Low Incidence of Bleeding-Related Morbidity with Left Ventricular Assist Device Implantation in the Current Era
Left ventricular assist device (LVAD) implantation is historically associated with high incidence of bleeding-related complications, very high reexploration rates, and frequently massive blood transfusion. Bleeding predisposes to mortality, sepsis, allosensitization, and right ventricular failure. We present results of an integrated approach to reduce bleeding complications. Analysis of 51 implantable LVADs implanted in 50 patients (mean age 52 years; male, 45; Intragency Registry for Mechanically Assisted Circulatory Support [INTERMACS] 1 or 2, 25) in our center in 2008 and 2009, including 15 reoperations. Preoperative coagulopathy was evident in 10 patients. Our strategy included: early LVAD implantation, preoperative nutritional support and hemodynamic optimization, preferential use of continuous flow LVADs, meticulous surgical hemostasis, liberal application of tricuspid annuloplasty, and blood product utilization based on point-of-care testing. Two patients (4%) were reexplored for bleeding. Median transfusion rates intraoperatively were: blood: 2 units (interquartile range [IQR] 0-4); plasma: 0 units (0-2.75); platelets: 0 pools (0-1.75), while postoperative transfusion rates for first 48 h were blood: 1 unit (0-2); plasma: 0 units (0-0.75); and platelets: 0 pools (0,1). Right ventricular assist device was utilized in six patients (11%). Median chest tube drainage in first 24 h was 1230 mL (IQR 862-1687). Median time on ventilator was 2 days, intensive care unit was 6 days, and hospitalization was 18 days. Hospital mortality was 20%. Using an integrated approach, we have experienced bleeding and transfusion rates similar to that seen in non-LVAD complex cardiac operations. The potential to reduce bleeding reduces invasiveness of LVAD surgery, reduces allosensitization, may improve outcomes, and may increase mainstream acceptability of LVADs as definitive therapy for heart failure.
