Thrombolysis as first-line therapy for Medtronic/HeartWare HVAD left ventricular assist device thrombosis
Kamen Dimitrov1, Julian Maier2, Sigrid Sandner1
1Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
Insights
Intravenous thrombolysis (TL) is a viable first-line treatment for Medtronic/HeartWare HVAD pump thrombosis (PT), with a 61.4% success rate. However, complications are common, necessitating careful risk-benefit assessment.
Area of Science:
- Cardiology
- Medical Devices
- Thrombosis Management
Background:
- Left ventricular assist devices (LVADs) like the Medtronic/HeartWare HVAD are crucial for end-stage heart failure.
- Pump thrombosis (PT) is a significant complication associated with LVADs, impacting device function and patient outcomes.
- Effective management strategies for PT are essential to improve patient survival and quality of life.
Purpose of the Study:
- To evaluate the efficacy and safety of intravenous thrombolysis (TL) as a first-line therapy for pump thrombosis (PT) in patients with the Medtronic/HeartWare HVAD.
- To determine the success rates of TL and its impact on subsequent treatment options such as device exchange or heart transplantation.
- To identify the incidence of complications associated with TL in this patient population.
Main Methods:
- Retrospective review of institutional experience with Medtronic/HeartWare HVAD patients from March 2006 to November 2018.
- Analysis of 48 PT events in 30 patients, focusing on outcomes of intravenous Alteplase as first-line therapy.
- Comparison of TL success rates with outcomes of pump exchange or urgent heart transplantation, particularly after TL failure or contraindications.
Main Results:
- Intravenous TL was employed as first-line therapy in 44 PT events across 28 patients, achieving a 61.4% success rate.
- Over half (55.6%) of successful TL events required more than one treatment cycle.
- The combined success rate of TL followed by heart transplantation or device exchange was 81.8%.
- Fatal outcomes occurred in 15.9% of PT events, attributed to TL complications (9.1%) or multi-organ failure (6.8%).
- Thromboembolic (11.5%) and bleeding (4.5%) complications, including intracranial bleeding, were observed following TL.
Conclusions:
- Intravenous TL can be a reasonable first-line treatment for HVAD pump thrombosis, not precluding subsequent interventions.
- Significant risks of thromboembolic and bleeding complications necessitate individualized treatment decisions.
- Balancing the risks and benefits of TL versus device exchange or transplantation is crucial for optimal patient management.
Objectives:
We reviewed our institutional experience with intravenous thrombolysis (TL) as first-line therapy in patients with Medtronic/HeartWare HVAD left ventricular assist device pump thrombosis (PT).
Methods:
From March 2006 to November 2018, 30 Medtronic/HeartWare HVAD left ventricular assist device patients had 48 PT events. We analysed outcomes with intravenous Alteplase as a first-line therapy for PT. Pump exchange or urgent heart transplantation was only considered after the failure of TL or existing contraindications to TL.
Results:
TL was used as the first-line therapy in 44 PT events in 28 patients without a contraindication to TL. TL was successful in 61.4% of PT events. More than 1 cycle of TL was necessary in 55.6% of events. The combined success of TL and heart transplantation or device exchange was 81.8%. In 15.9% of events, PT was fatal. Causes of death were severe complications (9.1%) related to TL or discontinuation of therapy for multi-organ failure (6.8%). Intracranial bleeding and arterial thromboembolism were observed in 4.5% and 11.5% of the PT events after TL.
Conclusions:
Intravenous TL as a first-line therapy for PT in Medtronic/HeartWare HVAD patients can be a reasonable treatment option and does not preclude subsequent heart transplantation or device exchange. However, thromboembolic and bleeding complications are common. The decision to perform TL or device exchange should, therefore, be made on an individual basis after balancing the risks and benefits of different treatment approaches.
