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Contemporary Report on Infectious Complications in Pediatric Patients Supported by Ventricular Assist Devices
S242
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
between contamination and infection, and would be a useful contribution for individual tailoring of antimicrobial treatment. 6( 28) Antibiotic Prophylaxis Strategies in LVAD Implantation and LVAD Infections: A Systematic Review of the Literature M. Bishawi , S. Bell, L. Cai, W. Landford, S. Arif, A. McLarty, L. Blue, B. Phillips, A. Nicoara, C. Patel, C. Milano. Duke University, Durham, NC. Purpose: There has been an increase in the use of left ventricular assist devices (LVAD) not only as a bridge to transplant, but also as destination therapy for patients with end stage heart failure. Secondary infections remain a challenging problem of LVAD usage with a significant associated morbidity and mortality. The purpose of this review is to identify current trends in antibiotics prophylaxis, common organisms isolated, location of infections, and overall outcomes for those with LVAD related and LVAD associated infections. Methods: Systematic electronic searches were performed in PubMed, OVID, and the Cochrane databases using MeSH terms for studies reporting on LVAD implantation and secondary infections. Human studies in all languages from 2003 to October 2015 were reviewed. For inclusion, publications had to report on the number of patients receiving LVAD and the number of documented infections. Results: A total of 359 studies were identified and abstracts reviewed. A total of 33 articles were included, with 4159 patients undergoing LVAD implantation. Staphylococcus aureus and S. epidermidis were the most commonly reported bacterial infections regardless of antibiotic regimen choice. Although highly variable, antibiotic prophylaxis protocols including vancomycin reported lower percentages of patients with infection compared to prophylactic protocols excluding vancomycin (32.4% vs 73.2%, respectively). The mean infection rates for prophylactic protocols including both vancomycin and fluconazole varied between 6.5% and 23%, with a combined average of 14.0%. The mean infection rates for prophylactic protocols including vancomycin but not fluconazole varied between 15% and 50%, with a combined average of 37.1%. Among prophylactic protocols that excluded vancomycin, the infection rates were comparable regardless of fluconazole use. Conclusion: The current literature lacks a consensus on the regimen and duration of antibiotic prophylaxis during LVAD implantation. The literature supports the use of vancomycin along with fluconazole confer the greatest benefit in minimizing infection rates in this population. Randomized controlled trials are warranted to best determine an optimal prophylactic antibiotic protocol.
6( 29) Is Multidrugresistance Pathogens Colonization a Contraindication to LVAD Implant? A Single Center Experience S. Sciacca ,1 G. Panarello,2 M.O. Campanella,3 R. Alduino,3 F. Clemenza,4 M. Pilato.1 1Cardiac Surgery, ISMETT, Palermo, Italy; 2Anesthesia, ISMETT, Palermo, Italy; 3ISMETT, Palermo, Italy; 4Cardiology, ISMETT, Palermo, Italy. Purpose: Ventricular assist device (VAD) is often used for management of patents affected by advanced heart failure. Infections are a serious complication of assist device therapy. VAD-specific and VAD-related infections remain a major cause of death in these patients. Prevalence of infection is influenced by the INTERMACS level patient at the time of implant. Aim of our study is to highlight VAD associated infections rate in our experience and to verify if MDR colonization/infection before VAD implant is a risk factor for post implant outcome. Methods: We retrospectively reviewed the charts of 41 patients who had LVAD implanted from Nov 2010 to Aug 2016. 40 patients were male and 1 female, with a mean age of 59 ± 6 ys. Heartware was used in all patients The mean follow up was 352 ± 333 dd. Results: At the time of VAD implant 20 patients were free from skin, nose and /or rectal colonization with MDR bacterias. Among those only 25% got colonized after LVAD implant after surgery. In the group of patients not colonized preoperatively 35% experienced an infection before LVAD implant and all of them had major infections after surgery; 23% died because of septic shock. In the group of patients colonized preoperatively (21 patients),
