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.

Dynamic tricuspid valve stenosis induced with a pacemaker lead: a case report.

Isolated severe tricuspid valve stenosis due to an endocardial pacemaker lead is extremely rare, and is usually caused by either fibrosis of a perforated or lacerated leaflet, or fibrotic adherence between the lead and the valvular apparatus. Reported cases typically include clinical manifestations of both systemic venous stasis and low cardiac output. The case is presented of a 20-year-old female with a surgically repaired congenital heart disease who developed severe tricuspid stenosis at six years after the implantation of a DDD pacemaker. Unexpectedly, the patient had no signs of venous stasis and suffered only from exercise intolerance. Right heart catheterization under fluoroscopic guidance revealed an atrial lead forming a loop at the level of the tricuspid valve. A paradoxical inspiratory decrease in the transvalvular diastolic gradient, caused by the caudal heart motion and straightening of the loop during inspiration, was noted. Such a dynamic nature with a temporary inspiratory relief of the obstruction may explain the partial clinical presentation of tricuspid stenosis in this case. The lead was removed and the tricuspid valve repaired surgically, after which the patient's recovery was uneventful with normalization of exercise tolerance.

Cardiac allograft vasculopathy: diagnosis, therapy, and prognosis.

Development of cardiac allograft vasculopathy represents the major determinant of long-term survival in patients after heart transplantation. Due to graft denervation, these patients seldom present with classic symptoms of angina pectoris, and the first clinical presentations are progressive heart failure or sudden cardiac death. Although coronary angiography remains the routine technique for coronary artery disease detection, it is not sensitive enough for screening purposes. This is especially the case in the first year after transplantation when diffuse and concentric vascular changes can be easily detected only by intravascular ultrasound. The treatment of the established vasculopathy is disappointing, so the primary effort should be directed toward early prevention and diagnosis. Due to diffuse vascular changes, revascularization procedures are restricted only to a relatively small proportion of patients with favorable coronary anatomy. Percutaneous coronary intervention is preferred over surgical revascularization since it leads to better acute results and patient survival. Although there is no proven long-term advantage of drug-eluting stents for the treatment of in-stent restenosis, they are preferred over bare-metal stents. Severe vasculopathy has a poor prognosis and the only definitive treatment is retransplantation. This article reviews the present knowledge on the pathogenesis, diagnosis, treatment, and prognosis of cardiac allograft vasculopathy.

Pretransplant and perioperative predictors of early heart transplantation outcomes.

Aim. To identify predictors of 3-month mortality after heart transplantation in a Croatian academic center. Methods. A retrospective review of institutional database identified 117 heart transplantations from January 2008 to July 2014. Two children <14 years were excluded from the study. The remaining 115 patients were dichotomized into survivors and non-survivors adjudicated at 3-months postoperatively, and their demographic, clinical, and longitudinal hemodynamic data were analyzed. Results. 3-month survival after heart transplantation was 86%. Non-survivors were older (59±8 vs 50±14 years, P=0.009), more likely to have previous cardiac surgery (44% vs 19%; odds ratio [OR] 3.28, 95% confidence interval [CI] 1.08-9.90; P=0.029), lower body mass index (BMI) (25±4 vs 28±2 kg/m(2), P=0.001), and be diabetics (44% vs 23%; OR 2.57, 95% CI 0.86-7.66; P=0.083). Creatinine clearance was marginally superior among survivors (59=19 vs 48 ± 20 mL/min, P=0.059). Donor age and sex did not affect outcomes. Non-survivors were more likely to have had ischemic cardiomyopathy (69% vs 32%, P=0.010). Postoperative utilization of epinephrine as a second line inotropic agent was a strong predictor of mortality (63% vs 7%; OR 21.91; 95% CI 6.15-78.06; P<0.001). Serum lactate concentrations were consistently higher among non-survivors, with the difference being most pronounced 2 hours after cardiopulmonary bypass (9.8±3.5 vs 5.2±3.2 mmol/L, P<0.001). The donor hearts exhibited inferior early hemodynamics in non-survivors (cardiac index 3.0±1.0 vs 4.0±1.1 L/min/m(2), P=0.001), stroke volume (49±24 vs 59±19 mL, P=0.063), and left and right ventricular stroke work indices (18±8 vs 30±11 g/beat/m(2), P<0.001 and 5±3 vs 7±4 g/beat/m(2), P=0.060, respectively). Non-survivors were more likely to require postoperative re-sternotomy (50% vs 12%; OR 7.25, 95% CI 2.29-22.92; P<0.001), renal replacement therapy (RRT) (69% vs 9%; OR 22.00, 95% CI 6.24-77.54; P<0.001), and mechanical circulatory assistance (MCS) (44% vs 5%; OR 14.62, 95% CI 3.84-55.62; P<0.001). Binary logistic regression revealed recipient age (P=0.024), serum lactates 2 hours after CPB (P=0.007), and epinephrine use on postoperative day 1 (P=0.007) to be independently associated with 3-month mortality. Conclusion. Pretransplant predictors of adverse outcome after heart transplantation were recipient age, lower BMI, ischemic cardiomyopathy, reoperation and diabetes. Postoperative predictors of mortality were inferior donor heart hemodynamics, epinephrine use, and serum lactate concentrations. Non-survivors were more likely to require re-sternotomy, MCS, and RRT.

Thrombosis of a biological pulmonary valve in a young patient on anticoagulant therapy with rivaroxaban: a case report.

BACKGROUND: Patients with repaired tetralogy Fallot often develop severe pulmonary regurgitation (PR) and need surgical or catheter valve replacement/implantation. Early valve failure is not expected and thrombosis of a biological valve in a mid-term period after surgery on pulmonary position is rare. CASE SUMMARY: We report a 33-year-old female patient, who presented with heart failure, 18 months after surgical implantation of a biological valve on pulmonary position for severe PR, after previous complete repair. The patient was on anticoagulant therapy with novel oral anticoagulants (NOACs) for paroxysmal atrial fibrillation. After revealing a big pulmonary valve (PV) thrombus as a cause of severe valve stenosis and right heart failure, patient was re-operated without complication. After surgery a long-term warfarin therapy was introduced. The patient had an uneventful 9-month follow-up. DISCUSSION: Thrombotic events after rivaroxaban therapy are rare in non-valvular disease and there is paucity of data for NOAC therapy related to valve thrombosis. In our case, severe heart failure 1 year and a half after PV replacement, in a patient taking anticoagulant therapy, was unexpected. The diagnosis of valve thrombosis was revealed by echocardiography, and confirmed by computed tomography. We did not find any sign of thrombophilia, or any mechanical reason for valve thrombosis.

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.