© 2014 Wiley Periodicals, Inc.
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PERIOPERATIVE MANAGEMENT_____________________________________________________
Amphetamine Abuse as a Rare Cause of Recurrent LVAD Pump Thrombosis Christian Heim, M.D., Markus Kondruweit, M.D., Michael Weyand, M.D., and Rene Tandler, M.D. Department of Cardiac Surgery, University of Erlangen-Nuremberg, Germany ABSTRACT We report a patient with recurrent left ventricular assist device (LVAD) thrombosis due to amphetamine addiction. The management of this complication is reviewed. doi: 10.1111/jocs.12504 (J Card
Surg 2015;30:215–216)
Our experience with third-generation continuousflow, centrifugal left ventricular assist devices (LVADs) suggests a relatively lower rate of pump thrombosis in HeartWare HVAD1 (HeartWare, Framingham, MA, USA) patients compared with other continuous flow devices.1 We report another etiology for LVAD pump thrombosis–amphetamine abuse. PATIENT PROFILE A 44-year-old male experienced his third pump thrombosis after HVAD implantation despite well adjusted coagulation status using phenprocoumon (international normalized ratio [INR] 2.0–2.5) and ASA/ dypiridamol. In Februrary 2013, LVAD implantation was performed due to cardiogenic shock as a result of a nonischemic dilated cardiomyopathy. Lactatedehydrogenase (LDH) and hydroxybutyrate dehydrogenase (aHBDH) levels dropped to normal values and remained unremarkable. The patient was released home and followed up in our outpatient care unit. The patient presented with LVAD alarms due to power consumption elevations six month after LVAD implantation. LDH levels were 4122 U/L (>16 times greater the upper limit of normal). Therefore, an intravenous thrombolysis (50 mg Alteplase i.v., 20 mg i.v. infusion over 60 minutes, then remaining 30 mg over next three hours, Actilyse1 [Boehringer Ingelheim RCV, Wien, Austria]) was performed in order to resolve
Conflicts of interest: The authors acknowledge no conflict of interest in the submission.
the thrombosis.2,3 After normalization of clinical and laboratory values, a malposition of the inflow cannula was excluded by chest X-ray. A transthoracic echocardiogram (TTE) was performed to exclude a LV thrombus or thrombus in the aortic root. Online data analysis using the HeartWare online support revealed complete recovery from the LVAD thrombus. A second antiplatelet agent (dipyridamole) was added to the antithrombotic therapy. The patient recovered and was sent home. LDH levels dropped to normal values on followup. Every four weeks, laboratory values and power curves on the HeartWare1 monitor were routinely checked. Four months later the patient presented again with LVAD alarms due to power elevations. LDH levels were elevated (3497U/L) and therefore thrombolytics were again administered. Clinical LVAD measurements and laboratory values normalized again. Outpatient follow-ups were completely uneventful with normal LDH levels and INR values in range (INR 2.0–2.5). Fourteen months after LVAD implantation, the patient again developed a pump thrombosis (LDH 5845 U/L; >23 times greater the upper limit of normal). Thrombolysis was performed to resolve the thrombus once again. Analysis of the coagulation status did not reveal an explanation for the recurrent pump thrombosis. Even though drug abuse was denied by the patient, a drug screening test was performed. Positive amphetamine and methamphetamine findings were detected and explained the recurrent pump thrombosis. Institutional review board approval and written, informed consent were obtained to report this case.
Disclosures: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript to disclose.