five patients (24%) had pre-implant infections and four of them experienced post-implant infection; the outcome was favorable in 2 of them. Conclusion: LVAD is a valid tool for management of advanced heart failure. The procedure is burdened by an infection rate of 17 %. Preimplant colonizations might have considered a risk factor for post surgical complications but it was not. The infection occurring before surgery was a predictor of poor prognosis Out of 12 patients having pre-operative infections, 67% died and preoperative infection was a statistically significant risk factor (p_value= 0.035). Our results are in agreement with Literature data even if the low number of analysed patients represents the main limitation of this study. Close follow-up is needed to capture these adverse events as early as possible and infection control measures are mandatory to reduce as much as possible the risk of infection. 6( 30) Long Term Management of Deep Mediastinal Infection for Durable Mechanical Circulatory Support Devices D.G. Tang ,1 O. De La Cruz,2 M. Quader,3 V. Kasirajan.3 1Virginia Commonwealth University, Richmond, VA; 2Division of Infectious Diseases, Virginia Commonwealth University, Richmond, VA; 3Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA. Purpose: Patient (pts) implanted with durable mechanical circulatory support (MCS) have an accumulating risk of infection. While heart transplantation remains the definitive treatment for major MCS associated infection, this is limited by organ availability and use as destination therapy. Treatment strategies such as device replacement and omental transposition are associated with high morbidity and mortality. Outcomes of patients treated with chronic drainage are analyzed. Methods: 350 pts implanted with MCS at a single institution from 2006 to 2016 were retrospectively reviewed. 12 pts developed deep mediastinal infections including subcostal pocket infections (4 Syncardia TAH, 6 Heartmate II, 1 Heartware HVAD, 1 Heartmate XVE,). Outcomes in these patients were analyzed. Results: Deep mediastinal infections were identified at a median of 218 d (range 28-526 d) after implant. Mediastinal organisms were: 5 staphyloccus, 1 enterococcus, 1 Klebsiella, 2 Serratia, 1 mycobacteria, and 2 unidentified. 5 patients underwent redo sternotomy (3 for pump replacement). 7 pts underwent drainage via a subxiphoid window. 2 pts underwent open subcostal drainage. 10 patients underwent short term continuous irrigation followed by long term chronic closed drainage. 8 patients were discharged home with chronic drains. Pts were supported with chronic drains for a median of 158 d (range 10 - 331 d). 5 pts expired with presumed active infection. 1 pt expired at the time of diagnosis and without drainage. 4 pts expired with chronic drainage at a median of 192 d (range 131-331 d). 3 pts were transplanted. Intraoperative cultures at the time of transplant in all 3 were negative. 3 pts had the pump replaced. Recurrence of mediastinal infection was identified in 1 pt after device replacement. 1 pt with chronic drainage developed bacteremia related to the original index infection. 2 pts remain on device support without apparent recurrence. 1 patient remains on chronic drainage. Conclusion: MCS associated deep mediastinal infection is a difficult problem with significant morbidity and mortality. Chronic drainage is a simple and effective option for sepsis control until transplant, device replacement, or long term palliation. 6( 31) Contemporary Report on Infectious Complications in Pediatric Patients Supported by Ventricular Assist Devices A.G. Cabrera ,1 J.F. Price,1 I. Adachi,2 A. Jeewa,1 B. Elias,2 S.W. Denfield,1 W.J. Dreyer,1 G.F. Jason,1 N.J. Rodgers,1 J. Vallejo,1 C.E. Bocchini.1 1Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX; 2Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX. Purpose: Limited data exist regarding infections and associated microbiology in pediatric patients supported by VADs. We describe the characteristics and outcomes in long-term VAD patients focusing on causative agent and risk factors for infection. Overall VAD- infection rate was compared to our previously published benchmark from 6/1999 to 12/2011.
