title: Prior hematologic conditions carry a high morbidity and mortality in patients supported with continuous-flow left ventricular assist devices.
abstract: BACKGROUND
  Mechanical support leads to an increased risk of both bleeding and thrombotic events, but little is known about the risk of device support in patients with a baseline predisposition to these events. The aim of this study was to examine outcomes among patients with baseline hematologic conditions who underwent continuous-flow LVAD implantation (CF-LVAD).
  
  
  METHODS
  We retrospectively reviewed records of 286 patients who underwent CF-LVAD implantation at the Columbia University Medical Center between April 2008 and December 2013. Patients diagnosed with the following hematologic conditions were enrolled: idiopathic thrombocytopenic purpura (ITP); Factor V Leiden; elevated Factor VIII; heparin-induced thrombocytopenia (HIT); or undefined hypercoagulable state.
  
  
  RESULTS
  Of the 286 CF-LVAD patients implanted during the study period, 12 were considered to have a significant hematologic condition predisposing them to either bleeding or thrombotic events. The study included 5 patients with ITP, 1 with Factor V Leiden, 1 with elevated Factor VIII, 2 with HIT and 3 patients with undefined hypercoagulable state. Patients were supported for a total of 168.46 months, with a median of 10.76 months (IQR 4.78 to 21.36 months). There was a high frequency of thrombotic (0.57 event per patient-year), neurologic (0.36 event per patient-year) and bleeding (0.64 event per patient-year). Actuarial survival rates at 6 and 12 months were 81.8%, but fell to 49% at 2 years.
  
  
  CONCLUSIONS
  Patients with a history of prior hematologic conditions are at high risk for bleeding, thrombotic and neurologic events during device support, leading to early mortality. This case series questions the benefit of CF-LVAD in these patients and the appropriate management with regard to anti-coagulation. Further studies on the outcomes of these patients are warranted.
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York.
authors.forename: Justin
authors.initials: J
authors.lastname: Fried
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York.
authors.forename: Allison P
authors.initials: AP
authors.lastname: Levin
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York.
authors.forename: Kanika M
authors.initials: KM
authors.lastname: Mody
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York.
authors.forename: Arthur R
authors.initials: AR
authors.lastname: Garan
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York.
authors.forename: Melana
authors.initials: M
authors.lastname: Yuzefpolsakaya
authors.affiliation: Department of Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Hiroo
authors.initials: H
authors.lastname: Takayama
authors.affiliation: Division of Hematology, Department of Medicine, Columbia University Medical Center, New York, New York.
authors.forename: David L
authors.initials: DL
authors.lastname: Diuguid
authors.affiliation: Department of Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Yoshifumi
authors.initials: Y
authors.lastname: Naka
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Jorde
authors.affiliation: Division of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois. Electronic address: urielnir@gmail.com.
authors.forename: Nir
authors.initials: N
authors.lastname: Uriel
mesh_terms: D015331:Cohort Studies; D005260:Female; D006353:Heart-Assist Devices; D006402:Hematologic Diseases / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology* / Q000401:mortality; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000209:etiology / Q000401:mortality; D057234:Preoperative Period; D012189:Retrospective Studies; D013927:Thrombosis / Q000453:epidemiology / Q000209:etiology / Q000401:mortality
keywords: ITP; LVAD; bleeding; hematological conditions; hypercoagulable; mechanical circulatory support; patient selection; thrombosis