Device thrombosis in HeartMate II continuous-flow Left ventricular assist devices: A multifactorial phenomenon
Device thrombosis in HeartMate II continuous-flow Left ventricular assist devices: A multifactorial phenomenon
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DOI：
10.1016/j.healun.2013.10.005
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发表时间：
2014-01-01
影响因子：
8.9
通讯作者：
Jorde, Ulrich P.
中科院分区：
文献类型：
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作者：
Uriel, Nir;Han, Jason;Jorde, Ulrich P.
背景：连续流左心室辅助装置(CF-LVAD)越来越多地被用于支持晚期心力衰竭(HF)患者。装置血栓形成是CF-LVADs的严重并发症，但其确切的患病率和病因尚不清楚。方法：对2009年1月1日至2012年11月15日期间植入心脏材料II(HM II)的所有植入装置血栓的患者进行根本原因分析。评估插管位置和弯曲解除完整性，并回顾图表，特别关注抗凝和感染情况。结果：177例患者中，19例(11%)在平均351+/-311天后发现各种原因的装置血栓形成，代表0.12事件/患者年。5例机械性血栓中，3例为流入管位置严重异常，2例为弯曲减压脱通畸形的流出段移植物。1例患者有高凝障碍，有动脉血栓形成史。在其余13名患者(年龄61+/-14岁，77%男性，69%高加索人)中，“非机械性”装置血栓形成发生在357+/-383天后；诊断时的INR为1.81(1.62~2.07)；平均装置速度为8,855+/-359转/分。13名患者中有5名(38%)在导致设备血栓形成的一个月内感染。值得注意的是，出院时发生非机械设备血栓的患者乳酸脱氢酶(LDH)已经升高(423[354比7661比352[272到373]U/L，p<；0.01)。结论：设备血栓是一个多因素的现象，区分机械和非机械原因是个体化诊断和治疗计划的关键步骤。需要进行更大规模的研究，排除有明显机械病因的患者，以调查设备血栓形成的生物和/或管理相关危险因素。我们的发现提示LDH可能是一个早期的危险标记物。由于治疗晚期设备血栓的困难，我们建议及早使用简单的测试来排除血栓形成的两种原因，如X射线和更密切的LDH监测(双周一次)。(C)2014年国际心肺移植学会。版权所有。
BACKGROUND: Continuous-flow left ventricular assist devices (CF-LVADs) are increasingly used to support patients with advanced heart failure (HF). Device thrombosis is a serious complication of CF-LVADs, but its precise prevalence and etiology remains uncertain.METHODS: Root-cause analysis was performed in all cases with device thrombosis confirmed upon explant among patients implanted with a HeartMate II (HM II) from January 1, 2009 to November 15, 2012. Cannula position and bend relief integrity were assessed and charts were reviewed with particular attention to anti-coagulation and infection profiles.RESULTS: Nineteen of 177 patients (11%) were found to have device thrombosis of various etiologies after a mean of 351 +/- 311 days, representing 0.12 event/patient-year. Of the 5 mechanically induced thromboses, proximate etiology was severely abnormal inflow cannula position in 3 patients and bend relief disconnect with deformed outflow graft in 2 patients. One patient had a hypercoagulable disorder with prior arterial embolism. In the remaining 13 patients (age 61 +/- 14 years, 77% male, 69% Caucasian), "non-mechanical" device thrombosis occurred after 357 +/- 383 days; INR at the time of diagnosis was 1.81 (1.62 to 2.07); and mean device speed was 8,855 +/- 359 rpm. Five of 13 patients (38%) had an infection during the month leading up to device thrombosis. Of note, lactate dehydrogenase (LDH) was already elevated at the time of discharge in patients who would later develop non-mechanical device thrombosis (423 [354 to 7661 vs 352 [272 to 373] U/liter, p < 0.01).CONCLUSIONS: Device thrombosis is a multifactorial phenomenon, and differentiation of mechanical and non-mechanical causes is an essential step for individual diagnosis and treatment plans. Larger studies excluding patients with obvious mechanical etiology are needed to investigate biologic and/or management-related risk factors for device thrombosis. Our findings suggest that LDH may be an early risk marker. Due to the difficulty in treating late-stage device thrombosis, we suggest early use of simple tests to rule out both causes of thrombosis, such as X-rays and closer LDH monitoring (bi-weekly). (C) 2014 International Society for Heart and Lung Transplantation. All rights reserved.