Blutgerinnungsstörungen unter ECMO- und LVAD-Therapie

Zusammenfassung

Bei Patienten mit schwerem respiratorischem und kardialem Versagen eignen sich die extrakorporale Membranoxygenierung (ECMO) und linksventrikuläre Herzunterstützungssysteme (LVAD) zur Stabilisierung der Vitalparameter. Deshalb sind ECMO- und LVAD-Systeme zu wichtigen Werkzeugen der modernen Medizin geworden. Sie können jedoch eine Koagulopathie induzieren, die durch hämorrhagische und thromboembolische Komplikationen geprägt ist.

Abstract

Extracorporal membrane oxygenation (ECMO) is used to stabilize severe cardiocirculatory and/or respiratory failure in emergency situations. Left ventricular assist devices (LVAD) are used for the treatment of severe chronic heart failure. ECMO and LVAD systems are increasingly employed and provide substantial benefit for respective patients. However, the use of ECMO and LVAD systems is associated with a multifactorial coagulopathy, which is characterized by thromboembolic and hemorrhagic complications. ECMO- and LVAD-induced thromboembolic events are caused by contact activation of plasmatic coagulation and platelets at the artificial surfaces of the respective system. Shear forces inside ECMO and LVADs further contribute to prothrombotic platelet activation. To prevent thrombotic occlusion of ECMO and LVAD systems anticoagulants are routinely administered. For this purpose heparin is primarily used. This may however result in heparin-induced thrombocytopenia, which can further complicate ECMO- and LVAD-associated coagulatory dysfunction. Bleeding complications during ECMO and LVAD therapy can be related to systemic anticoagulation. Qualitative and quantitative platelet defects as well as shear force induced acquired von Willebrand disease further contribute to hemorrhagic events. In conclusion, the management of the ECMO- and LVAD-associated coagulopathy is based on the understanding of its contributing factors. Respective causes for thrombotic and/or hemorrhagic complications should be identified with coagulation assays including viscoelastic point of care tests and platelet aggregometry. Once the underlying reason for the observed coagulopathy has been identified further treatment measures should be individually tailored.

Schlüsselwörter

extrakorporale Membranoxygenierung - ECMO - linksventrikuläre Herzunterstützungssysteme - LVAD - Koagulopathie - Von-Willebrand-Syndrom

Key words

extracorporeal membrane oxygenation - ECMO - left ventricular assist device - LVAD - coagulopathy

• Literatur

• 1 Gibbon jr. JH. Application of a mechanical heart and lung apparatus to cardiac surgery. Minn Med 1954; 37: 171-185
• 2 Hill JD, OʼBrien TG, Murray JJ. et al. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med 1972; 286: 629-634 doi:10.1056/NEJM197203232861204
• 3 Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, Davies A, Jones D, Bailey M. . et al. Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA 2009; 302: 1888-1895 doi:10.1001/jama.2009.1535
• 4 Kulkarni T, Sharma NS, Diaz-Guzman E. Extracorporeal membrane oxygenation in adults: A practical guide for internists. Cleve Clin J Med 2016; 83: 373-384 doi:10.3949/ccjm.83a.15021
• 5 Kirklin JK, Naftel DC, Pagani FD. et al. Seventh INTERMACS annual report: 15,000 patients and counting. J Heart Lung Transplant 2015; 34: 1495-1504 doi:10.1016/j.healun.2015.10.003
• 6 Liotta D, Hall CW, Henly WS. et al. Prolonged Assisted Circulation during and after Cardiac or Aortic Surgery. Prolonged Partial Left Ventricular Bypass by Means of Intracorporeal Circulation. Am J Cardiol 1963; 12: 399-405
• 7 Netuka I, Sood P, Pya Y. et al. Fully Magnetically Levitated Left Ventricular Assist System for Treating Advanced HF: A Multicenter Study. J Am Coll Cardiol 2015; 66: 2579-2589 doi:10.1016/j.jacc.2015.09.083
• 8 Annich GM. Extracorporeal life support: the precarious balance of hemostasis. J Thromb Haemost 2015; 13 (Suppl. 01) 336-342 doi:10.1111/jth.12963
• 9 Takagaki M, Yamaguchi H, Ikeda N. et al. Post-cardiotomy venovenous extracorporeal membrane oxygenation without heparinization. Gen Thorac Cardiovasc Surg 2018;
• 10 Winkler AM. Managing the Precarious Hemostatic Balance during Extracorporeal Life Support: Implications for Coagulation Laboratories. Semin Thromb Hemost 2017; 43: 291-299 doi:10.1055/s-0036-1593414
• 11 Muslem R, Caliskan K, Leebeek FWG. Acquired coagulopathy in patients with left ventricular assist devices. J Thromb Haemost 2018; 16: 429-440 doi:10.1111/jth.13933
• 12 Vaquer S, de Haro C, Peruga P. et al. Systematic review and meta-analysis of complications and mortality of veno-venous extracorporeal membrane oxygenation for refractory acute respiratory distress syndrome. Ann Intensive Care 2017; 7: 51 doi:10.1186/s13613-017-0275-4
• 13 Gray BW, Haft JW, Hirsch JC. et al. Extracorporeal life support: experience with 2,000 patients. ASAIO J 2015; 61: 2-7 doi:10.1097/MAT.0000000000000150
• 14 Keller M, Magunia H. Diagnostik und Therapie perioperativer Gerinnungsstörungen. Anasthesiol Intensivmed Notfallmed Schmerzther 2019; 54: 386-401
• 15 Ruggeri ZM. Platelets in atherothrombosis. Nat Med 2002; 8: 1227-1234
• 16 Weerasinghe A, Taylor KM. The platelet in cardiopulmonary bypass. Ann Thorac Surg 1998; 66: 2145-2152
• 17 Nascimbene A, Neelamegham S, Frazier OH. et al. Acquired von Willebrand syndrome associated with left ventricular assist device. Blood 2016; 127: 3133-3141 doi:10.1182/blood-2015-10-636480
• 18 Kalbhenn J, Schlagenhauf A, Rosenfelder S. et al. Acquired von Willebrand syndrome and impaired platelet function during venovenous extracorporeal membrane oxygenation: Rapid onset and fast recovery. J Heart Lung Transplant 2018;
• 19 Nagler M, Bakchoul T. Clinical and laboratory tests for the diagnosis of heparin-induced thrombocytopenia. Thromb Haemost 2016; 116: 823-834 doi:10.1160/TH16-03-0240
• 20 Glick D, Dzierba AL, Abrams D. et al. Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation. J Crit Care 2015; 30: 1190-1194 doi:10.1016/j.jcrc.2015.07.030
• 21 Schenk S, El-Banayosy A, Prohaska W. et al. Heparin-induced thrombocytopenia in patients receiving mechanical circulatory support. J Thorac Cardiovasc Surg 2006; 131: 1373-1381 doi:10.1016/j.jtcvs.2006.01.048