Anticoagulation strategies for left ventricular assist devices

Abstract

Recommendations for thromboprophylaxis in patients with LVADs are scarce. The International Society for Heart and Lung Transplantation has put together minimum criteria for perioperative anticoagulation; however, this is on the basis of poor level of evidence (observational studies and expert opinion). Ultimately, clinicians will need to individualize the intensity and timing of anticoagulation following LVAD implantation to ensure adequate thromboprophylaxis while simultaneously minimizing bleeding.

Assessing Anticoagulation Practice Patterns in Patients on Durable Mechanical Circulatory Support Devices

“…11,12 Some clinicians even endorse individualizing anticoagulation intensity and timing according to patient-specific risk factors. 13 As a result of these discordant recommendations, significant variability likely exists between implanting centers with regard to anticoagulation practices. However, the degree of variation has never been formally quantified until this analysis.…”

Hemostatic complications associated with ventricular assist devices

“…It was once standard that patients after VAD placement be treated with heparin until warfarin achieves a therapeutic INR. Now it is not uncommon to find heparin being held in this period to decrease early postoperative bleeding rates . However, this lack of heparin has led to recent concern of an association with increased risk of pump thrombosis.…”

“…Warfarin is started with varied INR goals among centers as well as consideration of patient risk factors for either bleeding or thrombosis . Most INR goals are in the 2 to 3 range, but many centers using HeartMate II will drop this to 1.5 to 2.5 based on data showing less bleeding with no increase in thrombosis with INRs in this range . Studies show that with HeartMate II patients, the highest rate of thrombosis was with INRs <1.5, but the rate was still high with INRs of 1.5 to 2.0.…”

“…Now it is not uncommon to find heparin being held in this period to decrease early postoperative bleeding rates. [84][85][86][87] However, this lack of heparin has led to recent concern of an association with increased risk of pump thrombosis. It may be prudent to limit holding heparin to patients at high risk of bleeding, such as those with previous GI bleeding or other risk factors for hemorrhage.…”

“…It may be prudent to limit holding heparin to patients at high risk of bleeding, such as those with previous GI bleeding or other risk factors for hemorrhage. 84 Given the role of platelet activation by surfaces and shear, aspirin is started when surgical bleeding stops. There is no consensus on dosing, with recommendations ranging from 81 to 325 mg depending on centers.…”