DISCUSSION
Address for correspondence: Christian Heim, M.D., Krankenhausstr.12, 91054 Erlangen, Germany. Fax: þ49 9131 85-32768; e-mail: [email protected]
Amphetamines are known to be prothrombotic by inducing tissue factor, the main trigger of coagulation, and thereby involved in arterial thrombus formation.4
216
HEIM, ET AL. AMPHETAMINE ABUSE AND RECURRENT LVAD THROMBOSIS
A number of reports about amphetamine-associated acute vascular syndromes have been published, including vasculitis, vasospasm, and prothrombotic states.5–8 On the basis of these reports and the previously published paper by Gebhard et al.,4 we performed a drug screening test in our patient, although drug intake was denied by the patient. The results revealed positive findings for amphetamines and methamphetamines. In conclusion, amphetamine abuse is a rare cause of recurrent LVAD pump thrombosis, especially in young men. In view of otherwise unexplainable recurrent pump thrombosis, a drug screening test should be considered in young patients at an early stage, especially in high-risk regions for amphetamine consumption. REFERENCES 1. Aaronson KD, Slaughter MS, Miller LW, et al: Use of an intrapericardial, continuous-flow, centrifugal pump in patients awaiting heart transplantation. Circulation 2012; 125:3191–3200.
J CARD SURG 2015;30:215–216
2. Muthiah K, Robson D, Macdonald PS, et al: Thrombolysis for suspected intrapump thrombosis in patients with continuous flow centrifugal left ventricular assist device. Artif Organs 2013;37:313–318. 3. Goldstein DJ, John R, Salerno C, et al: Algorithm for the diagnosis and management of suspected pump thrombus. J Heart Lung Transplant 2013;32:667–670. 4. Gebhard C, Breitenstein A, Akhmedov A, et al: Amphetamines induce tissue factor and impair tissue factor pathway inhibitor: Role of dopamine receptor type 4. Eur Heart J 2010;31:1780–1791. 5. Turnipseed SD, Richards JR, Kirk JD, et al: Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use. J Emerg Med 2003;24:369–373. 6. Furst SR, Fallon SP, Reznik GN, et al: Myocardial infarction after inhalation of methamphetamine. N Engl J Med 1990;323:1147–1148. 7. Bashour TT: Acute myocardial infarction resulting from amphetamine abuse: A spasm-thrombus interplay. Am Heart J 1994;128:1237–1239. 8. Zebis LP, Christensen TD, Bottcher M, et al: [Severe anterior myocardial infarction caused by amphetamine abuse]. Ugeskr Laeger 2007;169:423–424.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
215
PERIOPERATIVE MANAGEMENT_____________________________________________________
Amphetamine Abuse as a Rare Cause of Recurrent LVAD Pump Thrombosis Christian Heim, M.D., Markus Kondruweit, M.D., Michael Weyand, M.D., and Rene Tandler, M.D. Department of Cardiac Surgery, University of Erlangen-Nuremberg, Germany ABSTRACT We report a patient with recurrent left ventricular assist device (LVAD) thrombosis due to amphetamine addiction. The management of this complication is reviewed. doi: 10.1111/jocs.12504 (J Card
Surg 2015;30:215–216)
Our experience with third-generation continuousflow, centrifugal left ventricular assist devices (LVADs) suggests a relatively lower rate of pump thrombosis in HeartWare HVAD1 (HeartWare, Framingham, MA, USA) patients compared with other continuous flow devices.1 We report another etiology for LVAD pump thrombosis–amphetamine abuse. PATIENT PROFILE A 44-year-old male experienced his third pump thrombosis after HVAD implantation despite well adjusted coagulation status using phenprocoumon (international normalized ratio [INR] 2.0–2.5) and ASA/ dypiridamol. In Februrary 2013, LVAD implantation was performed due to cardiogenic shock as a result of a nonischemic dilated cardiomyopathy. Lactatedehydrogenase (LDH) and hydroxybutyrate dehydrogenase (aHBDH) levels dropped to normal values and remained unremarkable. The patient was released home and followed up in our outpatient care unit. The patient presented with LVAD alarms due to power consumption elevations six month after LVAD implantation. LDH levels were 4122 U/L (>16 times greater the upper limit of normal). Therefore, an intravenous thrombolysis (50 mg Alteplase i.v., 20 mg i.v. infusion over 60 minutes, then remaining 30 mg over next three hours, Actilyse1 [Boehringer Ingelheim RCV, Wien, Austria]) was performed in order to resolve
Conflicts of interest: The authors acknowledge no conflict of interest in the submission.
