Severe Pulmonary Bleeding after Assist Device Implantation: Incidence, Risk Factors and Prognostic Impact

Background: Continuous flow left ventricular assist devices (CF-LVAD) improve survival in patients with advanced heart failure but confer risk of bleeding complications. Whereas pathophysiology and risk factors for many bleeding complications are well investigated, the literature lacks reports about pulmonary bleeding. Therefore, it was the aim of the present study to assess incidence, risk factors, and clinical relevance of pulmonary bleeding episodes after LVAD implantation. Methods: We retrospectively analyzed our institutional database of 125 consecutive patients who underwent LVAD implantation between 2008 and 2017. Demographic and clinical variables related to bleeding were collected. The primary endpoint was incidence of severe pulmonary bleeding (SPB). Results: Nine out of 125 patients suffered from SPB during the postoperative course (7.2%) 11 days after surgery in the median. None of them had a known history of lung disease or bleeding disorder. History of prior myocardial infarction (0% vWD. 42.2%, p = 0.012) and ischemic cardiomyopathy (25.0% vs. 50.0%, p = 0.046) were less frequent in the SBP group. Concomitant aortic valve replacement was more common in the group with SPB (33.3% versus 7.0%, p = 0.034). Surgical (blood loss 9950 vs. 3800 mL, p = 0.012) as well as ear-nose-throat (ENT) bleedings (33% vs. 4.6%, p = 0.015) were observed more frequently in patients with SPB. SPB was associated with a complicated postoperative course with a higher incidence of acute kidney failure (100% versus 36.7%, p = 0.001) and delirium (44.4% versus 14.8%, p = 0.045); a higher need for red blood cell (26 packs versus 7, p < 0.001), fresh frozen plasma (18 units versus 6, p = 0.002), and platelet transfusion (8 pools versus 1, p = 0.001); longer ventilation time (1206 versus 171 h, p = 0.001); longer ICU-stay (58 versus 13 days, p = 0.002); and higher hospital mortality (66.7% vs. 29%, p = 0.029). Conclusion: SPB is a rare but serious complication after LVAD implantation and is significantly associated with higher morbidity and mortality. The pathophysiology and potential risk factors are unknown but may include coagulation disorders and frequent suctioning or empiric bronchoscopy causing airway irritation.