Stroke is a devastating complication in patients undergoing transcatheter aortic valve replacement (TAVR). We sought to determine whether early stroke intervention after TAVR would improve the neurological outcomes. Two patients experienced stroke immediately after TAVR, one treated with mechanical thrombectomy and localized lytic therapy and one treated with systemic lytic therapy. Our limited experience showed that early stroke intervention with either treatment option may reduce the risk of complications and improve neurological outcomes.

Intrapleural lytic therapy has been established as an important modality of treatment for many pleural disorders, including hemothorax and empyema. Retained traumatic hemothorax is a common and understudied subset of pleural disease. The current standard of care for retained traumatic hemothorax is operative management. The use of lytic therapy for avoidance of operative intervention in the trauma population has not been well established.
Randomized controlled trials (RCTs) and non-RCTs reporting operative intervention following the use of intrapleural lytic treatment for retained traumatic hemothorax were identified in the literature. The primary outcome was avoidance of surgery following treatment with any lytic agent. Meta-analysis was performed to pool the results of those studies. Subgroup analysis by type of lytic therapy and analysis of length of stay were also performed.
One RCT and nine non-RCTs including 162 patients were pooled in the analysis. Avoidance of surgery following treatment with any lytic agent was found to be 87% (95% CI, 81%-92%). Tissue plasminogen activator resulted in 83% operative avoidance (95% CI, 71%-94%), and other, non-tissue plasminogen activator lytic agents resulted in 87% operative avoidance (95% CI, 82%-93%). The average length of stay for patients undergoing lytic therapy was 14.88 days (95% CI, 12.88-16.88).
Lytic therapy could reduce the need for operative intervention in trauma patients with retained traumatic hemothorax. RCTs are indicated to definitively evaluate the benefit of this approach.

BACKGROUND: Pump thrombosis is a major adverse event in patients supported with a left ventricular assist device (LVAD). Treatment approaches include device exchange, lytic therapy, or augmentation of anticoagulation or antiplatelet therapy. The optimal strategy in the HeartWare HVAD Ventricular Assist System (HeartWare, Framingham, MA) is uncertain, and because few large studies have examined differing treatment outcomes, we have reviewed findings from the Mechanical Circulatory Support Research Network registry.
METHODS: Between March 2009 and August 2014, 175 patients (133 male) underwent implantation of the HeartWare HVAD at institutions that comprise the Mechanical Circulatory Support Research Network. Median age at implant was 59 years (range, 18-76 years). Follow-up was available in all patients for a median of 6 months (maximum, 61 months) and for a total of 163 patient-years of support. There were 36 pump thromboses (using Interagency Registry for Mechanically Assisted Circulatory Support criteria) in 21 patients for a total event rate of 0.22 events/patient-year of support; 13 patients had 1 event, 4 had 2, 2 had 3, 1 had 4, and 1 had 5. The median time to the first thrombosis was 6.4 months, and to each subsequent thrombosis was 4, 3, 2, and 2 months, respectively. Primary treatment success was defined as the patient remaining alive and within the first 30 days of the initial treatment be free from stroke, recurrence of pump thrombosis, device exchange, or urgent transplantation (United Network of Organ Sharing Status 1A). Medical treatment was defined as tissue plasminogen activator, heparin plus glycoprotein IIb/IIIa inhibitor, or heparin alone, not followed by surgical treatment within 72 hours.
RESULTS: Initial medical treatment was used in 29 episodes (tissue plasminogen activator in 24, heparin alone in 4, and heparin plus glycoprotein IIb/IIIa in 1) and surgical (device exchange) in 7. Medical treatment was successful in 14 of 29 episodes (48%). Complications of medical treatment included hemorrhagic stroke in 6 patients (21%), need for urgent device exchange/transplant in 6 (21%), and death in 3 (10%). Surgical treatment was successful in all 7 patients (100%). No significant early complications or early deaths occurred after device exchange.
CONCLUSIONS: In this large multicenter analysis, we observed that medical therapy, as the initial treatment strategy for HeartWare HVAD thrombosis, is associated with low success (48%) and a significant risk of hemorrhagic stroke (21%) and death (10%). However, initial treatment with device exchange was uniformly successful and not associated with significant early morbidity or death. Although the optimal treatment approach for HeartWare HVAD pump thrombosis remains undecided, these data do not support the routine use of medical therapy as an initial treatment strategy.