the thrombosis.2,3 After normalization of clinical and laboratory values, a malposition of the inflow cannula was excluded by chest X-ray. A transthoracic echocardiogram (TTE) was performed to exclude a LV thrombus or thrombus in the aortic root. Online data analysis using the HeartWare online support revealed complete recovery from the LVAD thrombus. A second antiplatelet agent (dipyridamole) was added to the antithrombotic therapy. The patient recovered and was sent home. LDH levels dropped to normal values on followup. Every four weeks, laboratory values and power curves on the HeartWare1 monitor were routinely checked. Four months later the patient presented again with LVAD alarms due to power elevations. LDH levels were elevated (3497U/L) and therefore thrombolytics were again administered. Clinical LVAD measurements and laboratory values normalized again. Outpatient follow-ups were completely uneventful with normal LDH levels and INR values in range (INR 2.0–2.5). Fourteen months after LVAD implantation, the patient again developed a pump thrombosis (LDH 5845 U/L; >23 times greater the upper limit of normal). Thrombolysis was performed to resolve the thrombus once again. Analysis of the coagulation status did not reveal an explanation for the recurrent pump thrombosis. Even though drug abuse was denied by the patient, a drug screening test was performed. Positive amphetamine and methamphetamine findings were detected and explained the recurrent pump thrombosis. Institutional review board approval and written, informed consent were obtained to report this case.
Disclosures: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript to disclose.
DISCUSSION
Address for correspondence: Christian Heim, M.D., Krankenhausstr.12, 91054 Erlangen, Germany. Fax: þ49 9131 85-32768; e-mail: [email protected]
Amphetamines are known to be prothrombotic by inducing tissue factor, the main trigger of coagulation, and thereby involved in arterial thrombus formation.4
216
HEIM, ET AL. AMPHETAMINE ABUSE AND RECURRENT LVAD THROMBOSIS
A number of reports about amphetamine-associated acute vascular syndromes have been published, including vasculitis, vasospasm, and prothrombotic states.5–8 On the basis of these reports and the previously published paper by Gebhard et al.,4 we performed a drug screening test in our patient, although drug intake was denied by the patient. The results revealed positive findings for amphetamines and methamphetamines. In conclusion, amphetamine abuse is a rare cause of recurrent LVAD pump thrombosis, especially in young men. In view of otherwise unexplainable recurrent pump thrombosis, a drug screening test should be considered in young patients at an early stage, especially in high-risk regions for amphetamine consumption. REFERENCES 1. Aaronson KD, Slaughter MS, Miller LW, et al: Use of an intrapericardial, continuous-flow, centrifugal pump in patients awaiting heart transplantation. Circulation 2012; 125:3191–3200.
J CARD SURG 2015;30:215–216
2. Muthiah K, Robson D, Macdonald PS, et al: Thrombolysis for suspected intrapump thrombosis in patients with continuous flow centrifugal left ventricular assist device. Artif Organs 2013;37:313–318. 3. Goldstein DJ, John R, Salerno C, et al: Algorithm for the diagnosis and management of suspected pump thrombus. J Heart Lung Transplant 2013;32:667–670. 4. Gebhard C, Breitenstein A, Akhmedov A, et al: Amphetamines induce tissue factor and impair tissue factor pathway inhibitor: Role of dopamine receptor type 4. Eur Heart J 2010;31:1780–1791. 5. Turnipseed SD, Richards JR, Kirk JD, et al: Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use. J Emerg Med 2003;24:369–373. 6. Furst SR, Fallon SP, Reznik GN, et al: Myocardial infarction after inhalation of methamphetamine. N Engl J Med 1990;323:1147–1148. 7. Bashour TT: Acute myocardial infarction resulting from amphetamine abuse: A spasm-thrombus interplay. Am Heart J 1994;128:1237–1239. 8. Zebis LP, Christensen TD, Bottcher M, et al: [Severe anterior myocardial infarction caused by amphetamine abuse]. Ugeskr Laeger 2007;169:423–424.
Copyright of Journal of Cardiac Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
