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Low Prevalence of Acquired von Willebrand Syndrome in Japanese Recipients of Continuous-Flow Ventricular Assist Devices
Abstracts S67 Results: The HF patients had preexisting condition of oxidative stress than healthy controls as evident from the higher oxLDL and MDA levels as well as depleted SOD and TAC. Leukocyte activation in terms of higher plasma MPO and PMNelastase were also prominent in HF patients than control. Persistent oxidative stress and reduced antioxidant status were found more belligerent in HF patients with SIRS after the implantation of CF-LVAD when compared to Non-SIRS patients. Similar to oxidative stress, the activation of blood leukocyte were significantly highlighted in SIRS patients after implantation compared to Non-SIRS. Conclusion: We identified that the plasma redox status and leukocyte activation became more prominent in CF-LVAD implanted HF patients who developed SIRS. Our findings suggest that plasma biomarkers of oxidative stress and leukocyte activation are associated with the development of SIRS after CF-LVAD implant surgery.
1( 58) Stroke Subtype Impacts Outcomes and Transplant Eligibility in CF-LVADS J.Z. Willey ,1 M. Gavalas,2 A. Levin,2 A. Breskin,2 V.K. Topkara,2 M. Yuzefpolskaya,2 K. Orlanes,3 M.R. Torres,3 M. Tiburcio,3 K. Ross,3 R.A. Garan,2 K. Wong,2 U.P. Jorde,4 D.M. Mancini,2 K. Takeda,3 H. Takayama,3 Y. Naka,3 P.C. Colombo.2 1Neurology, Columbia University, New York, NY; 2Medicine, Columbia University, New York, NY; 3Surgery, Columbia University, New York, NY; 4Medicine, Montefiore Medical Center, Bronx, NY. Purpose: Stroke is one of the leading and potentially fatal complications during continuous flow-left ventricular assist device (CF-LVAD) support. Risk factors have been well described, though less is known regarding efficacy of acute treatment and outcomes. We present a large single center experience on stroke outcome and transplant eligibility by stroke subtype in CF-LVAD pts. Methods: 314 pts underwent CF-LVAD implantation (275 HMII and 39 HVAD) at our center between 1/1/2008 and 6/30/2014. Stroke was defined as a focal neurological deficit with an attributable lesion on neuroimaging. Hemorrhagic stroke (HS) was defined as intra-parenchymal bleeding, excluding subdural hematoma and hemorrhagic conversion of an ischemic stroke (IS). Treatment in IS included intra-arterial embolectomy (IAE) in large vessel occlusion(s) presenting within 6 hrs. Treatment in HS included reversal of platelet inhibition and warfarin-induced coagulopathy. After HS or IS anti-thrombotics were resumed as per our previously published algorithm. Outcomes were in-hospital mortality, discharge disposition and transplant status. Stroke severity was measured with the National Institutes of Health Stroke Scale (NIHSS). Results: 40 pts (age 55±14 yrs) suffered a stroke: 8 HS (5 HM II, 3 HVAD) and 32 IS (27 HM II, 5 HVAD). Median duration of support at the time of stroke was 100 d for HS and 76 d for IS (p= 0.28). Among 8 HS there were 5 deaths (63%) (NIHSS 19±12 vs 2±1 in survivors, p= 0.04): 3 neurological and 2 non-neurological. Among 3 HS survivors, 2 were discharged to home and 1 to nursing home; 1 (33%) was BTT: none underwent transplant. Among 32 IS, 12 had hemorrhagic conversion and 5 were treated with IAE. There were 10 deaths (31%) (NIHSS 16±10 vs 7±8 in survivors, p= 0.01): 6 neurological (5 of them after hemorrhagic conversion) and 4 non-neurological. Among the 22 IS survivors, 7 were transferred to acute in-patient rehab, 14 discharged to home and 1 to nursing home; 17 (77%) were BTT: 12 of them underwent transplant (including 2 with IAE and 5 with hemorrhagic conversion) and 2 are awaiting transplant. Conclusion: In-hospital mortality after stroke is significantly affected by the initial neurological impairment (NIHSS), with treatment unlikely to have a
