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The Enigma of Spontaneous Intra-Aortic Balloon Pump Rupture
The 21st Annual Scientific Meeting
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HFSA
S127
355 Percutaneous Repair of Continuous Flow Left Ventricular Assist Device (CF-LVAD) Outflow Graft Stenosis: Single Center Experience Tamas Alexy, Norihiko Kamioka, Jose M. Iturbe, David J. Vega, Robert T. Cole, Sonjoy R. Laskar, Vasilis Babaliaros, Michael A. Burke; Emory University, Atlanta, Georgia Hemodynamically significant outflow graft stenosis is a rare but potentially lifethreatening complication of continuous flow left ventricular assist device (CF-LVAD) therapy. Causes include outflow graft thrombosis, kinking, compression from fibrinous exudate buildup between the outflow graft and bend–relief and/or protective outer graft as well as anastomosis-site stenosis that ultimately lead to low flow alarms and symptoms consistent with heart failure. Surgical replacement is curative; however such procedures are technically challenging and carry substantial peri-operative risk. Minimally invasive percutaneous interventions are attractive alternatives but data supporting such an approach is extremely limited. Here we present a case-series of three outflow graft stenoses including HeartMate II and HeartWare devices. In all cases, patients presented with low flow alarms, reduced power and progressive fatigue with one individual developing acute pulmonary edema. Doppler echocardiography as well as dedicated contrast-enhanced cardiac CT revealed hemodynamically significant outflow graft stenosis. Up to four bare metal stents were placed under general anesthesia into the grafts reducing the gradient by 80–90%. Reported CF-LVAD flow and pump power increased significantly immediately post-procedure, permitting optimization of pump parameters. Symptoms resolved shortly after graft stenting. One patient underwent successful heart transplantation 13 months post procedure and we detected no recurrence of stenosis at an average of 5.5 months. There were no procedural complications confirming that percutaneous therapy is a safe and highly effective intervention for CFLVAD outflow graft kinking/stenosis when performed in a high-volume center by an experienced heart team.
356 Impact of First GastrointestinalBleed on Outcomes of Patients with Left Ventricular Assist Devices Michael Pfeffer, Hector Ventura, Selim Krim; Ochsner Heart and Vascular Center, New Orleans, Louisiana Background: Management of gastrointestinal bleeding (GIB) in patients with left ventricular assist devices (LVADS) vary among institutions. Data on the efficacy and safety of reduction or discontinuation of antiplatelet therapy after such events remain scarce. Methods: Single center study of 100 consecutive patients with durable LVADS. Baseline demographics, antithrombotic and antiplatelet regimen, and outcomes were first compared between patients who experienced a GIB episode (group 1) and no bleeding episode (Group 2). Anticoagulation and antiplatelet regimens were assessed before and after first bleeding episode. Additionally, impact of change in antiplatelet and anticoagulation in Group1 on future bleeding episodes, strokes and pump thrombosis were also evaluated. Results: During the study period, a total of 128 bleeding events were observed in 35 patients (Group 1, 35%). At baseline, no significant differences with regards to gender, ethnicity, BMI, history of stroke, pump speed and antiplatelet therapy were noted between the 2 groups. Group 1 was more likely to be older (Age: 60.57 ± 8.6 vs. 49.97 ± 13.3, P = .000) and have a prior history of atrial fibrillation (44.1% vs 22.6%, P = .037). Similarly, Group1 was more likely to develop pump thrombosis when compared to group 2 (17.1% vs. 0%, P = .02). 40% of Group 1 patients underwent a change in anti-platelet therapy after a bleeding episode. Although there was a trend toward lower rates of bleeding and strokes among Group 1 patients who underwent change in antiplatelet therapy these were not statistically significant (bleeding: 37.5% vs. 62.5%, P = .467; Stroke: 33.3% vs. 66.7%, P = .544) when compared to Group 1 patients with no change in therapy (Figure). Conclusions: Our study showed a high prevalence of GIB among LVAD patients and change in antiplatelet therapy after a GIB was common. Although there were lower rates of bleeding and strokes among Group 1 patients who underwent change in antiplatelet therapy these were not statistically significant. Finally, LVAD patients with GIB are at a higher risk for pump thrombosis when compared to patients with no GIB.
