Dual mechanical assistance with veno-arterial extracorporeal membrane oxygenation and percutaneous continuous-flow device: double trouble for von Willebrand factor
A. Rauch, F. Vincent, E. Jeanpierre, C. Caron, A. Dupont, N. Rousse, A. Vincentelli, E. Robin, E. Van Belle, J. Goudemand, S. Susen (Lille, France)
Acquired problems and alterations of coagulation
Date: 17.02.2017,
Time: 17:15 - 18:15
Objective: The addition of the Impella-2.5 (Abiomed®) device is an emerging therapeutic option to control an acute pulmonary edema (APE) occurring under peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with refractory cardiogenic shock (CS). Both VA-ECMO and Impella-2.5 are high shear continuous-flow pumps known to promote von Willebrand factor (VWF) high molecular weight (HMW) multimers proteolytic degradation. We report here a severe acquired von Willebrand syndrome (AVWS), requiring VWF concentrates infusion, after the onset of dual continuous-flow mechanical circulatory support (CF-MCS).
Methods:
Results: A peripheral VA-ECMO was implanted in a 62-year-old male with refractory CS. VA-ECMO was associated with the induction of a partial HMW-multimers defect. Impella-2.5 percutaneous implantation was decided after 2 days because of an APE under VA-ECMO support. While rapidly reducing the APE, the addition of Impella-2.5 device was associated with the onset of major bleedings. Recurrent epistaxis and bleedings from all vascular accesses were observed under dual VA-ECMO/Impella-2.5 support. This recurrent bleeding pattern under dual CF-MCS was simultaneously associated with a complete HMW-multimers deficiency. To the opposite, platelet count remained above 80 G.L-1 during the 12 days of dual CF-MCS. In this context, off-label administration of a plasma-derived VWF concentrate almost devoid of FVIII (Wilfactin®) was decided. Bleeding was controlled by high doses of VWF concentrates infused every 24 hours for 3 days. Once VWF administration was stopped, we observed the recurrence of bleedings and transfusion dependency. The patient was further implanted with the LVAD HeartMate-II (HM-II) as a bridge to heart transplantation. The surgery was complicated by massive bleedings controlled by VWF concentrates infusions. After HM-II implantation, there was a partial recovery of HMW-multimers defect (HMW-multimers ratio=0.82). Despite requiring curative anticoagulation, no overt bleedings occurred under HM-II support. The patient was discharged home one month after HM-II implantation and underwent successful heart transplantation 3 months later.
Conclusion: We report a severe AVWS-related bleeding pattern under dual CF-MCS. The use of VWF concentrates as “rescue therapy” might be efficient to control severe bleedings under dual CF-MCS.