significant impact in primary HS. Pts with IS may benefit from in-hospital treatment and often make sufficient recovery to be able to progress to heart transplant. 1( 59) Low Prevalence of Acquired von Willebrand Syndrome in Japanese Recipients of Continuous-Flow Ventricular Assist Devices S. Nakajima ,1 O. Seguchi,1 K. Kuroda,1 E. Hisamatsu,1 T. Sato,1 H. Sunami,1 T. Sato,1 M. Yanase,1 H. Hata,2 T. Fujita,2 J. Kobayashi,2 T. Nakatani.1 1Department of Transplantation, National Cerebral and Cardiovascular Center, Osaka, Japan; 2Department of Adult Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan. Purpose: Bleeding due to acquired von Willebrand syndrome (AVWS) has been reported to be a major complication in recipients of continuous-flow left ventricular assist devices (CF-LVAD). The objective of this study is to elucidate the actual prevalence of bleeding events during CF-LVAD support and to characterize von Willebrand factor profiles in Japanese recipients of CF-LVAD. Methods: Twenty-two Japanese patients (mean age 41.2±12.1 years, 17 males) who received Heartmate II (HM-II) between April 2013 to May 2014 were enrolled for this study. Clinical characteristics and several coagulation markers including parameters for AVWS such as von Willebrand Factor (vWF) antigen and Ristocetin cofactor assay (vWF:Rco) were prospectively examined before and more than 4 months after LVAD implantation. Highmolecular-weight vWF multimers analysis were also examined and deficiency was graded on a scale of 0 (normal) to 3 (severe loss). Bleeding was defined as the events which need transfusion of packed red blood cells or some types of intervention to achieve bleeding cessation more than 7 days after device insertion. Blood transfusion for hemolysis and drug-induced anemia was excluded from the bleeding analysis. Results: Among 22 HM-II recipients, although no patient suffered from gastrointestinal bleeding, 8 patients (36%) experienced 13 non-surgical bleeding at 155±113 days (2 epistaxis, 3 stomatorrhagia, 2 hematothorax, 1 othemorrhea, 2 cerebral hemorrhage, 1 intraperitoneal hemorrhage, 1 cardiac tamponade, 1 subcutaneous bleeding). The average international normalized ratio was 2.32±0.45 at the events. Body surface area and pump speed at chronic stage (> 1 month after CF-LVAD implantation) were1.63±0.17m2 and 8591±169rpm, respectively. The vWF:Rco was impaired (< 60%) in 11 patients (50%) and 5 patients (23%) demonstrated severe loss of HMW vWF multimers but no correlation was seen between the severity of AWVS and bleeding events. Conclusion: The results of our study demonstrate low frequency of bleeding events and low prevalence of AVWS in Japanese recipients of CF-LVAD compared with previous reports from Western countries. Small shear stress as a result of low pump speeds for small-sized body in Japanese recipients may contribute to these results. 1( 60) Fortuity or Causality in Minimally Invasive LVAD Implantation: Relation Between Outflow Graft Height of Implantation Along the Ascending Aorta and Cerebral Ischemic Events J. Bejko , T. Bottio, G. Bortolussi, M. Gallo, R. Bianco, V. Tarzia, A. Guariento, G. Gerosa. Cardiac Surgery, Padova, Italy. Purpose: To evaluate whether the site of implantation of the outflow-graft on the ascending aorta is related to the incidence of cerebral ischemic stroke events in patients undergoing minimally-invasive-LVAD-implantation. Methods: We analyzed 41 patients who underwent minimally-invasiveLVAD-implantation (Padova: January-2011-September-2014). Implantation characteristics were assessed. Accordingly the patients were divided in 3 groups: bilateral-mini-thoracotomy (Group-1) (13 patients); mini-sternotomy, with opening of the sole manubrium, associated with minithoracotomy (Group-2) (12 patients); mid-sternotomy to the forth intercostal space associated with minithoracotomy (Group-3) (16 patients). We considered immediate postoperative period the first 12 hours after LVAD-implantation. Results: The groups were comparable for preoperative risk factors, perioperative and postoperative antithrombotic therapy. The groups differed for the site of outflow vascular tract implantation on the aorta. The graft was anastomosed laterally to the middle ascending aorta in Group-1, along the ascending aorta proximal of the aortic arch in Group-2, along the tubular portion of the ascending aorta proximal to sino-tubular junction in Group-3. A total of 4 patients (12.1%) presented ischemic stroke in the immediate
