International Society For Minimally Invasive Cardiothoracic Surgery

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Effective Strategy Of Rescue Treatment For Acute Pump Thrombosis In Patients With High Risk Of Bleeding Complications.
Anna Kędziora, Karol Wierzbicki, Izabela Górkiewicz-Kot, Maciej Stąpór, Dorota Sobczyk, Hubert Hymczak, Irena Milaniak, Michał Kaleta, Jacek Piątek, Bogusław Kapelak.
John Paul II Hospital, Kraków, Poland.

Background: Left ventricular assist devices (LVADs) are an attractive alternative to heart transplantation (HTX). Based on international data, LVADs are now being used for months to years in patients who will either face a long-term wait on the transplant list or in patients who are not eligible for transplantation as destination therapy. Nevertheless, thrombotic events remain a frequent complication that contribute significantly to patient mortality. The study presents an effective method of rescue treatment strategy for pump thrombosis (PT) in patients with high risk of bleeding complications, which was developed and successfully implemented in our Institution. Methods: The treatment strategy proposal is based on a our experience with managing 3 consecutive patients, who underwent LVAD implantation and presented symptoms of PT on emergent admission. All patients initially underwent LVAD implantation as a bridge to HTX and remained on an active, but not urgent, transplant list. All patients were evaluated to be at a high risk of bleeding complications when considering standard thrombolysis approach for PT. Results: All patients received intravenous unfractionated heparin bolus as soon as the PT diagnosis was established, however, no response to the treatment was observed and a constant increase in LVAD power consumption was noted. Facing this emergent need of rescue strategy and high-risk of bleeding complications, the decision was made to introduce thrombolytic treatment guided by the power consumption and flow curves. Thrombolysis was achieved with intravenous tissue plasminogen activator drip (50 mg/50 ml; starting flow 30ml/h), which resulted in quick but step-wise LVAD power consumption drop. The therapy was maintained until initial LVAD parameters were achieved, which was dynamically observed and analyzed on the power consumption and flow curves. In two patients PT reoccurred within the same hospitalization and thrombolytic treatment was implemented successfully once and twice again following the same strategy. Currently, within median follow-up of 9 months since the PT, all patients remain well presenting NYHA class I. Conclusions: Proposed treatment that combines thrombolysis using tissue plasminogen activator drip with constant LVAD parameters monitoring is a safe method of rescue therapy for PT in patients with high risk of bleeding complications.

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