Abstracts S243 Methods: Retrospective review of patients supported by VADs at Texas Children’s Hospital from 1/2012-3/2016. Infections were categorized using ISHLT definitions. Descriptive statistics were used for frequencies, means, medians and ranges. Fisher’s exact test and chi squared were used for categorical variables and Students t test for continuous variables. Univariate and Multiple regression analysis were performed to evaluate risk factor for VAD-infections. Results: Forty-three VADs (18 pulsatile and 25 CFVADs) were implanted in 42 patients (mean age 8.1 y, [4 m- 26 years]; Twenty one (50%) were female; All pulsatile devices were Berlin Heart. CFVADs included 6 HMII 19 HVAD. Forty two infections occurred in 23 (55%) patients. Overall VAD-infection rate was 3.2/1000 days of VAD support (benchmark 8/1000 days of VAD support). Infection characteristics are shown on Table No. 1. Factors associated with VAD-infection included continuous-flow (CF) VAD (p= 0.04) and Lymphopenia (ALC < 1000/UL) prior to surgery (p< 0.01). Four patients (9.5%), all receiving fluconazole prophylaxis, had invasive mold infections. Fungal infection was associated with total parental nutrition (TPN) use (p= 0.03) and perioperative prophylaxis regimens that included 3rd/4th generation cephalosporin’s (p= 0.04). Of 9 deaths during VAD support, 4 (44%) were associated with infection. Conclusion: Infections are common in pediatric VAD patients. Lymphopenia prior surgery and use of CF VADs were higher risk for VAD infections. Fungal VAD infections were associated with TPN and perioperative prophylaxis with 3rd and 4th generation cephalosporins.
Results: There were 14 patients (13 males, 5 ≤ 18yrs) with 17 episodes of bivalirudin therapy. The median age on initiation was 45 yrs (range 0-67) with 10 episodes associated with a Heartware HVAD, 5 a Heartmate II and 2 with a Berlin Heart EXCOR. The predominant indication of bivalirudin therapy was suspected pump thrombosis (13/17). In those patients who did not have a suspected pump thrombosis, indications for bivalirudin included suspected heparin induced thrombocytopenia (1), coagulopathy on unfractionated heparin (1) and acute kidney injury (1). The median time from VAD insertion to initiation of bivalirudin was 116 days (range 3-1870) with the median duration of therapy being 21days (range 3-113). In patients with pump thrombosis the mean baseline LDH was 229 ± 64 U/L, peak 690±380 U/L and decreased to 330 ±243 U/L when bivalirudin was stopped. The outcomes following suspected pump thrombosis included: transitioned to warfarin (n= 7), death in 2 destination therapy patients who did not undergo pump exchange, transplantation (n= 2), and pump exchange (n= 2). A major bleeding complication occurred in only 1 patient; this was a subdural hemorrhage associated with a fall and the patient made a full recovery. Conclusion: Our experience highlights the potential use of bivalirudin in a heterogenous VAD population. While these initial results suggest some potential role for direct thrombin inhibitors for use in long term VADs, larger prospective studies are required to support these preliminary observations and to determine which who may benefit and the side effect profile in this patient population.
6( 33) Experience and Perspective of Heparin -Antiplatelet Factor IV Antibody Testing for the Diagnosis of Heparin Induced Thrombocytopenia in Veno-Arterial Extracorporeal Membrane Oxygenation H.M. Gonzalez Bonilla ,1 P.A. Alvarez,2 D. Hailemariam,3 R. Ogunti,3 M. Puppala,3 S.N. Homer,3 F.R. Bostan,3 J.E. Fetter,4 L. Rice.5 1Internal Medicine, Houston Methodist Hospital, Houston, TX; 2Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX; 3Houston Methodist Hospital, Houston, TX; 4Anesthesia and Critical Care, Houston Methodist Hospital, Houston, TX; 5Hematology Department, Houston Methodist Hospital, Houston, TX.
6( 32) Bivalirudin Experience in a Heterogenous VAD Population J.L. Conway ,1 A. Bates,2 D. Freed,3 R. MacArthur,4 H. Buchholz.4 1Division of Cardiology, Department of Paediatrics, University of Alberta, Stollery Children's Hospital, Edmtonton, AB, Canada; 2Division of Critical Care Medicine, Department of Paediatrics, University of Alberta, Stollery Children's Hospital, Edmtonton, AB, Canada; 3Surgery, Division of Cardiac Surgery, University of Alberta, Edmtonton, AB, Canada; 4Division of Cardiac Surgery, University of Alberta, Edmtonton, AB, Canada. Purpose: Ventricular assist devices (VADs) are an increasingly common therapy for end stage heart failure across all ages as a bridge to recovery or transplant, and more recently as destination therapy. With increasing experience, and difficulties with establishing therapeutic heparin levels we have begun to explore the effectiveness of direct thrombin inhibitors in this patient population. Methods: This is a retrospective review of all long-term VAD patients, both adult and pediatric, who were anti-coagulated with bivalirudin between 01/09-01/16. The starting dose was 0.3mg/kg/hour and dose was titrated for a goal PTT of 70-100.
