Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America.
Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America.
Thromb Res. 2021 Jun;202:184-190. doi: 10.1016/j.thromres.2021.04.010. Epub 2021 Apr 19.
Chronic liver disease (CLD) and advanced heart failure (HF) often co-exist with coagulopathy and hematologic abnormalities being major concerns in this cohort. Perioperative outcomes of patients undergoing LVAD implantation can be affected by coagulopathy, associated with a higher International Normalized Ratio (INR) and cytopenias, as well as pre-operative use of antiplatelet therapy and systemic anticoagulation. Our study is aimed at evaluating the in-hospital mortality and clinical outcomes of patients with CLD who underwent LVAD implantation compared to patients who underwent LVAD implantation without CLD.
The National Inpatient Sample Database was queried from 2012 to 2017 for relevant International Classification of Diseases (ICD)-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients with chronic liver disease and those without, who underwent LVAD implantation.
A total of 22,955 patients underwent LVAD implantation, 2200 of which had CLD. There was no difference in mean age between those with and without CLD (52.8 ± 14.2 vs. 55.7 ± 15.4 years old, p < 0.001), and 23.7% of patients were female. The proportion of patients with CLD undergoing LVAD implantation trended downward between 2012 and 2017 (average annual growth rate: "-14.8%"). In-hospital post-LVAD outcomes revealed: all-cause inpatient mortality (14.8% vs. 11.1%), major bleeding (34.3% vs. 30.2%), transfusion of platelets (18.0% vs. 14.0%), subarachnoid hemorrhage (1.6% vs. 0.7%) and hospital length of stay were greater in patients with CLD (p < 0.001 for all values). LVAD thrombosis (6.6% vs. 9.4%) and postoperative ischemic stroke (3.4% vs. 6.1%) occurred less in patients with CLD (p < 0.001 for both). There were no statistically significant differences in occurrence of post-LVAD gastrointestinal bleeding and transfusion of fresh frozen plasma or packed red blood cells (p > 0.05 for all). Using a multivariate logistic regression model to adjust for confounding factors, CLD was predictive of increased in-hospital all-cause mortality in patients undergoing LVAD implantation (adjusted odds ratio: 1.29, 95% confidence interval [CI]; 1.06 to 1.56, p = 0.010).
LVAD implantation in patients with chronic liver disease was associated with increased mortality and post-LVAD major bleeding with increased utilization of platelet products yet comparable thrombotic complications. Further studies are needed to evaluate the balance and pathophysiology of bleeding risks when compared to thrombosis, as well as predictors in patients with chronic liver disease.
慢性肝病 (CLD) 和晚期心力衰竭 (HF) 常伴有凝血障碍和血液学异常，这是该队列的主要关注点。接受 LVAD 植入的患者的围手术期结局可能受到凝血障碍的影响，其特征为国际标准化比值 (INR) 和细胞减少症较高，以及术前使用抗血小板治疗和全身抗凝治疗。我们的研究旨在评估与未患有 CLD 的接受 LVAD 植入的患者相比，患有 CLD 的患者接受 LVAD 植入后的住院内死亡率和临床结局。
从 2012 年至 2017 年，通过国家住院患者样本数据库查询相关的国际疾病分类（ICD）-9 和 ICD-10 程序和诊断代码。比较患有和不患有 CLD 且接受 LVAD 植入的患者的基线特征和住院内结局。
共有 22955 名患者接受了 LVAD 植入，其中 2200 名患有 CLD。患有和不患有 CLD 的患者的平均年龄无差异（52.8±14.2 岁 vs. 55.7±15.4 岁，p<0.001），且 23.7%的患者为女性。2012 年至 2017 年间，接受 LVAD 植入的 CLD 患者比例呈下降趋势（平均年增长率：“-14.8%”）。住院后 LVAD 结果显示：全因住院死亡率（14.8% vs. 11.1%）、大出血（34.3% vs. 30.2%）、血小板输注（18.0% vs. 14.0%）、蛛网膜下腔出血（1.6% vs. 0.7%）和住院时间在 CLD 患者中更高（所有值 p<0.001）。CLD 患者的 LVAD 血栓形成（6.6% vs. 9.4%）和术后缺血性中风（3.4% vs. 6.1%）较少（所有 p<0.001）。LVAD 后胃肠道出血和新鲜冷冻血浆或浓缩红细胞输注的发生率无统计学差异（所有 p>0.05）。使用多变量逻辑回归模型调整混杂因素后，CLD 是接受 LVAD 植入的患者住院内全因死亡率增加的预测因素（调整后的优势比：1.29，95%置信区间 [CI]；1.06 至 1.56，p=0.010）。
患有慢性肝病的患者接受 LVAD 植入后死亡率增加，且与 LVAD 后主要出血相关，血小板产品的使用增加，但血栓形成并发症相似。需要进一步研究以评估与血栓形成相比出血风险的平衡和病理生理学，以及慢性肝病患者的预测因素。
