Abstract
Background
The aim of this study was to analyze the effect of device-dependent factors on epistaxis episodes comparing patients supported with a continuous-flow left ventricular assist device (CF-LVAD) to patients under the same antithrombotic therapy.
Methods
Patients who underwent CF-LVAD between 2012 and 2018 were reviewed retrospectively from the institutionally adopted electronic database. Patients who underwent mitral valve replacement (MVR) surgery receiving the same anticoagulant and antiaggregant therapy were included as a control group. Demographics, epistaxis episodes, and nonepistaxis bleeding between the two groups were compared.
Results
A total of 179 patients met the inclusion criteria (61 patients CF-LVAD group, 118 patients MVR group). The median (range) follow-up periods for the study (CF-LVAD) and control (MVR) groups were 370 (2819) and 545.70 (2356) days, respectively. There was a significant difference for frequency of bleeding episodes per month between CF-LVAD and MVR groups (p = 0.003 < 0.05). The most common site of bleeding was the anterior septum in both groups (90.9% for the CF-MVR group and 100% for the MVR group). While 14 patients (23%) had nonepistaxis bleeding in the CF-LVAD group, only two patients (1.7%) had nonepistaxis bleeding in the MVR group. There were significant differences in nonepistaxis bleeding rates between the CF-LVAD and MVR groups (χ2=19.79, p < 0.001).
Conclusion
Both epistaxis and nonepistaxis bleeding rates were higher in the CF-LVAD group than in the MVR group. This suggests that the use of CF-LVAD support could directly increase the risk of hemorrhagic complications.
Level of evidence
2A (Etiology/Harm)
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References
Raj A, Wadhwa V, Jain A (2019) Epidemiological profile of ent emergencies: our experience. Indian J Otolaryngol Head Neck Surg 71:301–304
Beck R, Sorge M, Schneider A, Dietz A (2018) Current approaches to epistaxis treatment in primary and secondary care. Dtsch Arztebl Int 115(1–02):12–22
Traboulsi H, Alam E, Hadi U (2015) Changing trends in the management of epistaxis. Int J Otolaryngol 2015:263987
Marin E, Watelet J, Gevaert P et al (2019) Severe spontaneous epistaxis: retrospective study in a tertiary ENT centre. Eur Arch Otorhinolaryngol 276:1693–1699
Buchberger AMS, Baumann A, Johnson F et al (2018) The role of oral anticoagulants in epistaxis. Eur Arch Otorhinolaryngol 275:2035–2043
Hollowell J, Ruigómez A, Johansson S, Wallander MA, García- Rodríguez LA (2003) The incidence of bleeding complications associated with warfarin treatment in general practice in the United Kingdom. Brit J Gen Pract 53(489):312–314
Najjar SS, Slaughter MS, Pagani FD et al (2014) An analysis of pump thrombus events in patients in the HeartWare advance bridge to transplant and continued access protocol trial. J Heart Lung Transplant 33(1):23–34
Frazier OH, Rose EA, McCarthy P et al (1995) Improved mortality and rehabilitation of transplant candidates treated with a long-term implantable left ventricular assist system. Ann Surg 222(3):327–338
Rose EA, Gelijns AC, Moskowitz AJ et al (2001) Randomized evaluation of mechanical assistance for the treatment of congestive heart failure (REMATCH) study group. Long- term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 345(20):1435–1443
Crow S, John R, Boyle A et al (2009) Gastrointestinal bleeding rates in recipients of nonpulsatile and pulsatile left ventricular assist devices. J Thorac Cardiovasc Surg 137(1):208–215
Genovese EA, Dew MA, Teuteberg JJ et al (2009) Incidence and patterns of adverse event onset during the first 60 days after ventricular assist device implantation. Ann Thorac Surg 88(4):1162–1170
Pagani FD, Miller LW, Russell SD et al (2009) HeartMate II investigators extended mechanical circulatory support with a continuous-flow rotary left ventricular assist device. J Am Coll Cardiol. 54(4):312–321
Kirklin JK, Naftel DC, Kormos RL et al (2011) Third INTERMACS Annual Report: the evolution of destination therapy in the United States. J Heart Lung Transplant 30(2):115–123
Patel SR, Vukelic S, Jorde UP (2016) Bleeding in continuous flow left ventricular assist device recipients: an acquired vasculopathy? J Thorac Dis 8(10):E1321–E1327
Susen S, Rauch A, Van Belle E, Vincentelli A, Lenting PJ (2015) Circulatory support devices: fundamental aspects and clinical management of bleeding and thrombosis. J Thromb Haemost 13(10):1757–1767
Fiore M, James C, Mouton C, Calderon J, Barandon L, Ouattara A, Picard F (2014) Assessment of platelet function with light transmission aggregometry in 24 patients supported with a continuous- flow left ventricular assist device: a single-center experience. J Thorac Cardiovasc Surg 148:3119–3125
Fressinaud E, Meyer D (1993) International survey of patients with von Willebrand disease and angiodysplasia. Thromb Haemost 70:546