Purpose: The optimal diagnostic strategy for heparin induced thrombocytopenia in ECMO is not well defined. We reviewed the use of heparin-platelet Factor IV antibody (HPF4A) testing in patients on veno-arterial extracorporeal membrane oxygenation (VAECMO). Methods: 247 patients underwent VAECMO at our center between 1/01/2006 and 12/31/2015. Patients were categorized into those tested and not tested for HPF4A. Platelet (Plt) were analyzed when available from 3 days prior (-3) to ECMO to 8 days after ECMO insertion. Percentage platelet change was defined as (Plt Day -3 minus Plt Day 0-ECMO insertion-)/Plt Day -3) *100. HPF4A was considered positive when Optical Density (OD) value was > 1. Results: 103 (41.7%) patients were tested for HPF4A. Patients tested for HPF4A had similar age (52.48vs54.88 p= 0.2201), sex (Male 68%vs63% p= 0.295), coronary artery disease (42.7%vs51.3% p = 0.129), congestive heart failure (72.8%vs63.1% p= 0.12), use of intra-aortic balloon pump (43.6%vs43.7% p= 0.99) and use of antibiotics with potential to cause thrombocytopenia (72.8%vs0.61 p= 0.07) but lower platelet counts (123.260vs181.540), hemoglobin (9.9vs10.92 p< 0.01), albumin (2.89vs3.46 p< 0.01) and fibrinogen (306.19vs371.62 p= 0.04). In addition they had a higher use of epinephrine (15%vs6.9% p= 0.03) and norepinephrine (27%vs13% p= 0.06). ECMO duration was significantly longer in patients tested 7.32vs3.57 days (p< 0.001). Only 4 (3.8%) had a positive HPF4A. The percentage platelet change was 38% in the patients tested compared to 27% in not tested. Patients who had a positive HPF4 had a 58% change. Conclusion: HPF4A testing is frequent in patients treated with VAECMO. The decision to test appears to be related to markers of increased disease severity. If a quantitatively interpretation of HPF4A is used the results are negative in > 95% of the patients. Platelet decrease was significantly higher in patients with positive HPF4A.
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
between contamination and infection, and would be a useful contribution for individual tailoring of antimicrobial treatment. 6( 28) Antibiotic Prophylaxis Strategies in LVAD Implantation and LVAD Infections: A Systematic Review of the Literature M. Bishawi , S. Bell, L. Cai, W. Landford, S. Arif, A. McLarty, L. Blue, B. Phillips, A. Nicoara, C. Patel, C. Milano. Duke University, Durham, NC. Purpose: There has been an increase in the use of left ventricular assist devices (LVAD) not only as a bridge to transplant, but also as destination therapy for patients with end stage heart failure. Secondary infections remain a challenging problem of LVAD usage with a significant associated morbidity and mortality. The purpose of this review is to identify current trends in antibiotics prophylaxis, common organisms isolated, location of infections, and overall outcomes for those with LVAD related and LVAD associated infections. Methods: Systematic electronic searches were performed in PubMed, OVID, and the Cochrane databases using MeSH terms for studies reporting on LVAD implantation and secondary infections. Human studies in all languages from 2003 to October 2015 were reviewed. For inclusion, publications had to report on the number of patients receiving LVAD and the number of documented infections. Results: A total of 359 studies were identified and abstracts reviewed. A total of 33 articles were included, with 4159 patients undergoing LVAD implantation. Staphylococcus aureus and S. epidermidis were the most commonly reported bacterial infections regardless of antibiotic regimen choice. Although highly variable, antibiotic prophylaxis protocols including vancomycin reported lower percentages of patients with infection compared to prophylactic protocols excluding vancomycin (32.4% vs 73.2%, respectively). The mean infection rates for prophylactic protocols including both vancomycin and fluconazole varied between 6.5% and 23%, with a combined average of 14.0%. The mean infection rates for prophylactic protocols including vancomycin but not fluconazole varied between 15% and 50%, with a combined average of 37.1%. Among prophylactic protocols that excluded vancomycin, the infection rates were comparable regardless of fluconazole use. Conclusion: The current literature lacks a consensus on the regimen and duration of antibiotic prophylaxis during LVAD implantation. The literature supports the use of vancomycin along with fluconazole confer the greatest benefit in minimizing infection rates in this population. Randomized controlled trials are warranted to best determine an optimal prophylactic antibiotic protocol.
