 3Division of Cardiovascular Medicine, Stanford University, Stanford, CA.
Purpose: Thromboembolism (TE) is common after left ventricular assist device (LVAD) implantation and early anticoagulation (AC) bridging to therapeutic international normalized ratio (INR) has been widely implemented to prevent this complication. However, some studies suggested that no early AC bridging after LVAD implantation decreases bleeding complications without increase in incidence of TE. This meta-analysis aimed to evaluate the association between early AC bridging after LVAD implantation and incidence of TE and bleeding complications. Methods: We performed a comprehensive literature search through September 2018 using MEDLINE and EMBASE. Included studies were prospective or retrospective cohort studies that compared the incidence of TE and bleeding in LVAD patients with and without early AC bridging to therapeutic INR. We calculated pooled odds ratio (OR) with 95% confidence intervals (CI) and I2 statistic using the random-effects model. Results: Six studies were included in this meta-analysis. All patients had continuous-flow LVADs implanted. TE events were reported in 6 studies involving 897 patients (611 with bridging, 286 without bridging). Bleeding complications were reported in 4 studies involving 623 patients (405 with bridging, 218 without bridging). Median follow-up was 3.5 months. There was no association between AC bridging and incidence of TE (RR: 0.68; 95% CI: 0.41-1.12, I2=0%) and bleeding complications (RR: 0.98; 95% CI: 0.61-1.57, I2=32%) (Figure). Conclusion: Our meta-analysis suggests that early AC bridging to therapeutic INR after LVAD implantation is not associated with decreased TE and increased bleeding complications. Controlled trials are warranted to further investigate the utility of early AC bridging after LVAD implantation in patients at high risk for TE complications.
Methods: We conducted a single-center, retrospective review of all CFLVAD patients at our institution who subsequently experienced GI bleeding events, underwent endoscopy, and were treated with thalidomide. Only patients who had bleeding from suspected or confirmed AVMs and had a trial both off and on thalidomide were included. Our primary endpoint was reduction in time to re-bleed, while secondary endpoints included reduction in number of GI bleeding events, reduction in packed red blood cell (PRBC) transfusion requirements, and adverse events related to thalidomide. Results: Of the 274 CF-LVAD patients at our institution, 11.3% had recurrent GI bleeding, of which 17 were treated with thalidomide and had a sufficient observation period prior to and during treatment. The risk of re-bleeding was significantly reduced in patients on thalidomide therapy versus off (hazard ratio = 0.23, p = 0.022). The median rate of GI bleeding events was reduced from 4.6 to 0.4 events per year (p = 0.0008) and the median PRBC requirement was lower (36.1 vs 0.9 units per year, p = 0.004) in those on thalidomide therapy. While side effects, including dizziness and peripheral neuropathy, were seen in approximately 59% of patients on thalidomide, most resolved with dose reduction without any increase in bleeding, and only 11% required discontinuation. Conclusion: Among patients with CF-LVAD implantation who subsequently experience recurrent GI bleeding related to AVMs, treatment with thalidomide markedly reduced the GI re-bleeding risk, number of recurrent bleeding events and PRBC transfusion requirement. Our findings suggest that thalidomide should be considered as a medical therapy for the treatment of recurrent GI bleeding in CF-LVAD patients.
455 WITHDRAWN
456 Diagnostic Yield of Endoscopy Procedures in the Management of Left Ventricular Assist Device Recipients Presenting with Gastrointestinal Bleeding A.Y. Lee,1 K.M. Tecson,2 H.E. Sheffield,3 M.E. Marcom,3 A.Z. Jacob,3 S. Patlolla,4 N.H. Kwak,5 B.L. Da,6 J. Felius,7 S.A. Hall,8 H. Kale,9 and P. Kale.8 1Baylor Heart and Vascular Hospital, Dallas, TX; 2Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, TX; 3College of Medicine, Texas A&M Health Science Center, Dallas, TX; 4 Department of Internal Medicine, Baylor Scott and White, Dallas, TX; 5 Department of Gastroenterology, SUNY Health Science Center, Brooklyn, NY; 6National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, MD; 7Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX; 8Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott and White, Dallas, TX; and the 9Digestive Health Associates of Texas, Baylor Scott and White, Dallas, TX. Purpose: Left ventricular assist device (LVAD) patients are predisposed to gastrointestinal bleeding (GIB) due to a combination of anticoagulation/ antiplatelet medications and continuous flow physiology of LVADs, resulting in arteriovenous malformations. The workup for GIB often includes multiple endoscopic procedures resulting in prolonged hospital length of stay (LOS).
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
453
454
Early Anticoagulation Bridging to Therapeutic International Normalized Ratio after Left Ventricular Assist Device Implantation is Not Associated with Thromboembolic and Bleeding Complications: A Systematic Review and Meta-Analysis V. Kittipibul,1 N. Angsubhakorn,2 J. Kewchareon,3 N. Prasitlumkum,3 and P. Rattanawong.3 1Department of Internal Medicine, University of Miami Miller School of Medicine, Miami, FL; 2Department of Internal Medicine, University of Minnesota, Minneapolis, MN; and the 3Department of Internal Medicine, University of Hawaii, Honolulu, HI.