357 The Enigma of Spontaneous Intra-Aortic Balloon Pump Rupture Omair Ali, Ugochukwu Egolum, Joann Lindenfeld; Vanderbilt University, Nashville, Tennessee We report a series of 6 IABP ruptures, in all cases they were placed percutaneously. Regarding percutaneous vs. surgical approaches, the hemodynamic effect and inability to insert the balloon were similar. Although a femoral IABP can be inserted with relatively low risk and ease, major disadvantages include risk of infection, limited duration of support, restriction of a patient’s mobility and higher vascular complication rate. This constraint further deconditions the patient. Insertion of an IABP via the axillary artery overcomes these disadvantages. The great majority of our institutions balloon pump placements have been via the axillary route. Recently, we have moved to placing them percutaneously in the cath lab. We were surprised when we had 6 IABPs rupture in just a month. Of the events described, 5/6 events had a safe exchange with one rupture being met with a catastrophic right sided ischemic stroke, delisting from cardiac transplantation and death from withdrawal of care. Pumps were placed with percutaneous interventional via axillary approach. Amongst the 6 events, 4 ruptures happened in IABPs placed via the left axillary artery and 2 ruptures happened in IABPs placed via the right axillary artery. All cases ruptured at 1:1 trigger setting, likely from increased aortic wall contact. It is our experience, that surgical cut down approach via the left axillary artery holds the safest profile, while interventional methods via the femoral artery holds the most hazardous profile. We decided to hold on further percutaneous placement of IABPs. At present, we have regulated to surgical cut down approaches only, with preference to placement via the left axillary artery where feasible. We will observe whether the rates of rupture decrease.
•
HFSA
S127
355 Percutaneous Repair of Continuous Flow Left Ventricular Assist Device (CF-LVAD) Outflow Graft Stenosis: Single Center Experience Tamas Alexy, Norihiko Kamioka, Jose M. Iturbe, David J. Vega, Robert T. Cole, Sonjoy R. Laskar, Vasilis Babaliaros, Michael A. Burke; Emory University, Atlanta, Georgia Hemodynamically significant outflow graft stenosis is a rare but potentially lifethreatening complication of continuous flow left ventricular assist device (CF-LVAD) therapy. Causes include outflow graft thrombosis, kinking, compression from fibrinous exudate buildup between the outflow graft and bend–relief and/or protective outer graft as well as anastomosis-site stenosis that ultimately lead to low flow alarms and symptoms consistent with heart failure. Surgical replacement is curative; however such procedures are technically challenging and carry substantial peri-operative risk. Minimally invasive percutaneous interventions are attractive alternatives but data supporting such an approach is extremely limited. Here we present a case-series of three outflow graft stenoses including HeartMate II and HeartWare devices. In all cases, patients presented with low flow alarms, reduced power and progressive fatigue with one individual developing acute pulmonary edema. Doppler echocardiography as well as dedicated contrast-enhanced cardiac CT revealed hemodynamically significant outflow graft stenosis. Up to four bare metal stents were placed under general anesthesia into the grafts reducing the gradient by 80–90%. Reported CF-LVAD flow and pump power increased significantly immediately post-procedure, permitting optimization of pump parameters. Symptoms resolved shortly after graft stenting. One patient underwent successful heart transplantation 13 months post procedure and we detected no recurrence of stenosis at an average of 5.5 months. There were no procedural complications confirming that percutaneous therapy is a safe and highly effective intervention for CFLVAD outflow graft kinking/stenosis when performed in a high-volume center by an experienced heart team.
