Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
Advanced Heart FailureCenter of Excellence
Diagnosis of Device Thrombosis
Andrew Civitello MD, FACCMedical Director, Heart Transplant ProgramDirector, Advanced Heart Failure Fellowship
Co-Director, Advanced Heart Failure Center of ExcellenceBaylor St. Luke's Medical Center / Texas Heart Institute
Advanced Heart FailureCenter of Excellence
Adapted from Mehra et al, J Heart Lung Transplant 2014;33:1-11
Trends in Patient Profiles, LVAD Volumes and Management Strategies
Secu
lar
Tren
ds
Implant Year 2008 2009 2010 2011 2012 2013
GI bleeding and vWF deficiencyLow reported thromboembolic events
Relaxed anticoagulation targetsReduced emphasis on post-op bridging
Aortic valve pathology emergesLower pump speed for AV openingM
anag
emen
t Co
nsid
erat
ions
Spike in HeartMate IIThrombosis
Advanced Heart FailureCenter of Excellence
• Development of clot within the flow path of any the pump components:
• Inflow cannula
• Pump housing / rotor
• Outflow graft
• Thrombus may originate in the pump, or
• from the left atrium or ventricle, or
• from right sided chambers and travel through a septal defect
• And lodge in any, or all, of the pump components
Definition of Pump Thrombosis
Goldstein, J Heart Lung Transplant 2013
Advanced Heart FailureCenter of Excellence
LVAD Thrombosis
Rotor
Outflow Cannula
Inflow Cannula
Advanced Heart FailureCenter of Excellence
Scandroglio, et al J Am Coll Cardiol. 2016;67(23):2758–68
Diagnosis of Pump Thrombosis May be Elusive
Tchantchaleishvili et al Ann Cardiothorac Surg 2014;3(5);490-495
Advanced Heart FailureCenter of Excellence
Adapted from Goldstein et al, J Heart Lung Transplant 2013:32;667-670
Algorithm for the Diagnosis of Suspected LVAD Thrombosis
Advanced Heart FailureCenter of Excellence
Diagnosis of VAD Thrombosis - 2018
Adapted from Rame and Birati, J Am Coll Cardiol HF 2015;3 (11); 857-858
Assess other causes of HF or change in pump parameters
Normal
Admit to HospitalConsider intravenous anticoagulation
>3X Upper Normal Limit
Check LDH
Clinical Suspicion of VAD Thrombosis (At least one of the following):• Signs of Symptoms Suggestive of VAD thrombosis• Evidence of hemolysis• Change in pump parameters
Advanced Heart FailureCenter of Excellence
Thrombus Formation
Hemolysis, but NoHemodynamic Compromise
Incomplete Thrombosis
Hemolysis, withAbnormal PumpFunction
Complete Thrombosis
Pump Stop WithCardiogenic Shock
The Relationship Between Hemolysis and VAD Thrombosis
Blitz, Ann Cardiothorac Surg 2014;3(5):450-471
Advanced Heart FailureCenter of Excellence
Elevated LDH Levels Within 3 Months After HM II Implantation
Starling et al, N Engl J Med 2013;370:33-40
Advanced Heart FailureCenter of Excellence
Shah et al, J Heart and Lung Transplant 2014:33;102-104
LDH and Serum Free Hb as Markers of Device Thrombosis
Advanced Heart FailureCenter of Excellence
Consider Pump Exchange or OHTNo
Diagnosis of VAD Thrombosis - 2018
Adapted from Rame and Birati, J Am Coll Cardiol HF 2015;3 (11); 857-858
Diagnosis:Echo Ramp studyHigher peak powerConsider CT angioConsider RHC
Assess other causes of HF or change in pump parameters
Normal
HM II HVAD
Yes
Hemodynamically Stable?
Admit to HospitalConsider intravenous anticoagulation
>3X Upper Normal Limit
Check LDH
Clinical Suspicion of VAD Thrombosis (At least one of the following):• Signs of Symptoms Suggestive of VAD thrombosis• Evidence of hemolysis• Change in pump parameters
Advanced Heart FailureCenter of Excellence
Echocardiography for Device Thrombosis
Increased LV size by LVIDd after LVAD thrombosis
Stainback et al, J Am Soc Echocardiogr 2015;28:853-909.)
Advanced Heart FailureCenter of Excellence
Echocardiography Ramp Test - Diagnosis of Device Thrombosis
Increased AV Opening Time by M-mode
Stainback et al, J Am Soc Echocardiogr 2015;28:853-909.)
Advanced Heart FailureCenter of Excellence
Echocardiography Ramp Test - Diagnosis of Device Thrombosis
Low Velocity Inflow Cannula Peak velocity
Stainback et al, J Am Soc Echocardiogr 2015;28:853-909.)
Advanced Heart FailureCenter of Excellence
Echocardiography Ramp Test - Diagnosis of Device Thrombosis
Abnormal Inflow Cannula Colorflow
Stainback et al, J Am Soc Echocardiogr 2015;28:853-909.)
