title: Clinical outcomes with use of erythropoiesis stimulating agents in patients with the HeartMate II left ventricular assist device.
abstract: OBJECTIVE
  This study evaluated clinical outcomes associated with erythropoiesis stimulating agent (ESA) use in left ventricular assist devices (LVAD)-supported patients.
  
  
  BACKGROUND
  Use of ESAs in patients with LVADs may minimize blood transfusions and decrease allosensitization. ESAs increase thrombotic events, which is concerning because LVADs are sensitive to pump thrombosis (PT).
  
  
  METHODS
  We retrospectively reviewed 221 patients at our center who received a HeartMate II (Thoratec Corp., Pleasanton, California) LVAD between January 1, 2009 and June 6, 2013. Patients were divided into those who received ESAs during index admission (n = 121) and those who did not (n = 100). Suspected PT was defined as evidence of thrombus in the LVAD or severe hemolysis (lactate dehydrogenase >1,000 mg/dl or plasma-free hemoglobin >40 mg/dl). Outcomes were compared between cohorts using inverse probability-weighted analyses.
  
  
  RESULTS
  During a mean follow-up of 14.2 ± 11.9 months, suspected PT occurred in 37 patients (ESA 23%, no ESA 12%; p =0.03). The ESA cohort received ESAs 13.9 ± 60.9 days after LVAD implantation. At 180 days, event-free rates for suspected PT were ESA 78.6% versus no ESA 94.5% (p < 0.001). ESA use had higher rates of suspected PT (hazard ratio [HR]: 2.35; 95% confidence interval [CI]: 1.38 to 4.00; p = 0.002). For every 100-unit increase in cumulative ESA dosage, the hazard of suspected PT increased by 10% (HR: 1.10; 95% CI: 1.04 to 1.16; p < 0.001). After inverse probability weighting, ESA use was associated with a significantly higher rate of all-cause mortality (HR: 1.62; 95% CI: 1.12 to 2.33; p = 0.01).
  
  
  CONCLUSIONS
  ESA use in LVAD patients is associated with higher rates of suspected PT.
authors: Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri.
authors: Michael E
authors: ME
authors: Nassif
authors: Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
authors: Jayendrakumar S
authors: JS
authors: Patel
authors: Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri.
authors: Jerrica E
authors: JE
authors: Shuster
authors: Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri.
authors: David S
authors: DS
authors: Raymer
authors: Division of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri.
authors: Ronald
authors: R
authors: Jackups
authors: Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri.
authors: Eric
authors: E
authors: Novak
authors: Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
authors: Brian F
authors: BF
authors: Gage
authors: Division of Cardiovascular Surgery, Washington University School of Medicine, St. Louis, Missouri.
authors: Sunil
authors: S
authors: Prasad
authors: Division of Cardiovascular Surgery, Washington University School of Medicine, St. Louis, Missouri.
authors: Scott C
authors: SC
authors: Silvestry
authors: Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri.
authors: Gregory A
authors: GA
authors: Ewald
authors: Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri. Electronic address: slarue@dom.wustl.edu.
authors: Shane J
authors: SJ
authors: LaRue
mesh_terms: D000068256:Darbepoetin alfa / Q000009:adverse effects; D000068817:Epoetin Alfa / Q000009:adverse effects; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000401:mortality* / Q000628:therapy*; D006353:Heart-Assist Devices; D006397:Hematinics / Q000009:adverse effects*; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D007770:L-Lactate Dehydrogenase / Q000097:blood; D008297:Male; D008875:Middle Aged; D008923:Missouri / Q000453:epidemiology; D012189:Retrospective Studies; D013927:Thrombosis / Q000188:drug therapy / Q000453:epidemiology; D018487:Ventricular Dysfunction, Left / Q000401:mortality* / Q000628:therapy*
chemical_list: D006397:Hematinics; D006454:Hemoglobins; D000068256:Darbepoetin alfa; D000068817:Epoetin Alfa; D007770:L-Lactate Dehydrogenase
keywords: erythropoiesis stimulating agent; left ventricular assist device; thrombosis