Abstract
The implantation of continuous – flow ventricular assist devices (VAD) is suggested to evoke angiodysplasia contributing to adverse events such as gastrointestinal bleeding. We evaluated in vivo capillary density and glycocalyx dimensions to investigate possible systemic microvascular changes in patients with chronic heart failure and VAD support vs. standard medical treatment. Forty-two patients with VAD support were compared to forty-one patients with ischemic and non-ischemic chronic heart failure (CHF) on standard pharmacotherapy and to a group of forty-two healthy subjects in a prospective cross-sectional study. Sublingual microcirculation was visualized using Sidestream Darkfield videomicroscopy and functional and perfused total capillary densities were quantified. Patients with VAD implantation were followed for one year and bleeding events were recorded. Median time after VAD implantation was 18 months. Patients were treated with centrifugal-flow devices (n = 31) or axial-flow devices (n = 11). Median functional capillary density was significantly lower in patients with VAD therapy as compared to CHF patients (196 vs. 255/mm2, p = 0.042, adjusted p-value). Functional and total capillary densities were 44% and 53% lower (both p < 0.001) in patients with VAD therapy when compared to healthy subjects. Cox regression analysis revealed loss of capillary density as a significant predictor of bleeding events during one -year follow-up of VAD patients (HR: 0.987, CI (95%): 0.977–0.998, p = 0.021 for functional and 0.992, CI (95%): 0.985–0.999, p = 0.03 for total capillary density). In conclusion, patients with VAD support exhibit capillary density rarefaction, which was associated with bleeding events. If confirmed independently, capillary impairment may be evaluated as novel marker of bleeding risk.
Highlights
The implantation of continuous – flow ventricular assist devices (VAD) is suggested to evoke angiodysplasia contributing to adverse events such as gastrointestinal bleeding
We hypothesized that rheologic alterations following the implantation of continuous-flow VAD despite macrovascular hemodynamic improvement - might be associated with systemic changes in microvascular hemodynamics, which could be visualized by in vivo sublingual videomicroscopy
Twenty-six patients with non-ischemic and 16 patients with ischemic cardiomyopathy were recruited into the VAD group
Summary
The implantation of continuous – flow ventricular assist devices (VAD) is suggested to evoke angiodysplasia contributing to adverse events such as gastrointestinal bleeding. Functional and total capillary densities were 44% and 53% lower (both p < 0.001) in patients with VAD therapy when compared to healthy subjects. Though the hemodynamics of the large vessels are greatly improved by VAD in heart failure patients as a result of the mechanical circulatory support, flow pattern changes potentially evoke stasis and the risk of pump thrombosis and stroke[2,3]. In patients with VAD treatment, adverse events such as bleeding, pump thrombosis and stroke are associated with altered hemodynamic conditions and biocompatibility[8,9,10]. We hypothesized that rheologic alterations following the implantation of continuous-flow VAD despite macrovascular hemodynamic improvement - might be associated with systemic changes in microvascular hemodynamics, which could be visualized by in vivo sublingual videomicroscopy
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