Task Force 4: Inpatient Management of Patients with MCSD - The ...

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issues, but many times MCS patients are hospitalized at the implanting center, often on the cardiology or cardiac surgery service, for non-MCS related issues. This section of the guidelines discusses some of the more frequent issues requiring inpatient management faced by patients with MCS. Gastrointestinal Bleeding All devices require anticoagulation with warfarin, which is typically initially started after post-operative bleeding has resolved and often after a period of intravenous heparin. This anticoagulation, in addition to the initiation of antiplatelet therapy, can often result in bleeding from surgical sites and even result in late tamponade up to several weeks post-operatively as previously noted in this section. Regardless of the source of post-operative bleeding, those who have bleeding episodes have worse shortterm outcomes than those who do not. 69 The need for transfusions leads to an increased chance for HLA sensitization, which may make it more difficult to find a suitable donor organ. 70 While many patients have bleeding as a result of the type and intensity of anticoagulation, bleeding in those with continuous flow devices, particularly gastrointestinal bleeding, may be the result of an acquired von Willebrand syndrome. Large multimers of von Willebrand factor (vWF) become unfolded due to the shear forces from the impeller, which eventually leads to enzymatic breakdown of the multimers. 71 This phenomenon has been most widely described with axial flow devices, but it also occurs with centrifugal flow devices. While the loss of large multimers of vWF is nearly universal with continuous flow pumps, bleeding is not. The bleeding propensity for a patient may be related to the level of vWF activity rather than loss of large multimers. 72 Gastrointestinal bleeding is usually ascribed to gastrointestinal arteriovenous malformations, which may themselves be more likely to form in those with continuous flow devices due to reduced pulsatility or increased vasodilation. 72 Rates of gastrointestinal bleeding in studies of continuous flow devices ranges from 19-22%. 73-75 However, only about a third have been found to arise from ateriovenous malformations. 75 22
For patients who present with gastrointestinal bleeding, warfarin may be held or even reversed, depending on the severity of the bleeding and INR. Antiplatelet therapy is often discontinued as well. Anticoagulation and antiplatelet therapy typically continue to be withheld until the source of the bleeding has been addressed or, if a source has not been identified, until the bleeding subsides. Devices which require a higher INR and/or have mechanical valves are likely at the highest risk for potential thrombotic complications in these circumstances. Recommendations for Management of Anticoagulation and Antiplatelet Therapy for Patients who Present with Gastrointestinal Bleeding: Class I: 1. Anticoagulation and antiplatelet therapy should be held in the setting of clinically significant bleeding. Level of Evidence: C. 2. Anticoagulation should be reversed in the setting of an elevated INR and clinically significant bleeding. Level of Evidence: C. 3. Anticoagulation and antiplatelet therapy should continue to be held until clinically significant bleeding resolves in the absence of evidence of pump dysfunction. Level of Evidence: C. 4. The patient, device parameters, and the pump housing (if applicable) should be carefully monitored while anticoagulation and antiplatelet therapy is being withheld or dose reduced. Level of Evidence: C. A source of the gastrointestinal bleeding should be sought after addressing the level of anticoagulation, supporting the patients with transfusions, and serially following blood counts. For the first episode of bleeding, all patients should have a comprehensive assessment for a bleeding source with a focus on gastrointestinal arteriovenous malformations for those with continuous flow devices. Consultation with the gastrointestinal consultation team is often critical to focus this evaluation. A 23
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Page 5 and 6: Recommendations for Neurohormonal B
Page 7 and 8: in Task Force 3. Some surgeons elec
Page 9 and 10: MCSD surgery is advised. 19 Preoper
Page 11 and 12: catheter care. 34 The same techniqu
Page 13 and 14: 3. Pre-albumin and C-reactive prote
Page 15 and 16: those patients with learning disabi
Page 17 and 18: may also be related to the type of
Page 19 and 20: appointments after discharge from M
Page 21: domains of HRQOL (e.g., depression,
Page 25 and 26: amenable to endoscopic or surgical
Page 27 and 28: INTERMACS also mandates administrat
Page 29 and 30: 6. Discontinuation or reversal of a
Page 31 and 32: Infectious Issues The classificatio
Page 33 and 34: Level of Evidence: B. 3. A possible
Page 35 and 36: Recommendations for Inpatient Treat
Page 37 and 38: could be actuated with a hand pump
Page 39 and 40: heparin, or a heparin-alternative,
Page 41 and 42: Level of Evidence: C. Class II: 1.
Page 43 and 44: 19. Holman WL, Rayburn BK, McGiffin
Page 45 and 46: 60. McGrady A, McGinnis R, Badenhop
Page 47 and 48: 98. Cadeiras M, Nagaraj H, Kirklin
Page 49 and 50: Table 1. Causes of Deviation from N
Page 51 and 52: Table 3. Determination of MCSD Infe
Page 53: B. Deep MCSD-specific Percutaneous

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