Thalidomide Use Reduces Risk of Refractory Gastrointestinal Bleeding in Patients with Continuous Flow Left Ventricular Assist Devices P. Namdaran,1 T.A. Zikos,2 J.Y. Pan,2 and D. Banerjee.3 1Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT; 2Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA; and the 3Division of Cardiovascular Medicine, Stanford University, Stanford, CA.
Purpose: Thromboembolism (TE) is common after left ventricular assist device (LVAD) implantation and early anticoagulation (AC) bridging to therapeutic international normalized ratio (INR) has been widely implemented to prevent this complication. However, some studies suggested that no early AC bridging after LVAD implantation decreases bleeding complications without increase in incidence of TE. This meta-analysis aimed to evaluate the association between early AC bridging after LVAD implantation and incidence of TE and bleeding complications. Methods: We performed a comprehensive literature search through September 2018 using MEDLINE and EMBASE. Included studies were prospective or retrospective cohort studies that compared the incidence of TE and bleeding in LVAD patients with and without early AC bridging to therapeutic INR. We calculated pooled odds ratio (OR) with 95% confidence intervals (CI) and I2 statistic using the random-effects model. Results: Six studies were included in this meta-analysis. All patients had continuous-flow LVADs implanted. TE events were reported in 6 studies involving 897 patients (611 with bridging, 286 without bridging). Bleeding complications were reported in 4 studies involving 623 patients (405 with bridging, 218 without bridging). Median follow-up was 3.5 months. There was no association between AC bridging and incidence of TE (RR: 0.68; 95% CI: 0.41-1.12, I2=0%) and bleeding complications (RR: 0.98; 95% CI: 0.61-1.57, I2=32%) (Figure). Conclusion: Our meta-analysis suggests that early AC bridging to therapeutic INR after LVAD implantation is not associated with decreased TE and increased bleeding complications. Controlled trials are warranted to further investigate the utility of early AC bridging after LVAD implantation in patients at high risk for TE complications.
Methods: We conducted a single-center, retrospective review of all CFLVAD patients at our institution who subsequently experienced GI bleeding events, underwent endoscopy, and were treated with thalidomide. Only patients who had bleeding from suspected or confirmed AVMs and had a trial both off and on thalidomide were included. Our primary endpoint was reduction in time to re-bleed, while secondary endpoints included reduction in number of GI bleeding events, reduction in packed red blood cell (PRBC) transfusion requirements, and adverse events related to thalidomide. Results: Of the 274 CF-LVAD patients at our institution, 11.3% had recurrent GI bleeding, of which 17 were treated with thalidomide and had a sufficient observation period prior to and during treatment. The risk of re-bleeding was significantly reduced in patients on thalidomide therapy versus off (hazard ratio = 0.23, p = 0.022). The median rate of GI bleeding events was reduced from 4.6 to 0.4 events per year (p = 0.0008) and the median PRBC requirement was lower (36.1 vs 0.9 units per year, p = 0.004) in those on thalidomide therapy. While side effects, including dizziness and peripheral neuropathy, were seen in approximately 59% of patients on thalidomide, most resolved with dose reduction without any increase in bleeding, and only 11% required discontinuation. Conclusion: Among patients with CF-LVAD implantation who subsequently experience recurrent GI bleeding related to AVMs, treatment with thalidomide markedly reduced the GI re-bleeding risk, number of recurrent bleeding events and PRBC transfusion requirement. Our findings suggest that thalidomide should be considered as a medical therapy for the treatment of recurrent GI bleeding in CF-LVAD patients.
455 WITHDRAWN
456 Diagnostic Yield of Endoscopy Procedures in the Management of Left Ventricular Assist Device Recipients Presenting with Gastrointestinal Bleeding A.Y. Lee,1 K.M. Tecson,2 H.E. Sheffield,3 M.E. Marcom,3 A.Z. Jacob,3 S. Patlolla,4 N.H. Kwak,5 B.L. Da,6 J. Felius,7 S.A. Hall,8 H. Kale,9 and P. Kale.8 1Baylor Heart and Vascular Hospital, Dallas, TX; 2Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, TX; 3College of Medicine, Texas A&M Health Science Center, Dallas, TX; 4 Department of Internal Medicine, Baylor Scott and White, Dallas, TX; 5 Department of Gastroenterology, SUNY Health Science Center, Brooklyn, NY; 6National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, MD; 7Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX; 8Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott and White, Dallas, TX; and the 9Digestive Health Associates of Texas, Baylor Scott and White, Dallas, TX. Purpose: Left ventricular assist device (LVAD) patients are predisposed to gastrointestinal bleeding (GIB) due to a combination of anticoagulation/ antiplatelet medications and continuous flow physiology of LVADs, resulting in arteriovenous malformations. The workup for GIB often includes multiple endoscopic procedures resulting in prolonged hospital length of stay (LOS).