1( 58) Stroke Subtype Impacts Outcomes and Transplant Eligibility in CF-LVADS J.Z. Willey ,1 M. Gavalas,2 A. Levin,2 A. Breskin,2 V.K. Topkara,2 M. Yuzefpolskaya,2 K. Orlanes,3 M.R. Torres,3 M. Tiburcio,3 K. Ross,3 R.A. Garan,2 K. Wong,2 U.P. Jorde,4 D.M. Mancini,2 K. Takeda,3 H. Takayama,3 Y. Naka,3 P.C. Colombo.2 1Neurology, Columbia University, New York, NY; 2Medicine, Columbia University, New York, NY; 3Surgery, Columbia University, New York, NY; 4Medicine, Montefiore Medical Center, Bronx, NY. Purpose: Stroke is one of the leading and potentially fatal complications during continuous flow-left ventricular assist device (CF-LVAD) support. Risk factors have been well described, though less is known regarding efficacy of acute treatment and outcomes. We present a large single center experience on stroke outcome and transplant eligibility by stroke subtype in CF-LVAD pts. Methods: 314 pts underwent CF-LVAD implantation (275 HMII and 39 HVAD) at our center between 1/1/2008 and 6/30/2014. Stroke was defined as a focal neurological deficit with an attributable lesion on neuroimaging. Hemorrhagic stroke (HS) was defined as intra-parenchymal bleeding, excluding subdural hematoma and hemorrhagic conversion of an ischemic stroke (IS). Treatment in IS included intra-arterial embolectomy (IAE) in large vessel occlusion(s) presenting within 6 hrs. Treatment in HS included reversal of platelet inhibition and warfarin-induced coagulopathy. After HS or IS anti-thrombotics were resumed as per our previously published algorithm. Outcomes were in-hospital mortality, discharge disposition and transplant status. Stroke severity was measured with the National Institutes of Health Stroke Scale (NIHSS). Results: 40 pts (age 55±14 yrs) suffered a stroke: 8 HS (5 HM II, 3 HVAD) and 32 IS (27 HM II, 5 HVAD). Median duration of support at the time of stroke was 100 d for HS and 76 d for IS (p= 0.28). Among 8 HS there were 5 deaths (63%) (NIHSS 19±12 vs 2±1 in survivors, p= 0.04): 3 neurological and 2 non-neurological. Among 3 HS survivors, 2 were discharged to home and 1 to nursing home; 1 (33%) was BTT: none underwent transplant. Among 32 IS, 12 had hemorrhagic conversion and 5 were treated with IAE. There were 10 deaths (31%) (NIHSS 16±10 vs 7±8 in survivors, p= 0.01): 6 neurological (5 of them after hemorrhagic conversion) and 4 non-neurological. Among the 22 IS survivors, 7 were transferred to acute in-patient rehab, 14 discharged to home and 1 to nursing home; 17 (77%) were BTT: 12 of them underwent transplant (including 2 with IAE and 5 with hemorrhagic conversion) and 2 are awaiting transplant. Conclusion: In-hospital mortality after stroke is significantly affected by the initial neurological impairment (NIHSS), with treatment unlikely to have a