356 Impact of First GastrointestinalBleed on Outcomes of Patients with Left Ventricular Assist Devices Michael Pfeffer, Hector Ventura, Selim Krim; Ochsner Heart and Vascular Center, New Orleans, Louisiana Background: Management of gastrointestinal bleeding (GIB) in patients with left ventricular assist devices (LVADS) vary among institutions. Data on the efficacy and safety of reduction or discontinuation of antiplatelet therapy after such events remain scarce. Methods: Single center study of 100 consecutive patients with durable LVADS. Baseline demographics, antithrombotic and antiplatelet regimen, and outcomes were first compared between patients who experienced a GIB episode (group 1) and no bleeding episode (Group 2). Anticoagulation and antiplatelet regimens were assessed before and after first bleeding episode. Additionally, impact of change in antiplatelet and anticoagulation in Group1 on future bleeding episodes, strokes and pump thrombosis were also evaluated. Results: During the study period, a total of 128 bleeding events were observed in 35 patients (Group 1, 35%). At baseline, no significant differences with regards to gender, ethnicity, BMI, history of stroke, pump speed and antiplatelet therapy were noted between the 2 groups. Group 1 was more likely to be older (Age: 60.57 ± 8.6 vs. 49.97 ± 13.3, P = .000) and have a prior history of atrial fibrillation (44.1% vs 22.6%, P = .037). Similarly, Group1 was more likely to develop pump thrombosis when compared to group 2 (17.1% vs. 0%, P = .02). 40% of Group 1 patients underwent a change in anti-platelet therapy after a bleeding episode. Although there was a trend toward lower rates of bleeding and strokes among Group 1 patients who underwent change in antiplatelet therapy these were not statistically significant (bleeding: 37.5% vs. 62.5%, P = .467; Stroke: 33.3% vs. 66.7%, P = .544) when compared to Group 1 patients with no change in therapy (Figure). Conclusions: Our study showed a high prevalence of GIB among LVAD patients and change in antiplatelet therapy after a GIB was common. Although there were lower rates of bleeding and strokes among Group 1 patients who underwent change in antiplatelet therapy these were not statistically significant. Finally, LVAD patients with GIB are at a higher risk for pump thrombosis when compared to patients with no GIB.
357 The Enigma of Spontaneous Intra-Aortic Balloon Pump Rupture Omair Ali, Ugochukwu Egolum, Joann Lindenfeld; Vanderbilt University, Nashville, Tennessee We report a series of 6 IABP ruptures, in all cases they were placed percutaneously. Regarding percutaneous vs. surgical approaches, the hemodynamic effect and inability to insert the balloon were similar. Although a femoral IABP can be inserted with relatively low risk and ease, major disadvantages include risk of infection, limited duration of support, restriction of a patient’s mobility and higher vascular complication rate. This constraint further deconditions the patient. Insertion of an IABP via the axillary artery overcomes these disadvantages. The great majority of our institutions balloon pump placements have been via the axillary route. Recently, we have moved to placing them percutaneously in the cath lab. We were surprised when we had 6 IABPs rupture in just a month. Of the events described, 5/6 events had a safe exchange with one rupture being met with a catastrophic right sided ischemic stroke, delisting from cardiac transplantation and death from withdrawal of care. Pumps were placed with percutaneous interventional via axillary approach. Amongst the 6 events, 4 ruptures happened in IABPs placed via the left axillary artery and 2 ruptures happened in IABPs placed via the right axillary artery. All cases ruptured at 1:1 trigger setting, likely from increased aortic wall contact. It is our experience, that surgical cut down approach via the left axillary artery holds the safest profile, while interventional methods via the femoral artery holds the most hazardous profile. We decided to hold on further percutaneous placement of IABPs. At present, we have regulated to surgical cut down approaches only, with preference to placement via the left axillary artery where feasible. We will observe whether the rates of rupture decrease.