6( 29) Is Multidrugresistance Pathogens Colonization a Contraindication to LVAD Implant? A Single Center Experience S. Sciacca ,1 G. Panarello,2 M.O. Campanella,3 R. Alduino,3 F. Clemenza,4 M. Pilato.1 1Cardiac Surgery, ISMETT, Palermo, Italy; 2Anesthesia, ISMETT, Palermo, Italy; 3ISMETT, Palermo, Italy; 4Cardiology, ISMETT, Palermo, Italy. Purpose: Ventricular assist device (VAD) is often used for management of patents affected by advanced heart failure. Infections are a serious complication of assist device therapy. VAD-specific and VAD-related infections remain a major cause of death in these patients. Prevalence of infection is influenced by the INTERMACS level patient at the time of implant. Aim of our study is to highlight VAD associated infections rate in our experience and to verify if MDR colonization/infection before VAD implant is a risk factor for post implant outcome. Methods: We retrospectively reviewed the charts of 41 patients who had LVAD implanted from Nov 2010 to Aug 2016. 40 patients were male and 1 female, with a mean age of 59 ± 6 ys. Heartware was used in all patients The mean follow up was 352 ± 333 dd. Results: At the time of VAD implant 20 patients were free from skin, nose and /or rectal colonization with MDR bacterias. Among those only 25% got colonized after LVAD implant after surgery. In the group of patients not colonized preoperatively 35% experienced an infection before LVAD implant and all of them had major infections after surgery; 23% died because of septic shock. In the group of patients colonized preoperatively (21 patients),
five patients (24%) had pre-implant infections and four of them experienced post-implant infection; the outcome was favorable in 2 of them. Conclusion: LVAD is a valid tool for management of advanced heart failure. The procedure is burdened by an infection rate of 17 %. Preimplant colonizations might have considered a risk factor for post surgical complications but it was not. The infection occurring before surgery was a predictor of poor prognosis Out of 12 patients having pre-operative infections, 67% died and preoperative infection was a statistically significant risk factor (p_value= 0.035). Our results are in agreement with Literature data even if the low number of analysed patients represents the main limitation of this study. Close follow-up is needed to capture these adverse events as early as possible and infection control measures are mandatory to reduce as much as possible the risk of infection. 6( 30) Long Term Management of Deep Mediastinal Infection for Durable Mechanical Circulatory Support Devices D.G. Tang ,1 O. De La Cruz,2 M. Quader,3 V. Kasirajan.3 1Virginia Commonwealth University, Richmond, VA; 2Division of Infectious Diseases, Virginia Commonwealth University, Richmond, VA; 3Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA. Purpose: Patient (pts) implanted with durable mechanical circulatory support (MCS) have an accumulating risk of infection. While heart transplantation remains the definitive treatment for major MCS associated infection, this is limited by organ availability and use as destination therapy. Treatment strategies such as device replacement and omental transposition are associated with high morbidity and mortality. Outcomes of patients treated with chronic drainage are analyzed. Methods: 350 pts implanted with MCS at a single institution from 2006 to 2016 were retrospectively reviewed. 12 pts developed deep mediastinal infections including subcostal pocket infections (4 Syncardia TAH, 6 Heartmate II, 1 Heartware HVAD, 1 Heartmate XVE,). Outcomes in these patients were analyzed. Results: Deep mediastinal infections were identified at a median of 218 d (range 28-526 d) after implant. Mediastinal organisms were: 5 staphyloccus, 1 enterococcus, 1 Klebsiella, 2 Serratia, 1 mycobacteria, and 2 unidentified. 5 patients underwent redo sternotomy (3 for pump replacement). 7 pts underwent drainage via a subxiphoid window. 2 pts underwent open subcostal drainage. 10 patients underwent short term continuous irrigation followed by long term chronic closed drainage. 8 patients were discharged home with chronic drains. Pts were supported with chronic drains for a median of 158 d (range 10 - 331 d). 5 pts expired with presumed active infection. 1 pt expired at the time of diagnosis and without drainage. 4 pts expired with chronic drainage at a median of 192 d (range 131-331 d). 3 pts were transplanted. Intraoperative cultures at the time of transplant in all 3 were negative. 