significant impact in primary HS. Pts with IS may benefit from in-hospital treatment and often make sufficient recovery to be able to progress to heart transplant. 1( 59) Low Prevalence of Acquired von Willebrand Syndrome in Japanese Recipients of Continuous-Flow Ventricular Assist Devices S. Nakajima ,1 O. Seguchi,1 K. Kuroda,1 E. Hisamatsu,1 T. Sato,1 H. Sunami,1 T. Sato,1 M. Yanase,1 H. Hata,2 T. Fujita,2 J. Kobayashi,2 T. Nakatani.1 1Department of Transplantation, National Cerebral and Cardiovascular Center, Osaka, Japan; 2Department of Adult Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan. Purpose: Bleeding due to acquired von Willebrand syndrome (AVWS) has been reported to be a major complication in recipients of continuous-flow left ventricular assist devices (CF-LVAD). The objective of this study is to elucidate the actual prevalence of bleeding events during CF-LVAD support and to characterize von Willebrand factor profiles in Japanese recipients of CF-LVAD. Methods: Twenty-two Japanese patients (mean age 41.2±12.1 years, 17 males) who received Heartmate II (HM-II) between April 2013 to May 2014 were enrolled for this study. Clinical characteristics and several coagulation markers including parameters for AVWS such as von Willebrand Factor (vWF) antigen and Ristocetin cofactor assay (vWF:Rco) were prospectively examined before and more than 4 months after LVAD implantation. Highmolecular-weight vWF multimers analysis were also examined and deficiency was graded on a scale of 0 (normal) to 3 (severe loss). Bleeding was defined as the events which need transfusion of packed red blood cells or some types of intervention to achieve bleeding cessation more than 7 days after device insertion. Blood transfusion for hemolysis and drug-induced anemia was excluded from the bleeding analysis. Results: Among 22 HM-II recipients, although no patient suffered from gastrointestinal bleeding, 8 patients (36%) experienced 13 non-surgical bleeding at 155±113 days (2 epistaxis, 3 stomatorrhagia, 2 hematothorax, 1 othemorrhea, 2 cerebral hemorrhage, 1 intraperitoneal hemorrhage, 1 cardiac tamponade, 1 subcutaneous bleeding). The average international normalized ratio was 2.32±0.45 at the events. Body surface area and pump speed at chronic stage (> 1 month after CF-LVAD implantation) were1.63±0.17m2 and 8591±169rpm, respectively. The vWF:Rco was impaired (< 60%) in 11 patients (50%) and 5 patients (23%) demonstrated severe loss of HMW vWF multimers but no correlation was seen between the severity of AWVS and bleeding events. Conclusion: The results of our study demonstrate low frequency of bleeding events and low prevalence of AVWS in Japanese recipients of CF-LVAD compared with previous reports from Western countries. Small shear stress as a result of low pump speeds for small-sized body in Japanese recipients may contribute to these results. 1( 60) Fortuity or Causality in Minimally Invasive LVAD Implantation: Relation Between Outflow Graft Height of Implantation Along the Ascending Aorta and Cerebral Ischemic Events J. Bejko , T. Bottio, G. Bortolussi, M. Gallo, R. Bianco, V. Tarzia, A. Guariento, G. Gerosa. Cardiac Surgery, Padova, Italy. Purpose: To evaluate whether the site of implantation of the outflow-graft on the ascending aorta is related to the incidence of cerebral ischemic stroke events in patients undergoing minimally-invasive-LVAD-implantation. Methods: We analyzed 41 patients who underwent minimally-invasiveLVAD-implantation (Padova: January-2011-September-2014). Implantation characteristics were assessed. Accordingly the patients were divided in 3 groups: bilateral-mini-thoracotomy (Group-1) (13 patients); mini-sternotomy, with opening of the sole manubrium, associated with minithoracotomy (Group-2) (12 patients); mid-sternotomy to the forth intercostal space associated with minithoracotomy (Group-3) (16 patients). We considered immediate postoperative period the first 12 hours after LVAD-implantation. Results: The groups were comparable for preoperative risk factors, perioperative and postoperative antithrombotic therapy. The groups differed for the site of outflow vascular tract implantation on the aorta. The graft was anastomosed laterally to the middle ascending aorta in Group-1, along the ascending aorta proximal of the aortic arch in Group-2, along the tubular portion of the ascending aorta proximal to sino-tubular junction in Group-3. A total of 4 patients (12.1%) presented ischemic stroke in the immediate