Aspirin resistance in patients with ventricular assist devices: A follow-up study.

BACKGROUND: Despite combined anticoagulation therapy consisting of a vitamin K antagonist and an antiplatelet agent, thromboembolic complications often occur in patients with a left ventricular assist device (LVAD). In addition, bleeding events are also common. Resistance to antiplatelet drugs is a well-known phenomenon; however, the utilization of laboratory chemistry testing for the presence of such resistance, and then switching therapy, is controversial. METHODS: We tested 132 patients with LVAD (HeartWare n = 57, HeartMate II n = 22, HeartMate 3 n = 53) on acetylsalicylic acid (ASA) therapy for resistance and followed them for a maximum of 7 years regarding pump thrombosis. Light transmission aggregometry (LTA) and impedance aggregometry (IPA) were performed for testing platelet function. RESULTS: We could show that patients with ASA resistance displayed an increased risk of pump thrombosis, regardless of the test used (LTA: OR = 6.20, CI [1.86-20.64], p = 0.003; IPA: OR = 12.14, CI [3.00-49.07], p < 0.001). In patients with a HeartMate 3, we could not detect any pump thrombosis associated with aspirin resistance. Furthermore, there was no significant difference in bleeding events between patients with ASA resistance and ASA responders. CONCLUSION: Laboratory testing of ASA resistance seems to be a good tool to detect an increased risk of pump thrombosis, at least for patients with a HeartWare or HeartMate II. The extent to which these thromboses can be prevented with a change of medication has to be investigated in further studies. No pump thrombosis was detected in patients with a HeartMate 3, and the question should be asked as to what constellation of underlying and concomitant diseases must be present to justify ASA therapy for these patients.

Occurrence of multiple fistulas decades after ingestion and neglect of numerous thermometers: a case report.

BACKGROUND: Ingestion of thermometers is a very rare occurrence and associated with penetrations of hollow organs. An event decades ago can lead to the development of fistulas. CASE PRESENTATION: We present a case of a 62-year-old male who swallowed multiple thermometers with a length of up to 22 cm over a period of 40 years. Diagnostic imaging presented a retroperitoneal abscess due to a duodenal perforation of the longest thermometer as well as multiple other thermometers stuck in the small intestine. After all thermometers were removed and the abscess drained, the patient showed a clinical deterioration. In further operations we found a duodeno-sigmoid fistula and a gastro-thoracal fistula, which were not visible in the initial operations and imaging. CONCLUSION: We recommend an active search for fistulas especially in the case of long-foregone ingestion.

Endovascular maneuvers for contralateral stent graft limb misplacement in endovascular aortic repair.

Cannulation and placement of the contralateral stent graft limb during endovascular aortic repair (EVAR) procedure are crucial steps as mispositioning may lead to conversion to open aortic repair. Endovascular bail-out strategies for stent graft relocation in EVAR are underreported though detailed knowledge may facilitate application and prevent conversion. We present three endovascular bail-out strategies for repositioning of a mispositioned contralateral stent graft limb. (1) Retraction of the mispositioned component with an inflated reliant balloon and placement of an interposition stent graft after successful cannulation; (2) Push-maneuver of the mispositioned stent graft into the infrarenal aortic aneurysm with an inflated reliant balloon supported by a large lumen introducer sheath and (3) Parallel placement of a second contralateral stent graft limb displacing the mispositioned one against the atrial wall in cases with adequate vessel diameter. Prevention of stent graft mispositioning by applying recognized tests to ensure correct placement are essential, following the slogan: check twice, deploy once.