3 pts had the pump replaced. Recurrence of mediastinal infection was identified in 1 pt after device replacement. 1 pt with chronic drainage developed bacteremia related to the original index infection. 2 pts remain on device support without apparent recurrence. 1 patient remains on chronic drainage. Conclusion: MCS associated deep mediastinal infection is a difficult problem with significant morbidity and mortality. Chronic drainage is a simple and effective option for sepsis control until transplant, device replacement, or long term palliation. 6( 31) Contemporary Report on Infectious Complications in Pediatric Patients Supported by Ventricular Assist Devices A.G. Cabrera ,1 J.F. Price,1 I. Adachi,2 A. Jeewa,1 B. Elias,2 S.W. Denfield,1 W.J. Dreyer,1 G.F. Jason,1 N.J. Rodgers,1 J. Vallejo,1 C.E. Bocchini.1 1Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX; 2Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX. Purpose: Limited data exist regarding infections and associated microbiology in pediatric patients supported by VADs. We describe the characteristics and outcomes in long-term VAD patients focusing on causative agent and risk factors for infection. Overall VAD- infection rate was compared to our previously published benchmark from 6/1999 to 12/2011.
Abstracts S243 Methods: Retrospective review of patients supported by VADs at Texas Children’s Hospital from 1/2012-3/2016. Infections were categorized using ISHLT definitions. Descriptive statistics were used for frequencies, means, medians and ranges. Fisher’s exact test and chi squared were used for categorical variables and Students t test for continuous variables. Univariate and Multiple regression analysis were performed to evaluate risk factor for VAD-infections. Results: Forty-three VADs (18 pulsatile and 25 CFVADs) were implanted in 42 patients (mean age 8.1 y, [4 m- 26 years]; Twenty one (50%) were female; All pulsatile devices were Berlin Heart. CFVADs included 6 HMII 19 HVAD. Forty two infections occurred in 23 (55%) patients. Overall VAD-infection rate was 3.2/1000 days of VAD support (benchmark 8/1000 days of VAD support). Infection characteristics are shown on Table No. 1. Factors associated with VAD-infection included continuous-flow (CF) VAD (p= 0.04) and Lymphopenia (ALC < 1000/UL) prior to surgery (p< 0.01). Four patients (9.5%), all receiving fluconazole prophylaxis, had invasive mold infections. Fungal infection was associated with total parental nutrition (TPN) use (p= 0.03) and perioperative prophylaxis regimens that included 3rd/4th generation cephalosporin’s (p= 0.04). Of 9 deaths during VAD support, 4 (44%) were associated with infection. Conclusion: Infections are common in pediatric VAD patients. Lymphopenia prior surgery and use of CF VADs were higher risk for VAD infections. Fungal VAD infections were associated with TPN and perioperative prophylaxis with 3rd and 4th generation cephalosporins.
Results: There were 14 patients (13 males, 5 ≤ 18yrs) with 17 episodes of bivalirudin therapy. The median age on initiation was 45 yrs (range 0-67) with 10 episodes associated with a Heartware HVAD, 5 a Heartmate II and 2 with a Berlin Heart EXCOR. The predominant indication of bivalirudin therapy was suspected pump thrombosis (13/17). In those patients who did not have a suspected pump thrombosis, indications for bivalirudin included suspected heparin induced thrombocytopenia (1), coagulopathy on unfractionated heparin (1) and acute kidney injury (1). The median time from VAD insertion to initiation of bivalirudin was 116 days (range 3-1870) with the median duration of therapy being 21days (range 3-113). In patients with pump thrombosis the mean baseline LDH was 229 ± 64 U/L, peak 690±380 U/L and decreased to 330 ±243 U/L when bivalirudin was stopped. The outcomes following suspected pump thrombosis included: transitioned to warfarin (n= 7), death in 2 destination therapy patients who did not undergo pump exchange, transplantation (n= 2), and pump exchange (n= 2). A major bleeding complication occurred in only 1 patient; this was a subdural hemorrhage associated with a fall and the patient made a full recovery. Conclusion: Our experience highlights the potential use of bivalirudin in a heterogenous VAD population. While these initial results suggest some potential role for direct thrombin inhibitors for use in long term VADs, larger prospective studies are required to support these preliminary observations and to determine which who may benefit and the side effect profile in this patient population.