Advanced Heart FailureCenter of Excellence
Advanced Heart FailureCenter of Excellence
LVAD Ramp Study: Normal Patient LVAD Ramp Study: Thrombosis Patient
Normal vs Device Thrombosis RAMP Echo Study
Uriel et al, J Am Coll Cardiol 2012;60:1764-75
Advanced Heart FailureCenter of Excellence
Ramp Echo Study - Normal vs Device Thrombosis
Uriel et al, J Am Coll Cardiol 2012;60:1764-75
Advanced Heart FailureCenter of Excellence
Ramp Echo Study - Normal vs. Device Thrombosis
LVEDD Slopes
LDH Values
Obstruction to Flow
No Obstruction to Flow
No Obstruction to Flow
Obstruction to Flow
Uriel et al, J Am Coll Cardiol 2012;60:1764-75
No patient with VAD Thrombosis had a
LVEDD Slope <- 0.16
Best LDH Cutoff>1103
(5X ULM)
Advanced Heart FailureCenter of Excellence
LVEDD Slope > -0.16 LVEDD Slope < -0.16RAMP echo
Check for Hemolysis: LDH, Plasma Free HemoglobinCheck Anticoagulation: INR, PTT
Using RAMP Echo Studies to Predict VAD Thrombosis
Adapted from Uriel et al, J Am Coll Cardiol:60;1764-75
Suspected Device MalfunctionLDH Elevation, Power Spikes
Device Thrombosis is Likely No Device Thrombosis or Malfunction
Advanced Heart FailureCenter of Excellence
Consider Pump Exchange or OHTNo
Diagnosis of VAD Thrombosis - 2018
Adapted from Rame and Birati, J Am Coll Cardiol HF 2015;3 (11); 857-858
Diagnosis:Echo Ramp studyHigher peak powerConsider CT angioConsider RHC
Assess other causes of HF or change in pump parameters
Normal
HM II HVAD
Yes
Hemodynamically Stable?
Admit to HospitalConsider intravenous anticoagulation
>2.5X Upper Normal Limit
Check LDH
Clinical Suspicion of VAD Thrombosis (At least one of the following):• Signs of Symptoms Suggestive of VAD thrombosis• Evidence of hemolysis• Change in pump parameters
Advanced Heart FailureCenter of Excellence
Computed Tomography Angiography (CTA)
• Helpful in diagnosing mechanical issues predisposing to pump thrombosis
• Important positive findings include:
- Left ventricular thrombus
- Dilated left ventricle
- Cannula malposition toward any of the left ventricular walls
- Outflow graft thrombus, kinking or twisting
- Lack of opacification of the outflow graft
Blitz, Ann Cardiothorac Surg 2014;3(5):450-471Birati et al Curr Treat Options Cardio Med (2015) 17: 2
Advanced Heart FailureCenter of Excellence
Misdirection of the apical cannula toward the interventricular septum
Computed Tomography Angiography (CTA)
Milano et al, J Heart Lung Transplant 2011;30:838–40
Advanced Heart FailureCenter of Excellence
Computed Tomography Angiography (CTA)
Krishnan et al, J Cardiovasc Comp Tomography 2014;8:473-474
Mural thrombus in the proximal LVAD outflow cannula
Advanced Heart FailureCenter of Excellence
Consider Pump Exchange or OHTNo
Diagnosis of VAD Thrombosis - 2018
Diagnosis:• Log file analysis• Higher peak powerConsider CT angioConsider RHC
Adapted from Rame and Birati, J Am Coll Cardiol HF 2015;3 (11); 857-858
Diagnosis:Echo Ramp studyHigher peak powerConsider CT angioConsider RHC
Assess other causes of HF or change in pump parameters
Normal
HM II HVAD
Yes
Hemodynamically Stable?
Admit to HospitalConsider intravenous anticoagulation
>3X Upper Normal Limit
Check LDH
Clinical Suspicion of VAD Thrombosis (At least one of the following):• Signs of Symptoms Suggestive of VAD thrombosis• Evidence of hemolysis• Change in pump parameters
Advanced Heart FailureCenter of Excellence
RAMP Echo Slope Does Not Diagnosis HVAD Thrombosis
Uriel et al, J Cardiac Fail 2015:21;785-791
Advanced Heart FailureCenter of Excellence
HVAD Log File Analysis to Diagnosis Thrombosis
Najjar et al, J Heart Lung Transplant 2014;33:23–34
Advanced Heart FailureCenter of Excellence
HVAD Log File Analysis to Diagnosis Thrombosis
Najjar et al, J Heart Lung Transplant 2014;33:23–34
Advanced Heart FailureCenter of Excellence
Consider Pump Exchange or OHTNo
Diagnosis of VAD Thrombosis - 2018
Diagnosis:Log file analysisConsider CT angioConsider RHC
Adapted from Rame and Birati, J Am Coll Cardiol HF 2015;3 (11); 857-858
Diagnosis:Echo Ramp studyIncreased peak powerConsider CT angioConsider RHC
Assess other causes of HF or change in pump parameters
Normal
HM II HVAD
Yes
Hemodynamically Stable?
Admit to HospitalConsider intravenous anticoagulation
>3X Upper Normal Limit
Check LDH
Clinical Suspicion of VAD Thrombosis (At least one of the following):• Signs of Symptoms Suggestive of VAD thrombosis• Evidence of hemolysis• Change in pump parameters
Advanced Heart FailureCenter of Excellence
Questions?