Zeljko Baricevic

Bleeding and Thrombotic Events in Patients Undergoing Mechanical Circulatory Support: A Review of Literature

Bleeding and thrombotic events are among the most common complications detected in patients with mechanical circulatory support (MCS). Herein, we reviewed the available evidence on the prevalence, etiology, and management of bleeding and thrombotic events in patients following MCS procedures, such as implantation of both intra- and paracorporeal devices that generate either pulsatile or nonpulsatile flow. Extracorporeal life support procedures providing support to the failing heart and lungs were also reviewed. Most bleeding and thromboembolic events occur despite appropriate hemostatic and anticoagulation management based on conventional coagulation laboratory parameters. Prevalence of bleeding events in this population ranges between 5 and 81%. Wide range in prevalence of bleeding reported in literature may be explained by different devices with different anticoagulation protocols being used, as well as different definitions of bleeding outcomes. Although bleeding events are more common than thromboembolic events, the consequences of thrombotic events are often detrimental. Management of bleeding events remains challenging and measures to prevent and treat bleeding events are often followed by thromboembolic events. Therefore, a personalized approach based on point-of-care hemostatic tests and adjusted to device type and patient comorbidities is therefore warranted. To provide advanced understanding of hemostatic disturbances during MCS, prospective trials focused on bleeding and thromboembolic events as primary endpoints should be conducted. Better understanding of the underlying pathophysiology and a shift towards a personalized approach based on functional point-of-care hemostatic properties assessment may provide more favorable clinical outcomes. This should, however, be coupled with further technological improvements providing better device surface hemocompatibility as interaction between blood and device surface affects the hemostatic equilibrium.

Urgent Heart Retransplant in an Adult Patient With Anthracycline-Induced Cardiomyopathy After Diffuse Large B-Cell Lymphoma - Case Report.

Heart retransplant is a treatment option for some patients with graft failure. With heart donor short-age, it is important to assess candidates carefully for cardiac retransplant. An adult patient had a successful urgent heart retransplant due to severe toxic cardiomyopathy (anthracycline-induced) after posttransplant lymphoproliferative disease that was a diffuse large B-cell lymphoma.

The change in pulmonary vascular resistance after left ventricular assist device implantation - the predictive role of platelets revisited

E-mail: marijan.pasalic@yahoo.com Purpose: While analyzing the group of patients implanted with a left ventricular assist device (LVAD) at our institution to verify which of the preand postoperative factors constitute the optimal survival outcome predictors, we determined a significant increase in postoperative pulmonary vascular resistance (PVR) values in the expired patients1. The aim of this study was to further analyze the data in order to determine which of the preoperative factors were related to the aforementioned increase in postoperative PVR values. Methods: For the 20 patients (18 M, 2 F; mean age 58.7±8.3 years) that have been implanted with an LVAD in our institution during the past 2 years, preimplantation echocardiography, right heart catheterization (RHC) and laboratory data were collected and compared according to the values of the postimplantation PVR. The groups were compared by using the adequate statistical test (t-test, Mann Whitney U test, statistical significance set at 0.05). Correlation analysis and linear regression were performed. Results: Among the 20 patients, 14 had postoperative RHC data and 4 of them were proven to have elevated PVR values (>2.4 WU). When comparing the pts. with elevated to those with normal PVR values, no significant difference was found neither in the RV function (FAC 33±7% vs 22±12%, TAPSE 1,0±0,7 cm vs 1.6±0.5 cm, NS), nor in the RV and LV dimensions (RVIDd 34±9 mm vs 35±12 mm, LVIDd 65±10 mm vs 73±9 mm). The borderline significance was found in the left ventricular EF (28±3% vs 19±8%, p=0.06) and the degree of the MR (median values 1 vs 2, p=0.05). The preoperative RHC parameters were not found to be predictive of changes in postoperative PVR (preoperative PVR 4,2±3,4 vs 3,4±1,5 WU, C.I. 1,8±0,7 vs 1,9±0,4 L/min/m, TPG 14±11 vs 13±4 mmHg and RVSWI 11,4±2,2 vs 8,9±2,1, NS). As for the laboratory values, only the platelet count significantly differed between the groups (128 ±73 vs 246±65 E3/mm, p<0.05). The correlation analysis showed a strong negative correlation between the platelet count and postoperative PVR values (r=-0,761, p<0.01). The linear regression verified the following relationship between the variables PVR=6,247-0,017xPLT, p<0.01). Conclusion: These preliminary data show that the platelet count is a significant predictor of the postoperative PVR values in patients with an LVAD (a previously shown survival predictor1). Further investigation will be conducted to explain the role of platelets in the etiology of PVR in our group of pts.

Global radial strain is reduced in healthy heart transplant patients

Cardiologia CROATICA Background: Allograft rejection and vasculopathy in heart transplant (HTx) patients require timely recognition, with coronary angiography and endomyocardial biopsy being the diagnostic gold standards. Finding a non-invasive alternative remains the major objective. Speckle tracking echocardiography (STE) permits early recognition of myocardial dysfunction. The reduction in strain has been shown to denote both rejection and vasculopathy. However, deformation indices are also reduced in “healthy” HTx recipients ≥1 year after transplantation when compared with control subjects. Whether the reduction in strain is a chronic progressive process or the immediate result of transplantation (due to allograft ischaemia, denervation, cardioplegia etc.) has not yet been established. Hence, the lack of STE reference values in HTx population, especially during early post-transplant period, is one of the reasons that strain has not been used to follow-up these patients. The aim of the study was to evaluate whether radial deformation parameters are reduced in “healthy” HTx recipients during the first post-transplant year. Methods: Two-dimensional STE was used to evaluate radial strain in 15 “healthy” patients up to 6 months following heart transplantation. Patients were excluded if they had histologic evidence of acute rejection (>1A ISHLT), reduced LVEF (<55%), significant coronary vasculopathy (epicardial coronary narrowing >50% assessed by coronary angiography), wide QRS-complex (>120 ms), significant valvular disease or major cardiac events. Frame rates of ≈50 to 70s to avoid speckle decorrelation and good image quality for accurate tracking were mandatory. Segmental radial strain analysis was performed at the LV basal, middle and apical levels, and values were averaged to determine global radial strain. The results were then compared with the healthy normal subjects’ values, using recent meta-analysis data. Results: Global radial strain was significantly lower in transplant patients when compared with control subjects — mean 39.2% (95% CI 33.5 to 44.9%) vs. 47.3% (95% CI 43.6 to 51.0%), p 0.008. Conclusions: The reduction of global radial strain in “healthy” HTx subjects during early post-transplant period may be an immediate consequence of the transplant procedure. The baseline strain values should be obtained in all transplant patients soon after the transplantation, so that these values can later be used as a reference for early detection of myocardial abnormalities.