Antiplatelet and anticoagulation strategies for left ventricular assist devices

Abstract

Left ventricular assist devices (LVAD) have revolutionized the management of advanced heart failure. However, complications rates remain high, among which hemorrhagic and thrombotic complications are the most important. Antiplatelet and anticoagulation strategies form a cornerstone of LVAD management and may directly affect LVAD complications. Concurrently, LVAD complications influence anticoagulation and anticoagulation management. A thorough understanding of device, patient, and management, including anticoagulation and antiplatelet therapies, are important in optimizing LVAD outcomes. This article provides a comprehensive state of the art review of issues related to antiplatelet and anticoagulation management in LVADs. We start with a historical overview, the epidemiology and pathophysiology of bleeding and thrombotic complications in LVADs. We then discuss platelet and anticoagulation biology followed by considerations prior to, during, and after LVAD implantation. This is followed by discussion of anticoagulation and the management of thrombotic and hemorrhagic complications. Specific problems, including management of heparin-induced thrombocytopenia, anticoagulant reversal, novel oral anticoagulants, artificial heart valves, and noncardiac surgeries are covered in detail.

Left Ventricular Assist Device Pump Thrombosis in a Patient Treated with Apixaban

“…HeartWare, the manufacturer for this patient’s ventricular assist device, specifically recommend aspirin 325 mg daily and warfarin with a goal INR of 2.0 to 3.0 for long-term anticoagulation [ 6 ]. Sufficient safety data for the use of DOACs is still lacking; therefore, they are not recommended for primary anticoagulation in patients with HVADs [ 3 ]. The presumed superiority of vitamin K antagonists may be explained by the underlying mechanism responsible for thrombus formation in this setting.…”

“…One meta-analysis of 5 studies showed that patients with continuous-flow LVADs had a time in therapeutic range (TTR) of only 46.6% [ 2 ]. The many challenges with VKA led to an interest in using direct oral anticoagulants (DOAC) as an alternative option because of their ease of use and limited dietary interactions, despite the lack of solid safety data in LVAD patients [ 3 ]. Here, we present a case of a patient who developed an LVAD pump thrombosis while taking apixaban.…”

Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature

“…LMWH should be discontinued 12 h prior to surgery and UFH 6 h prior to surgery. 111 Preoperative temporary MCS, in particular VA‐ECMO, requires continuation of antithrombotic regimen with intravenous UFH. 109 …”

“…Depending on the indication for anticoagulation, bridging with UFH and LWMH can be used to limit the time off anticoagulation prior to surgery. LMWH should be discontinued 12 h prior to surgery and UFH 6 h prior to surgery 111 . Preoperative temporary MCS, in particular VA‐ECMO, requires continuation of antithrombotic regimen with intravenous UFH 109 …”

“…LMWH should be discontinued 12 h prior to surgery and UFH 6 h prior to surgery. 111 Preoperative temporary MCS, in particular VA-ECMO, requires continuation of antithrombotic regimen with intravenous UFH. 109 In the early post-operative phase, the International Society for Heart and Lung Transplantation guidelines recommend initiating intravenous UFH within 48 h after LVAD implantation.…”