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© 2013 Wiley Periodicals, Inc. and International Center for Artificial Organs and Transplantation

Thoughts and Progress Incidence and Outcome of Pediatric Patients With Intracranial Hemorrhage While Supported on Ventricular Assist Devices *,**Robert A. Niebler, †Sean M. Lew, ‡**Steven D. Zangwill, §**Ronald K. Woods, §**Michael E. Mitchell, §**James S. Tweddell, and *,**Nancy S. Ghanayem *Department of Pediatrics, Section of Critical Care; †Department of Neurosurgery; ‡Department of Pediatrics, Section of Cardiology; §Department of Cardiothoracic Surgery, The Medical College of Wisconsin; and **Herma Heart Center, Children’s Hospital of Wisconsin, Milwaukee, WI, USA Abstract: Pediatric patients supported on ventricular assist devices (VADs) require systemic anticoagulation and are at risk for intracranial hemorrhage (ICH). Little is known about the incidence or outcomes of pediatric patients with ICH while supported on a VAD. A retrospective chart review of all patients receiving VAD support was completed. Patients diagnosed with ICH while supported on a VAD were identified. Significant factors prior to diagnosis of ICH, medical/surgical treatment of ICH, and patient outcomes were assessed. Five of 30 (17%) patients supported on a VAD from January 2000 to November 2012 were diagnosed with an ICH. Four patients had an identified cerebral thromboembolic injury prior to the ICH. Four patients required interruption in their anticoagulation regimen due to other bleeding concerns prior to ICH. Neurosurgical intervention consisted of evacuation of hemorrhage in one, whereas two others required management of hydrocephalus with external ventricular drainage. Three of the five patients died on VAD support. Two deaths were directly related to ICH, whereas the third was unrelated. Two patients were successfully transplanted; one remains with a significant neurological impairment, and the other has recovered with minimal residual impairment following neurosurgical evacuation of a large subdural hematoma. ICH is a devastating complication of VAD support. Prior

doi:10.1111/aor.12209 Received May 2013; revised August 2013. Address correspondence and reprint requests to Dr. Robert A. Niebler, 9000 W. Wisconsin Ave., Suite 647, PO Box 1997 (MS 681), Milwaukee, WI 53201, USA. E-mail: [email protected] Presented in part at the 9th International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion held May 8–11, 2013 in Hershey, PA, USA.

ischemic infarcts and interruptions to anticoagulation may put a patient at risk for ICH. Prompt neurosurgical evaluation/intervention can result in positive outcomes. Key Words: Ventircular assist device—Intracranial hemorrhage—Complication—Anticoagulation.

Neurologic complications during ventricular assist device (VAD) support in the pediatric population occur in 6–29% of patients (1,2). Ischemic infarction is the most common reported neurologic event (2), but given the need for anticoagulation, the risk of intracranial hemorrhage (ICH) is not negligible. An ICH in a patient supported on a VAD is often a devastating complication as the ongoing need for anticoagulation to prevent pump dysfunction and thromboembolic events runs contrary to the need to stop the bleeding and increases the risk of any neurosurgical intervention. As more pediatric patients are supported by a VAD (3), strategies need to be developed to manage these devastating complications. The published literature on management of patients with ICH while supported with a VAD is limited (4–10). The aim of this study is to describe the incidence and outcomes of patients with ICH while supported on a VAD at Children’s Hospital of Wisconsin.

PATIENTS AND METHODS Following the local institutional review board approval, a retrospective review of all patients supported with a VAD from January 2000 through November 2012 at Children’s Hospital of Wisconsin was completed. Records of all cranial radiological examinations (ultrasound and computed tomography [CT]) were reviewed for evidence of an ICH. An ICH was defined as extravascular blood seen on a radiologic examination. Petechial hemorrhages and small amounts of subarachnoid or subdural blood were not considered significant. The records of patients with ICH were further reviewed for anticoagulation management before and after the discovery of the ICH, symptomatology prompting the evaluation, medical and surgical management of the ICH, and patient outcomes. Given the descriptive nature of the study, no statistical evaluation was completed. Artificial Organs 2014, 38(1):73–95

Artif Organs, Vol. 38, No. 1, 2014

Berlin LVAD

Berlin LVAD

10 years old/CHD

12 years old/DCM

*Low-molecular-weight heparin anti-Xa assay. BiVAD, bi-ventricular assist device; CHD, congenital heart disease; DCM, dilated cardiomyopathy; LVAD, left ventricular assist device.

Subdural hematoma evacuation 0.98* 278 43 1.13

Not done 294 60 3.63

Thoratec BiVAD 20 years old/CHD

Warfarin, aspirin, dipyridamole Enoxaparin, aspirin, dipyridamole

Incidence and outcome of pediatric patients with intracranial hemorrhage while supported on ventricular assist devices.

Pediatric patients supported on ventricular assist devices (VADs) require systemic anticoagulation and are at risk for intracranial hemorrhage (ICH). ...
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