Meyer AL, Malehsa D, Budde U, Bara C, Haverich A, Strueber M (2014) Acquired von Willebrand syndrome in patients with a centrifugal or axial continuous flow left ventricular assist device. JACC Heart Fail 2(2):141–145
Crow S, Chen D, Milano C et al (2010) Acquired von Willebrand syndrome in continuous-flow ventricular assist device recipients. Ann Thorac Surg 90(4):1263–1269
Uriel N, Pak SW, Jorde UP et al (2010) Acquired von Willebrand syndrome after continuous-flow mechanical device support contributes to a high prevalence of bleeding during long-term support and at the time of transplantation. J Am Coll Cardiol 56(15):1207–1213
Brown CS, Hachem R, Jang DW (2018) Management of epistaxis in patients with ventricular assist device: a retrospective review. J Otolaryngol Head Neck Surg 47(1):48
Biggs TC, Baruah P, Mainwaring J, Harries PG, Salib RJ (2013) Treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients. J Laryngol Otol 127:483–488
Bola S, Marsh R, Braggins S, Potter C, Hickey S (2016) Does the continuation of warfarin change management outcomes in epistaxis patients? J Laryngol Otol 130:256–260
Stadler RR, Kindler R, Holzmann D et al (2016) The long-term fate of epistaxis patients with exposure to antithrombotic medication. Eur Arch Otorhinolaryngol 273:2561–2567
Holmes DR Jr, Kereiakes DJ, Kleiman NS, Moliterno DJ, Patti G, Grines CL (2009) Combining antiplatelet and anticoagulant therapies. J Am Coll Cardiol 54:95–109
Paikin JS, Wright DS, Eikelboom JW (2011) Effectiveness and safety of combined antiplatelet and anticoagulant therapy: a critical review of the evidence from randomized controlled trials. Blood Rev 25:123–129
Schaffer JM, Arnaoutakis GJ, Allen JG et al (2011) Bleeding complications and blood product utilization with left ventricular assist device implantation. Ann Thorac Surg 91:740–747
Dassanayaka S, Slaughter MS, Bartoli CR (2013) Mechanistic pathway (s) of acquired von Willebrand syndrome with a continuous-flow ventricular assist device: in vitro findings. ASAIO J 59:123–129
Meyer AL, Malehsa D, Bara C et al (2010) Acquired von Willebrand syndrome in patients with an axial flow left ventricular assist device. Circ Heart Fail 3:675–681
Starke RD, Ferraro F, Paschalaki KE et al (2011) Endothelial von Willebrand factor regulates angiogenesis. Blood 117:1071–1080
Baghai M, Heilmann C, Beyersdorf F et al (2015) Platelet dysfunction and acquired von Willebrand syndrome in patients with left ventricular assist devices. Eur J Cardiothorac Surg 48:421–427
Wever-Pinzon O, Selzman CH, Drakos SG et al (2013) Pulsatility and the risk of nonsurgical bleeding in patients supported with the continuous-flow left ventricular assist device HeartMate II. Circ Heart Fail 6:517–526
Bhat P, Nassif ME, Vader JM et al (2014) Epistaxis in patients with left ventricular assist devices - incidence, risk factors, and implications. J Heart Lung Transplant 33:256
Rudmik L, Smith TL (2012) Management of intractable spontaneous epistaxis. Am J Rhinol Allergy 26(1):55–60
Miller LW, Pagani FD, Russell SD et al (2007) Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 357:885–896
Kirklin JK, Naftel DC, Pagani FD et al (2014) Sixth INTERMACS annual report: a 10.000-patient database. J Heart Lung Transplant 33:555–564
Stulak JM, Lee D, Haft JW et al (2014) Gastrointestinal bleeding and subsequent risk of thromboembolic events during support with a left ventricular assist device. J Heart Lung Transplant 33:60–64
Borel-Derlon A, Federici AB, Roussel-Robert V et al (2007) Treatment of severe von Willebrand disease with a high-purity von Willebrand factor concentrate (Wilfactin): a prospective study of 50 patients. J Thromb Haemost 5:1115–1124
Fischer Q, Huisse MG, Voiriot G et al (2015) Von Willebrand factor, a versatile player in gastrointestinal bleeding in left ventricular assist device recipients? Transfusion 55:51–54
Cushing M, Kawaguchi K, Friedman KD, Mark T (2012) Factor VIII/ von Willebrand factor concentrate therapy for ventricular assist device-associated acquired von Willebrand disease. Transfusion 52:1535–1541
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The authors would like to thank Wiley Editing Services for English language editing.
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This retrospective study was performed after approval of the Ethical Committee of the University Hospital (Baskent University Medical and Health Sciences Research Council and Ethics Committee, KA 19/90) and has been performed according to the ethical standards of the Helsinki Declaration.
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Koycu, A., Vural, O., Bahcecitapar, M. et al. Device-related epistaxis risk: continuous-flow left ventricular assist device-supported patients. Eur Arch Otorhinolaryngol 277, 2767–2773 (2020). https://doi.org/10.1007/s00405-020-06127-z
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DOI: https://doi.org/10.1007/s00405-020-06127-z