Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
J Heart Lung Transplant. 2017 Nov;36(11):1164-1173. doi: 10.1016/j.healun.2017.05.008. Epub 2017 May 11.
Over the past decade, continuous-flow rotary pumps have dramatically improved survival for patients with advanced systolic heart failure. Bleeding and thrombosis, however, continue to be the Achilles heel of left ventricular assist device (LVAD) therapy. There is a dynamic and complex interaction between the patient and pump. The net effect of a variety of hematologic derangements, such as hemolysis, high-molecular-weight von Willebrand degradation, platelet activation and diminished pulsatility, is poorly understood. A combination of these factors mediates the common adverse events of gastrointestinal bleeding, device thrombosis and stroke. In this review we incorporate information from translational investigations in LVAD patients to understand how continuous-flow pumps activate the coagulation system and platelets predisposing to thrombosis, while, in parallel, degrade high-molecular-weight von Willebrand factor and trigger abnormal angiogenesis predisposing to bleeding. Finally, we propose novel strategies to develop a personalized approach to anti-thrombotic monitoring and titration of anti-coagulants to minimize the bleeding and thrombotic event rates of future LVAD recipients.
在过去的十年中，连续流旋转泵极大地提高了晚期收缩性心力衰竭患者的生存率。然而，出血和血栓形成仍然是左心室辅助装置（LVAD）治疗的致命弱点。患者和泵之间存在着动态而复杂的相互作用。各种血液学紊乱的综合效应，如溶血、高分子量 von Willebrand 降解、血小板激活和脉动减弱，目前还不太清楚。这些因素共同介导了胃肠道出血、装置血栓形成和中风等常见不良事件。在这篇综述中，我们结合 LVAD 患者的转化研究信息，以了解连续流泵如何激活凝血系统和血小板导致血栓形成，同时降解高分子量 von Willebrand 因子并引发异常血管生成导致出血。最后，我们提出了新的策略来制定个性化的抗血栓监测和抗凝剂滴定方法，以最大限度地降低未来 LVAD 受者的出血和血栓形成事件发生率。
