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384 Mechanical Circulatory Support for
Advanced Heart Failure

common with continuous-flowpumps and occurs due setting of hemorrhagic stroke, intracranial hemor-
to commissural fusion associated with reduced rates rhage, and subdural hemorrhage. Anticoagulation
of aortic valve opening. Medical management of aor- should be reversed immediately with prothrombin
tic insufficiency includes aggressive blood pressure factor concentrates or fresh frozen plasma.Warfa-
management to reduce the pressure gradientbetween rin and antiplatelet agents typically continue to be
the aorta and left ventricles. While percutaneous clo- withheld until the source ofthe hemorrhage has been
sure of the aortic valveand transcatheter aortic valve addressed or, if a source has not been identified,
replacement have been reported the best long term until the bleeding subsides and the affected area is
solution is surgical replacement. determined to be small enough to not bleed again.
In the setting of ischemic stroke, antihypertensive
Management of Pump Thrombosis and medications should be with held to allow for a high-
Pump Malfunction er systemic pressure (mean arterial pressure of 80-
90 mmHgor recovery of some pulsatility) to improve
Continuous flow devices are more likely to fail due to perfusion to the affected brain areas. In the setting
pump thrombosis rather than mechanical pump fail- of hemorrhagic stroke, intracranial hemorrhage, and
ure. In the vast majority of cases, pump thrombosis subdural hemorrhage,the blood pressure targets are
isdue to poor surgical pump or outflow graft position- lower. If the patient recovers, warfarin and aspirin are
ing, and/or suboptimal long-term anticoagulation. reinstituted upon discharge. All patients are provided
Typical presentations for pump thrombosis range with intensive in patient physical and occupational
from asymptomatic rise in plasma free hemoglobin therapy with the goal of discharging the patient to a
or lactate dehydrogenase, to hemolysis with hemo- stroke rehabilitation center to maximize their func-
globinuria, or to frank heart failure symptoms, asso- tional recovery.
ciated with ventricular assist device flow and power
elevations. Initial management strategies focus on
patient stabilization and consideration of emergent Conclusions
surgical interventions or thrombolytic agents, espe- Mechanical circulatory support devices represent a
cially in Medtronic HVAD pumps, which seem to be significant advancement in the field of heart failure.
more amenable to medical management. For these Device technology continues to evolve rapidly and
patients, low doses of tissue plasminogen activator patient survival is improving, both for those with car-
has been used in a dose of 10 mg intravenousas bo- diogenic shock and for those with chronic advanced-
lus, followed by an infusion of 10 mg over an hour, heart failure. Better patient selection, surgical tech-
with high dose unfractionated heparin (partial throm- niques and post-operative and long-term manage-
boplastin time of 70-80 s). If successful(normaliza- ment can minimize the device-related complications
tion of pump power and a decrease of lactate dehy- and allow more patients to benefit from this therapy.
drogenase levelsbelow 400 U/L), aggressive chronic It is likely than within a decade advanced heart failure
therapy should be used to prevent further thrombosis patients will benefit from a completely implantable
(INR 2.5-3). In patients with hemolysis refractory to assist device that will replace heart transplantation
intensification of antithrombotic therapy early device as the treatment of choice for advance heart failure.
exchange should be considered in order to minimize This device will provide full support, including phys-
the risk of stroke and death. iologic optimization (i.e. during exercise), will be im-
planted via a minimally invasive surgery, will enjoy
Management of Neurological Events limited complications rate, will be remotely monitored
and accessed, and will do so within cost effective
Neurological events (strokes) are relatively frequent parameters.
in patients with ventricular assist devices, with a
higher proportion of patients supported by Medtron-
ic HVADhaving hemorrhagic strokes compared to
patients supported by Abbott HeartMate II devices
(10% vs. 5%). Data from recent clinical trials havesh-
own that these events are likely due to uncontrolled
blood pressure. Ischemic strokes are equally fre-
quently seen in the two devices (5%) and are due
to suboptimal anticoagulation. All patients present-
ing with a neurological event should be hospitalized
and warfarin and antiplatelet agents withheld in the

GCDC 2017