Dmitry Abramov

The Use of Eptifibatide Alone or in Combination With Heparin or Argatroban for Suspected Thrombosis in Patients With Left Ventricular Assist Devices

Pump thrombosis and hemolysis in patients with left ventricular assist devices (LVADs) are associated with significant morbidity and mortality. Intensification of anticoagulation has been suggested as potential therapy, with mixed results. The aim of this study is to assess the safety and efficacy of adding eptifibatide with or without an anticoagulation agent in managing patients with LVAD presenting with hemolysis and suspected pump thrombosis. This retrospective single center study included all patients who presented with their first episode of suspected pump thrombosis and were treated with eptifibatide with or without an anticoagulant between March 1, 2011 and July 30, 2015. A total of 27 patients (23 HeartMate II, 4 HeartWare) were identified. The average age was 55 years (range 19-75) and time from implant to event averaged 513 days (range 35-1760). The average lactate dehydrogenase on presentation was 1111 and 63% of patients had power elevations. The average international normalized ratio (INR) on admission was 2.4, with INR of ≥2 in 21/27 patients. All patients received eptifibatide: 10 received eptifibatide only, 9 received eptifibatide and argatroban, and 8 received eptifibatide and heparin. Warfarin was continued in 25/27 patients. Overall, 21 patients (77.8%) were successfully treated medically, 5 (18.5%) underwent pump exchange, and 1 (3.7%) died. There were no differences in outcomes or complications between the three treatment groups. Despite initial success, 12/21 patients developed repeat episodes of hemolysis at 1 year. The 1-year survival in the patients treated medically was 90% and surgically was 60%. Our experience indicates that medical therapy for hemolysis and suspected LVAD thrombosis with warfarin and eptifibatide alone or in combination with argatroban or heparin appears safe and may be effective, although the episodes of recurrent hemolysis after medical management remain high.

Effects of Beta Blockers and ACE Inhibitors after Left Ventricular Assist Device Implantation

While Beta blockers (BB) and Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers (ACEinh/ARB) are important components in advanced heart failure (HF) therapy, their use after left ventricular assist device (LVAD) implantation remains controversial. Concern has been raised about possible adverse effects of BB on right ventricular (RV) function while tolerance and efficacy/outcome data for ACEinh are lacking. This study aimed to characterize the use of medical therapy post-LVAD implantation and to evaluate its safety and efficacy.

Safety and Efficacy of Routine Bridging Anticoagulation for Subtherapeutic Anticoagulation in Outpatients with a Left Ventricular Assist Device

In this retrospective study, a total of 60 LVAD outpatients had 110 episodes of subtherapeutic INR noted on routine testing. 34 of these episodes were managed with parenteral bridging anticoagulation and 76 were managed with only an adjusted dose of warfarin. The rates of bleeding and thromboembolic adverse events following these episodes of subtherapeutic INR were measured to evaluate the safety and efficacy of bridging anticoagulation in this population.

Right Ventricular Failure Post Left Ventricular Assist Device Implantation

Heart failure epidemic has been on the rise over the last few decades. With limited organ donors, the number of left ventricular assist device implantation (LVAD) has been on the rise. LVAD support comes with different complications including right ventricular failure (RVF). The incidence of RVF post LVAD implantation is estimated to be around 10–40%. Mechanism of RVF post LVAD implantation has a complex pathophysiology that involves patient hemodynamics, biochemical profile, comorbidities, and pump mechanics. Predicting RVF has been an extensive area of research. Multiple risk scores have been developed to predict RVF post-op and the need of a right ventricular assist device. Moreover, multiple echocardiographic and hemodynamic parameters have been reported in the literature that could predict RVF. After diagnosis, management of RVF remains complex and involves judicious optimization of hemodynamics and biochemical profile in the perioperative period. Despite optimal management many patients will end up developing chronic RVF, which has been associated with worse outcome even among patients undergoing heart transplantation. Additionally, RVF has been reported to be a strong risk factor for acute kidney injury and progression to renal failure post LVAD implantation. This chapter reviews the pathophysiology, diagnosis, and management of RVF post LVAD implantation.

Capsule Endoscopy in Left Ventricular Assist Device Patients: Retrospective Review of Efficacy and Necessity

Background Capsule endoscopy (CE) is mainstream in the evaluation of obscure gastrointestinal bleeding (GIB) in the general population. However, the diagnostic and therapeutic impact of CE in LVAD patients susceptible to transient bleeding remains largely unexplored. This study aimed to assess the benefits of CE in the evaluation of LVAD associated GIB.