ASAIO journal : a peer-reviewed journal of the American Society for Artificial Internal Organs
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All patients supported with continuous flow-left ventricular assist devices (CF-LVADs) develop acquired von Willebrand syndrome due to the loss of von Willebrand factor (vWF) high molecular weight (HMW) multimers and this phenomenon has been associated with clinical manifestation of bleeding diatheses. The precise timing of postoperative recovery of HMW multimers and correction of this condition after CF-LVAD explantation and heart transplantation is unknown. ⋯ Using densitometric analysis of multimer patterns, we demonstrated complete recovery of HMW multimers within the first few hours following CF-LVAD explant and OHT. These findings have critical implications in the context of perioperative bleeding diatheses in patients bridged to transplantation with a CF-LVAD.
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Gastrointestinal (GI) bleeding is the most common cause of readmission in patients supported by continuous flow left ventricular assist devices (CF-LVAD). We describe our experience in the off-label use of octreotide in the management of recurrent GI bleed in this population. Of 116 patients implanted with a CF-LVAD at our institution, seven had recurrent GI bleeding unresponsive to conventional management and were started in chronic octreotide injections. ⋯ When one patient with differing characteristics was excluded from the analysis there was a trend (p = 0.06) to a reduction of hospitalizations due to GI bleeding, number of blood transfusions, and number of endoscopic procedures. Octreotide exhibit a favorable trend in the frequency of admissions, blood transfusions, and endoscopic procedures in most patients with recurrent GI bleed. Further prospective studies are needed to clarify its benefits in this population.
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The number of patients with the failing Fontan physiology is increasing. We tested a novel in situ microaxial pump (Impella) to support the failing atrio-pulmonary Fontan circulation in an acute pig model. A Fontan model was established in eight juvenile pigs by connecting the right atrium to the main pulmonary artery after tricuspid valve destruction. ⋯ Cardiac output and stroke volume were similar during baseline and mechanically assisted Fontan (p = not significant). This acute pig study demonstrated the feasibility of mechanical circulatory support in the failing Fontan physiology. The in situ microaxial pump maintained cardiac output while increasing blood pressure and reducing venous pressure.
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Review Case Reports
Modern use of extracorporeal life support in pregnancy and postpartum.
Extracorporeal membrane oxygenation (ECMO) use during pregnancy and the postpartum period are thought to be associated with an increased risk for maternal or fetal bleeding complications. We present our recent institutional experience in managing pregnant and postpartum patients with ECMO. We also performed a literature review of modern use of ECMO in pregnant and postpartum patients utilizing Pubmed and Embase databases. ⋯ Mild-to-moderate vaginal bleeding was reported in a few cases, with rare occurrences of catastrophic postpartum hemorrhage. There was no consensus on an optimal anticoagulation strategy in these patients, though most preferred to keep anticoagulation at lower therapeutic levels. We conclude that ECMO, in well-selected pregnant and postpartum patients, appears to be safe and associated with low risk of maternal and fetal complications.
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This is a review of the University of Michigan experience with extracorporeal life support (ECLS) also known as extracorporeal membrane oxygenation (ECMO). Two thousand patients were managed with ECMO from 1973 to 2010. The first 1,000 patients were reported previously. ⋯ Intracranial bleeding or infarction occurred in 8% of patients, with a 43% survival rate. This is the largest series of ECLS at one institution reported in the world to date. Our experience has shown that ECLS saves lives of moribund patients with acute pulmonary and cardiac failure in all age groups.