From the Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada\.
Division of Cardiothoracic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.
ASAIO J. 2019 May/Jun;65(4):307-317. doi: 10.1097/MAT.0000000000000833.
Pump thrombosis is a major adverse event in patients supported on continuous-flow left ventricular assist devices (CF-LVAD). The aim of this systematic review and meta-analysis was to determine the outcomes of various treatment approaches for pump thrombosis, including surgical as compared to medical therapy. Electronic search was performed to identify all studies in the English literature addressing surgical and medical management of pump thrombosis in the modern CF-LVAD era. All identified articles were systematically assessed for inclusion and exclusion criteria. In the meta-analysis, because of significant overlap of the data, reports based on trials, registries, and individual cohort studies were analyzed separately. Forty-three studies were included in the analysis (2 trials, 4 registry reports, and 37 individual cohort studies). 2,281/28,728 (10.6%) patients developed pump thrombosis, of which 44.4% and 55.1% were supported on the HeartWare and HeartMate II, respectively. To avoid overlap in studies and to seek more granular data, pooled individual cohort studies were found to be representative of the entire population, and further in-depth analysis of this category was performed. Of the 610/5,545 (11.8%) patients with pump thrombosis in these individual cohort studies, 225 patients had surgical pump exchange, and 186 were treated medically. Surgical therapy resulted in higher success as compared to medical therapy (81.3% vs. 45.4%; p < 0.001), lower 30 day mortality rate (16.7% vs. 34.5%; p = 0.013) and recurrence rate (11.8% vs. 38.3%; p < 0.001). Meta-regression of all studies demonstrates a possible temporal increase of pump thrombosis rate (p = 0.040). Surgical pump exchange is superior to medical therapy with a higher success rate of pump thrombosis resolution, lower mortality rate, and lower recurrence rate. Randomized controlled prospective studies are needed to compare these clinical approaches and their resultant outcomes to guide decision-making for the management of CF-LVAD thrombosis.
泵血栓是接受连续流动左心室辅助装置（CF-LVAD）支持的患者的主要不良事件。本系统评价和荟萃分析的目的是确定各种治疗泵血栓的方法的结果，包括与药物治疗相比的手术治疗。进行了电子搜索，以确定所有在现代 CF-LVAD 时代解决泵血栓的手术和药物治疗的英文文献中的研究。对所有确定的文章进行系统评估，以确定其是否符合纳入和排除标准。在荟萃分析中，由于数据的显著重叠，根据试验、登记处和个别队列研究的报告分别进行了分析。43 项研究被纳入分析（2 项试验、4 项登记报告和 37 项个别队列研究）。2281/28728（10.6%）名患者发生泵血栓，其中 44.4%和 55.1%分别接受 HeartWare 和 HeartMate II 支持。为了避免研究重叠并寻求更详细的数据，发现汇集的个别队列研究能够代表整个人群，并对这一类进行了更深入的分析。在这些个别队列研究中，610/5545（11.8%）名发生泵血栓的患者中，有 225 名患者接受了手术泵更换，186 名患者接受了药物治疗。与药物治疗相比，手术治疗的成功率更高（81.3%对 45.4%；p <0.001），30 天死亡率（16.7%对 34.5%；p = 0.013）和复发率（11.8%对 38.3%；p <0.001）更低。所有研究的荟萃回归表明泵血栓发生率可能存在时间上的增加（p = 0.040）。与药物治疗相比，手术泵更换具有更高的血栓溶解成功率、更低的死亡率和更低的复发率。需要进行随机对照前瞻性研究，以比较这些临床方法及其结果，从而为 CF-LVAD 血栓的管理决策提供指导。
