Abstract
Axial flow pumps are standard treatment in cases of cardiogenic shock and high-risk interventions in cardiology and cardiac surgery, although the optimal anticoagulation strategy remains unclear. We evaluated whether laboratory findings could predict bleeding complications and acquired von Willebrand syndrome (avWS) among patients who were treated using axial flow pumps. We retrospectively evaluated 60 consecutive patients who received Impella devices (Impella RP: n = 20, Impella CP/5.0: n = 40; Abiomed Inc., Danvers, USA) between January 2019 and December 2020. Thirty-two patients (53.3%) experienced major or fatal bleeding complications (Bleeding Academic Research Consortium score of > 3) despite intravenous heparin being used to maintain normal activated partial thromboplastin times (40–50 s). Extensive testing was performed for 28 patients with bleeding complications (87.5%). Relative to patients with left ventricular support, patients with right ventricular support were less likely to develop avWS (87.5% vs. 58.8%, p = 0.035). Bleeding was significantly associated with avWS (odds ratio [OR]: 20.8, 95% confidence interval [CI]: 3.3–128.5; p = 0.001) and treatment duration (OR: 1.3, 95% CI 1.09–1.55; p = 0.003). Patients with avWS had longer Impella treatment than patients without avWS (2 days [1–4.7 days] vs. 7.3 days [3.2–13.0 days]). Bleeding complications during Impella support were associated with avWS in our cohort, while aPTT monitoring was not sufficient to prevent bleeding complications. A more targeted anticoagulation monitoring might be needed for patients who receive Impella devices.
Highlights
Bleeding complications in patients who receive permanent or temporary MCS devices are associated with a risk of acquired von Willebrand syndrome[8,9,10,11,12,13,14,15]
Federici et al suggested that acquired von Willebrand syndrome (avWS) could be identified based on a history of bleeding symptoms plus reduced von Willebrand factor (vWF) activity (< 50–65 IU/dL depending on blood type) and a reduced vWF activity-to-antigen ratio (< 0.7)[20,21]
VWF activity and antigen levels are typically elevated in these settings, along with other coagulation factors, such as fibrinogen and coagulation factor VIII (FVIII), which can complicate the diagnosis of avWS
Summary
Bleeding complications in patients who receive permanent or temporary MCS devices are associated with a risk of acquired von Willebrand syndrome (avWS)[8,9,10,11,12,13,14,15]. Impaired hemostasis related to vWF abnormalities may be a risk factor for procedural bleeding. VWF activity and antigen levels are typically elevated in these settings, along with other coagulation factors, such as fibrinogen and coagulation factor VIII (FVIII), which can complicate the diagnosis of avWS. There are limited data regarding the incidence of avWS and possible bleeding complications in patients who have received Impella RP devices. This study evaluated patients who received left or right ventricular Impella support to determine whether the development of avWS was associated with bleeding complications. To the best of our knowledge, this is the largest single-center study to evaluate the relationship between avWS and bleeding complications in this setting
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