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Prediction of Hemostatic Dysfunction in Patients Implanted with the HeartMate II LVAD
Abstracts S243 range and corrected with clinical intervention. Other ROTEM parameters (angle, A20, MCF, and FIBTEM) remained consistently within the normal range. Conclusion: This study suggests that the ROTEM may be useful as a predictive monitor for hemostatic adverse events in LVAD patients, allowing for early and targeted adjustment of anticoagulant, anti-platelet medication, or other clinical intervention. 6( 57) Changes in Platelet Count After Heart Mate II Insertion Implications for Rationale Use of Anti Platelet Factor IV Antibodies P. Alvarez , M. Kassi, A.M. Cordero-Reyes, C. Uribe, P. De hoyos, A. Bhimaraj, B.H. Trachtenberg, G. Ashrith, G. Torre-Amione, L. Rice, J.D. Estep. Cardiology, Houston Methodist Hospital, Houston, TX.
6( 56) Prediction of Hemostatic Dysfunction in Patients Implanted with the HeartMate II LVAD J.M. Walenga ,1 V. Escalante,1 B. Duebner,2 G. Pemsl,2 E. Boyes,2 J. Bailey,3 A. Casillian,1 E. Pedone,3 W. Jeske,1 A. Heroux,2 E. Coglianese,2 J.P. Schwartz,1 M. Bakhos.1 1Thoracic-CV Surgery, Loyola University Medical Center, Maywood, IL; 2Heart Failure / Heart Transplant Program, Loyola University Medical Center, Maywood, IL; 3Stritch School of Medicine, Loyola University Chicago, Maywood, IL. Purpose: Left ventricular assist devices (LVADs), mechanical pumps used to augment cardiac function in heart failure patients, are effectively utilized as a bridge to transplant or destination therapy. LVAD patients can exhibit varied states of hemostasis being predisposed to bleeding or thrombosis depending upon the balance of multiple factors. Of these complex mechanisms, an induced von Willebrand factor deficiency and alterations in platelet activation pathways have been found to be, in part, responsible for bleeding. The standard warfarin monitoring does not consistently mitigate bleeding or thrombotic risk in these patients, and aspirin therapy is not monitored. To identify a means to predict the onset of adverse hemostatic events in this patient population, thrombelastography using the ROTEM instrument (EXTEM, INTEM, FIBTEM whole blood assays) was used. Methods: Under ethical board approval blood specimens were collected on patients with implanted Thoratec HeartMate II LVADs during their monthly clinic visits and when ordered by the physician. Results: Analyzing data on LVAD patients (n= 1 8) who did not experience hemostatic issues at time of blood collection, we have established ‘normal LVAD’ values for all ROTEM parameters (Clin Appl Thromb/Hemost 2012;19:249). Of 60 other patients being followed since February 2013 (average n= 1 5 samples/patient), 9 of 9 with clinical events demonstrated abnormal ROTEM parameters that were temporally associated with bleeding (hematuria, melena, anemia), thrombosis (CVA, TIA, pump thrombosis), and/or infection (UTI, bacteremia, driveline infection). The CT parameter of the EXTEM and INTEM assays (to a lesser extent the CFT) demonstrated trends in ROTEM values preceding a clinical event (increasing values = hypocoagulable; decreasing values = hypercoagulable), which occurred when the parameter became out of
Purpose: Characterize Platelets dynamics in the first 30 days after HeartMate II insertion to aid in the identification of patients with platelet factor IV antibodies. Methods: We reviewed 142 consecutive patients who underwent Heart Mate II device insertion from January 2010 to December 2012. Patients with thrombocytopenia before insertion and with a survival of less than one month were excluded from the present analysis. Preoperative and postoperative platelets at days 1-2-3-4-5-6-7-8-9-10-15-30 were recorded for each patient.Area under the curves were constructed to analyze the delta values of platelets from day 0-day 30, p-values < 0.05 were considered significant. Results: Of the 142 patients, 23 were excluded. There mean age was 56 +/-12 years and 83 % were male. As a group the platelet count nadir was in postoperative day 3. Patients with positive antiplatelet factor antibodies had a significant lower platelet count in the first two weeks of the postoperative period .(Day 0= 0.2, day 1= 0.2, day2= 0.1, day 3= 0.02, day 4= 0.04, day 5= 0.09, day 6= 0.02, day 7= 0.01, day 8= 0.06, day 9= 0.02, day 10= 0.01) after day 15 the difference was not significant. The rebound phenomenon (increase of the platelet count over the preoperative value) was seen in almost all patients in this population. We explore the impact of the degree of increase over baseline on prognosis and we observed that an increase of more than 35% was significantly associated with death (Sensitivity: 80% Specifity: 60%, AUC 0.68; p-value de 0.007). Conclusion: Lower platelets counts are seen in patients with positive anti platelet factor IV antibodies early in the postoperative period. Rebound phenomenon is common in this population and deserves further investigation.
6( 58) Nasal Mucosal Changes during Continuous Flow (CF)- LVAD Support S. Gunda , R. Jermyn, D. Casazza, C. Nucci, J. Shin, P. Loftus, A. Jackman, D. Goldstein. Cardiology, Montefiore Medical Center, Bronx, NY. Purpose: Mucosal bleeding is a frequent and significant cause of morbidity after continuous flow (CF)-LVAD support. While most attention has focused on the gastrointestinal tract, thorough evaluation is challenging. We hypothesized that the nasal mucosa may be a more accessible surrogate to study changes in microvasculature during CF-LVAD support. Therefore, we sought to systematically characterize intranasal mucosal vascular abnormalities in a cohort of CF-LVAD subjects. Methods: Subjects were prospectively recruited from the LVAD clinic at Montefiore Medical Center if they were ≥ 60 days post implantation of CF-LVAD. Systematic evaluation of intranasal vasculature was performed with nasal endoscopy using both a 0 degree and 30 degree endoscope with 3 passes into each nasal cavity. The sites of all vascular abnormalities were recorded with particular attention to areas of hemorrhage and the presence of hypervascularity, which is a risk factor for future hemorrhage.
