The Role of Medical Management for Acute Intravascular Hemolysis in Patients Supported on Axial Flow LVAD

Hasin, Tal*; Deo, Salil; Maleszewski, Joseph J.; Topilsky, Yan*; Edwards, Brooks S.*; Pereira, Naveen L.*; Stulak, John M.; Joyce, Lyle; Daly, Richard; Kushwaha, Sudhir S.*; Park, Soon J.

doi: 10.1097/MAT.0000000000000012
Adult Circulatory Support

Continuous flow left ventricular assist devices (LVADs) are used with good outcome. However, acute intravascular hemolysis due to thrombus in the pump remains a clinical challenge. We screened for LVAD-related intravascular hemolysis among 115 consecutive patients surviving HeartMateII implantation and investigated the role of medical therapy in resolving the hemolysis. Hemolytic events were identified in 7% of patients, 2–26 months after implant, manifested by peak lactate dehydrogenase (LDH) levels >6 times normal. With the institution of heparin and enhanced antiplatelet therapy, LDH levels receded rapidly reaching a stable trough level near baseline within 2 weeks with the resolution of clinical symptoms except in one patient who required additional therapy with tissue plasminogen activator (tPA). Complications included transient renal failure, one splenic infarct, and a cerebrovascular attack after tPA. The acute event of hemolysis resolved with medical therapy, and all were successfully discharged. However, recurrent hemolysis was common (6/8 patients over the next 1–7 months). At the end of follow-up, three patients were transplanted, one patient died refusing LVAD exchange for recurrent hemolysis, and 4 remained alive on LVAD support. Medical treatment with intensification of anticoagulation can be effective in resolving the acute hemolytic event. However, a definitive long-term strategy should be planned because the recurrence rate is high.

From the *Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota; and Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota.

Submitted for consideration March 2013; accepted for publication in revised form July 2013.

Disclosures: Drs. Hasin, Kushwaha, and Park declare accepting a nonrestricted clinical research grant from Thoratec to study endothelial function post-LVAD. Park declares consulting for Thoratec. Dr. Joyce declares accepting a clinical research grant from Thoratec to study GI bleeding post-LVAD. The remaining authors declare no conflicts of interest to disclose.

Reprint Requests: Soon J. Park, MD, Division of Cardiovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Email: park.soon@mayo.edu.

Copyright © 2014 by the American Society for Artificial Internal Organs