6( 33) Experience and Perspective of Heparin -Antiplatelet Factor IV Antibody Testing for the Diagnosis of Heparin Induced Thrombocytopenia in Veno-Arterial Extracorporeal Membrane Oxygenation H.M. Gonzalez Bonilla ,1 P.A. Alvarez,2 D. Hailemariam,3 R. Ogunti,3 M. Puppala,3 S.N. Homer,3 F.R. Bostan,3 J.E. Fetter,4 L. Rice.5 1Internal Medicine, Houston Methodist Hospital, Houston, TX; 2Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX; 3Houston Methodist Hospital, Houston, TX; 4Anesthesia and Critical Care, Houston Methodist Hospital, Houston, TX; 5Hematology Department, Houston Methodist Hospital, Houston, TX.
6( 32) Bivalirudin Experience in a Heterogenous VAD Population J.L. Conway ,1 A. Bates,2 D. Freed,3 R. MacArthur,4 H. Buchholz.4 1Division of Cardiology, Department of Paediatrics, University of Alberta, Stollery Children's Hospital, Edmtonton, AB, Canada; 2Division of Critical Care Medicine, Department of Paediatrics, University of Alberta, Stollery Children's Hospital, Edmtonton, AB, Canada; 3Surgery, Division of Cardiac Surgery, University of Alberta, Edmtonton, AB, Canada; 4Division of Cardiac Surgery, University of Alberta, Edmtonton, AB, Canada. Purpose: Ventricular assist devices (VADs) are an increasingly common therapy for end stage heart failure across all ages as a bridge to recovery or transplant, and more recently as destination therapy. With increasing experience, and difficulties with establishing therapeutic heparin levels we have begun to explore the effectiveness of direct thrombin inhibitors in this patient population. Methods: This is a retrospective review of all long-term VAD patients, both adult and pediatric, who were anti-coagulated with bivalirudin between 01/09-01/16. The starting dose was 0.3mg/kg/hour and dose was titrated for a goal PTT of 70-100.
Purpose: The optimal diagnostic strategy for heparin induced thrombocytopenia in ECMO is not well defined. We reviewed the use of heparin-platelet Factor IV antibody (HPF4A) testing in patients on veno-arterial extracorporeal membrane oxygenation (VAECMO). Methods: 247 patients underwent VAECMO at our center between 1/01/2006 and 12/31/2015. Patients were categorized into those tested and not tested for HPF4A. Platelet (Plt) were analyzed when available from 3 days prior (-3) to ECMO to 8 days after ECMO insertion. Percentage platelet change was defined as (Plt Day -3 minus Plt Day 0-ECMO insertion-)/Plt Day -3) *100. HPF4A was considered positive when Optical Density (OD) value was > 1. Results: 103 (41.7%) patients were tested for HPF4A. Patients tested for HPF4A had similar age (52.48vs54.88 p= 0.2201), sex (Male 68%vs63% p= 0.295), coronary artery disease (42.7%vs51.3% p = 0.129), congestive heart failure (72.8%vs63.1% p= 0.12), use of intra-aortic balloon pump (43.6%vs43.7% p= 0.99) and use of antibiotics with potential to cause thrombocytopenia (72.8%vs0.61 p= 0.07) but lower platelet counts (123.260vs181.540), hemoglobin (9.9vs10.92 p< 0.01), albumin (2.89vs3.46 p< 0.01) and fibrinogen (306.19vs371.62 p= 0.04). In addition they had a higher use of epinephrine (15%vs6.9% p= 0.03) and norepinephrine (27%vs13% p= 0.06). ECMO duration was significantly longer in patients tested 7.32vs3.57 days (p< 0.001). Only 4 (3.8%) had a positive HPF4A. The percentage platelet change was 38% in the patients tested compared to 27% in not tested. Patients who had a positive HPF4 had a 58% change. Conclusion: HPF4A testing is frequent in patients treated with VAECMO. The decision to test appears to be related to markers of increased disease severity. If a quantitatively interpretation of HPF4A is used the results are negative in > 95% of the patients. Platelet decrease was significantly higher in patients with positive HPF4A.