title: The vexing problem of thrombosis in long-term mechanical circulatory support.
abstract: Durable left ventricular assist devices (LVADs) have not only enhanced longevity but also conferred sustained improvements in quality of life, symptom control, and functional capacity in patients with medically refractory advanced heart failure. Problems with device-related infection, bleeding, neurologic events, right-sided heart failure, and device malfunction have dominated the clinical care of patients living on mechanical support. Even as adoption of durable LVADs accelerated globally, we began to encounter a growing dilemma of pump malfunction caused by thrombosis. In early 2011, clinicians began to notice a spike in the incidence of pump thrombosis with the HeartMate II (Thoratec Corp, Pleasanton, CA) LVAD. By 2012, the problem of thrombosis in LVADs began to consume most of the scientific direction as centers and collaborative groups began to dissect this nascent phenomenon. In this perspective, we describe the magnitude and implications of pump thrombosis, discuss secular and management trends in this unique population, attempt to dissect the problem at its root, offer guidance on surveillance and therapeutic principles, and outline issues that deserve our immediate and collaborative attention.
authors.affiliation: The Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts. Electronic address: mmehra@partners.org.
authors.forename: Mandeep R
authors.initials: MR
authors.lastname: Mehra
authors.affiliation: The Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts.
authors.forename: Garrick C
authors.initials: GC
authors.lastname: Stewart
authors.affiliation: The Daniel K. Inouye College of Pharmacy, University of Hawaii, Hilo, Hawaii.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Uber
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D004868:Equipment Failure / Q000706:statistics & numerical data; D006333:Heart Failure / Q000628:therapy*; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D015994:Incidence; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D015995:Prevalence; D013927:Thrombosis / Q000453:epidemiology* / Q000517:prevention & control; D018487:Ventricular Dysfunction, Left / Q000628:therapy*
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors
keywords: HeartMate II; HeartWare; left ventricular assist device; thrombosis