Amit Badiye

Argatroban as novel therapy for suspected thrombosis in patients with continuous-flow left ventricle assist device and hemolysis

The growing use of left ventricular assist devices as a bridge to transplant and their increased duration as destination therapy in patients successfully treated for advance heart failure unwrap a new spectrum of complications seen in long-term use of the devices. Device thrombosis remains a therapeutic dilemma, and limited data are available for the use of direct thrombin inhibitors as a treatment option. We performed a review of literature and present a series of four patients with suspected left ventricular assist device-associated thrombosis, manifesting as hemolysis, who were treated empirically with argotraban, a direct thrombin inhibitor with the ability to interact with both free and clot-bound thrombin. In this case series, we treated four patients with argatroban for suspected device thrombosis. All showed significant improvement of hemolysis according to lactate dehydrogenase measurements, and device removal was prevented in three. Bleeding complications occurred when therapy was used closer to the operative period. Argatroban can be a viable option to treat patients with hemolysis from suspected device thrombosis in patients with HeartMate II continuous-flow left ventricular assist device. Prompt attention is needed to monitor any bleeding complications.

Incidence of Hemolysis in Patients with Cardiogenic Shock Treated with Impella Percutaneous Left Ventricular Assist Device.

Impella assist devices have been increasingly used in cardiogenic shock (CS). This study aims to assess the incidence of hemolysis when Impella support is used longer than 6 hours in CS. We retrospectively studied all patients who required Impella between April 2009 and September 2013. Demographic data and hemolysis indicators were sampled and analyzed using paired t-test. A total of 118 devices were placed and 40 used longer than 6 hours. The average time of support was 86.63 hours, and the 30 and 90 days of survival were 65% and 60%, respectively. After 24 hours of support, the hemoglobin (Hb) decreased significantly despite 17% of patients receiving blood transfusion (p = 0.0001). By the time of removal, 65% of patients were transfused to maintain a Hb of 10 mg/dl (p = 0.0014). The lactate dehydrogenase (LDH) increased to 5,201 U/L (n = 22; p = 0.0096), the bilirubin to 5.6 mg/dl (p = 0.008), and the haptoglobin level was 15.4 mg/dl (n = 25). The cumulative incidence of hemolysis was 62.5%. Hemolysis is a common occurrence in patients with long-term Impella support for CS, evaluated by the persistent decline in Hb and haptoglobin as well as increase in LDH and bilirubin. Strict monitoring of hemolysis parameters at baseline and at frequent intervals is crucial.

Outcomes of hemodynamic support with Impella in very high-risk patients undergoing balloon aortic valvuloplasty: Results from the Global cVAD Registry

BACKGROUND Reports on the role of hemodynamic support devices in patients with severe aortic stenosis (AS) and left ventricular (LV) dysfunction undergoing balloon aortic valvuloplasty (BAV) are limited. METHODS Patients were identified from the cVAD registry, an ongoing multicenter voluntary registry at selected sites in North America that have used Impella in >10 patients. RESULTS A total of 116 patients with AS who underwent BAV with Impella support were identified. Mean age was 80.41±9.03years and most patients were male. Mean STS score was 18.77%±18.32, LVEF was 27.14%±16.07, and 42% underwent concomitant PCI. In most cases Impella was placed electively prior to BAV, whereas 26.7% were placed as an emergency. The two groups had similar baseline characteristics except for higher prevalence of CAD and lower LVEF in the elective group, and higher STS score in the emergency group. Elective strategy was associated higher 1-year survival compared to emergency placement (56% vs. 29.2%, p=0.003). One-year survival was higher when BAV was used as a bridge to definitive therapy as opposed to palliative treatment (90% vs. 28%, p<0.001). On multivariate analysis, STS score and aim of BAV (bridge to definitive therapy vs. palliative indication) were independent predictors of mortality. CONCLUSION In this large cohort of patients with AS and severe LV dysfunction undergoing BAV, our results demonstrates feasibility and promising long-term outcomes using elective Impella support with the intention to bridge to a definitive therapy.

Endovascular crossover perfusion of lower limb in patients supported on veno-arterial extracorporeal membrane oxygenation: rescue therapy or thoughtful approach

Abstract There has been a dramatic increase in the use of Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) for hemodynamic support. Limb ischemia is a known complication of peripheral cannulation and an antegrade perfusion cannula can be inserted into the femoral or superficial femoral artery to minimize the risk of peripheral limb ischemia. Often, it is difficult to obtain antegrade access for limb perfusion due to anatomical or technical difficulties. Herein we report 5 cases in which a unique limb perfusion strategy was utilized using contralateral access for limb perfusion, as antegrade access was not feasible. To our knowledge, this is the first reported series of this approach.

Extracorporeal membrane oxygenation: Establishing a robust, tertiary extracorporeal membrane oxygenation referral center in South Florida

The age of mechanical support for failing organs is part of our routine medical care, and technology has allowed us to provide support for kidney, lung, heart, and even liver function. While this technology is still imperfect, progress is being made. This is highlighted in the realm of extracorporeal membrane oxygenation (ECMO). Over the last year, we have worked diligently to establish the adult ECMO program at Jackson Health System (JHS) in conjunction with the Miami Transplant Institute (MTI) and the University of Miami. This collaboration of institutions is known as the Miami Atlantic Southeast CArdiopulmonary REscue Network (MAS-CARE Network). Here, we describe some of the key components that established the MAS-CARE network as a robust, tertiary referral center.

A Weaning Protocol for Venovenous Extracorporeal Membrane Oxygenation With a Review of the Literature: VV ECMO WEANING PROTOCOL

Several articles have discussed the weaning process for venoarterial extracorporeal membrane oxygenation; however, there is no published report to outline a standardized approach for weaning a patient from venovenous extracorporeal membrane oxygenation (ECMO). This complex process requires an organized approach and a thorough understanding of ventilator management and ECMO physiology. The purpose of this article is to describe the venovenous ECMO weaning protocol used at our institution as well as provide a review of the literature.

Stent-Based Mechanical Thrombectomy in Left Main Coronary Artery Thrombus Presenting as ST-Segment Elevation Myocardial Infarction

The left main coronary artery (LMCA) as an infract-related artery in acute ST-segment elevation myocardial infarction (STEMI) is rare, with rates ranging from 0.8% to 1.7% of all STEMI cases [(1)][1]. Aspiration thrombectomy and AngioJet (Medrad Interventional/Possis, Minneapolis, Minnesota) have