6( 56) Prediction of Hemostatic Dysfunction in Patients Implanted with the HeartMate II LVAD J.M. Walenga ,1 V. Escalante,1 B. Duebner,2 G. Pemsl,2 E. Boyes,2 J. Bailey,3 A. Casillian,1 E. Pedone,3 W. Jeske,1 A. Heroux,2 E. Coglianese,2 J.P. Schwartz,1 M. Bakhos.1 1Thoracic-CV Surgery, Loyola University Medical Center, Maywood, IL; 2Heart Failure / Heart Transplant Program, Loyola University Medical Center, Maywood, IL; 3Stritch School of Medicine, Loyola University Chicago, Maywood, IL. Purpose: Left ventricular assist devices (LVADs), mechanical pumps used to augment cardiac function in heart failure patients, are effectively utilized as a bridge to transplant or destination therapy. LVAD patients can exhibit varied states of hemostasis being predisposed to bleeding or thrombosis depending upon the balance of multiple factors. Of these complex mechanisms, an induced von Willebrand factor deficiency and alterations in platelet activation pathways have been found to be, in part, responsible for bleeding. The standard warfarin monitoring does not consistently mitigate bleeding or thrombotic risk in these patients, and aspirin therapy is not monitored. To identify a means to predict the onset of adverse hemostatic events in this patient population, thrombelastography using the ROTEM instrument (EXTEM, INTEM, FIBTEM whole blood assays) was used. Methods: Under ethical board approval blood specimens were collected on patients with implanted Thoratec HeartMate II LVADs during their monthly clinic visits and when ordered by the physician. Results: Analyzing data on LVAD patients (n= 1 8) who did not experience hemostatic issues at time of blood collection, we have established ‘normal LVAD’ values for all ROTEM parameters (Clin Appl Thromb/Hemost 2012;19:249). Of 60 other patients being followed since February 2013 (average n= 1 5 samples/patient), 9 of 9 with clinical events demonstrated abnormal ROTEM parameters that were temporally associated with bleeding (hematuria, melena, anemia), thrombosis (CVA, TIA, pump thrombosis), and/or infection (UTI, bacteremia, driveline infection). The CT parameter of the EXTEM and INTEM assays (to a lesser extent the CFT) demonstrated trends in ROTEM values preceding a clinical event (increasing values = hypocoagulable; decreasing values = hypercoagulable), which occurred when the parameter became out of
Purpose: Characterize Platelets dynamics in the first 30 days after HeartMate II insertion to aid in the identification of patients with platelet factor IV antibodies. Methods: We reviewed 142 consecutive patients who underwent Heart Mate II device insertion from January 2010 to December 2012. Patients with thrombocytopenia before insertion and with a survival of less than one month were excluded from the present analysis. Preoperative and postoperative platelets at days 1-2-3-4-5-6-7-8-9-10-15-30 were recorded for each patient.Area under the curves were constructed to analyze the delta values of platelets from day 0-day 30, p-values < 0.05 were considered significant. Results: Of the 142 patients, 23 were excluded. There mean age was 56 +/-12 years and 83 % were male. As a group the platelet count nadir was in postoperative day 3. Patients with positive antiplatelet factor antibodies had a significant lower platelet count in the first two weeks of the postoperative period .(Day 0= 0.2, day 1= 0.2, day2= 0.1, day 3= 0.02, day 4= 0.04, day 5= 0.09, day 6= 0.02, day 7= 0.01, day 8= 0.06, day 9= 0.02, day 10= 0.01) after day 15 the difference was not significant. The rebound phenomenon (increase of the platelet count over the preoperative value) was seen in almost all patients in this population. We explore the impact of the degree of increase over baseline on prognosis and we observed that an increase of more than 35% was significantly associated with death (Sensitivity: 80% Specifity: 60%, AUC 0.68; p-value de 0.007). Conclusion: Lower platelets counts are seen in patients with positive anti platelet factor IV antibodies early in the postoperative period. Rebound phenomenon is common in this population and deserves further investigation.
6( 58) Nasal Mucosal Changes during Continuous Flow (CF)- LVAD Support S. Gunda , R. Jermyn, D. Casazza, C. Nucci, J. Shin, P. Loftus, A. Jackman, D. Goldstein. Cardiology, Montefiore Medical Center, Bronx, NY. Purpose: Mucosal bleeding is a frequent and significant cause of morbidity after continuous flow (CF)-LVAD support. While most attention has focused on the gastrointestinal tract, thorough evaluation is challenging. We hypothesized that the nasal mucosa may be a more accessible surrogate to study changes in microvasculature during CF-LVAD support. Therefore, we sought to systematically characterize intranasal mucosal vascular abnormalities in a cohort of CF-LVAD subjects. Methods: Subjects were prospectively recruited from the LVAD clinic at Montefiore Medical Center if they were ≥ 60 days post implantation of CF-LVAD. Systematic evaluation of intranasal vasculature was performed with nasal endoscopy using both a 0 degree and 30 degree endoscope with 3 passes into each nasal cavity. The sites of all vascular abnormalities were recorded with particular attention to areas of hemorrhage and the presence of hypervascularity, which is a risk factor for future hemorrhage.