Assessment of Bleeding and Thrombosis Based on Aspirin Responsiveness after Continuous-Flow Left Ventricular Assist Device Placement

Floroff, Catherine; Rieger, K.; Veasey, Tara; Strout, Sara; DeNino, Walter F.; Meadows, Holly B.; Stroud, Martha R.; O’Toole, John M.; Heyward, D.; Brisco‐Bacik, Meredith A.; Cook, Jennifer; Lazarchick, John; Uber, Walter E.

doi:10.1097/mat.0000000000000535

Cited by 6 publications

(15 citation statements)

References 38 publications

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“…While aspirin doses were up‐titrated in nonresponders, there was no difference in median aspirin dose between the bleeding and non‐bleeding group. In addition, a separate analysis from our center found no difference in bleeding between aspirin standard dose responders and nonresponders whose dose was titrated per protocol …”

Section: Discussionmentioning

confidence: 86%

“…15,16,32,33 In our LVAD population, we assessed for aspirin nonresponsiveness and titrated the aspirin dose accordingly using the VerifyNow Aspirin test. 26,27 While aspirin doses were up-titrated in nonresponders, there was no difference in median aspirin dose between the bleeding and non-bleeding group. In addition, a separate analysis from our center found no difference in bleeding between aspirin standard dose responders and nonresponders whose dose was titrated per protocol.…”

Section: Discussionmentioning

confidence: 99%

“…However, other reports have been unable to attribute increased bleeding to anticoagulation intensity and studies have attempted to identify patient factors that might predict risk for bleeding complications . In our LVAD population, we assessed for aspirin nonresponsiveness and titrated the aspirin dose accordingly using the VerifyNow Aspirin test . While aspirin doses were up‐titrated in nonresponders, there was no difference in median aspirin dose between the bleeding and non‐bleeding group.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, a separate analysis from our center found no difference in bleeding between aspirin standard dose responders and nonresponders whose dose was titrated per protocol. 26 Patient characteristics correlated with bleeding risk in prior literature are varied and include DT, older age, female, ischemic etiology, higher body mass index, lower left ventricular end-diastolic diameter, higher cardiac index, higher blood urea nitrogen, history of diabetes, lower hemoglobin, total bilirubin, pulmonary artery systolic pressure, preoperative RV dysfunction, increased pump speed, and infection post-implant. 15,16,34,35 While predictive characteristics are not entirely consistent among available studies, there is a common theme that risk for bleeding may be predictable for these patients.…”

Section: Discussionmentioning

confidence: 99%

“…The antithrombotic protocol has been previously published. 26 Aspirin was initiated at a dose of 81 mg daily in addition to subcutaneous heparin (5000 units every 8 h) on postoperative day (POD) 1 unless there was a high risk for postoperative bleeding as determined by the cardiothoracic surgeon. Warfarin at a dose of 2-10 mg daily was started at the discretion of the cardiothoracic surgeon.…”

Section: Treatment Protocolmentioning

confidence: 99%

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Evaluation of anticoagulation and nonsurgical major bleeding in recipients of continuous‐flow left ventricular assist devices

et al. 2019

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Continuous‐flow left ventricular assist device (LVAD) placement has become a standard of care in advanced heart failure treatment. Bleeding is the most frequently reported adverse event after LVAD implantation and may be increased by antithrombotic agents used for prevention of pump thrombosis. This retrospective cohort included 85 adult patients implanted with a Heartmate II LVAD. Major bleeding was defined as occurring >7 days after implant and included intracranial hemorrhage, events requiring 2 units of packed red blood cells within a 24‐h period, and death from bleeding. Primary outcome was intensity of anticoagulation between patients with or without at least one incidence of nonsurgical major bleeding. Major bleeding occurred in 35 (41%) patients with 0.48 events per patient year and a median (IQR) time to first bleed of 134.5 (39.3, 368.5) days. The median (IQR) INR at time of bleed was 1.7 (1.4, 2.5). Median INR during follow‐up did not differ between groups and patients with major bleeding were not more likely to have a supra‐therapeutic INR. Patients who bled were more likely to have received LVAD for destination therapy, to have lower weight, worse renal function, and lower hemoglobin at baseline. Duration of LVAD support and survival were similar between groups with no difference in occurrence of thrombosis. Incidence of nonsurgical major bleeding was not significantly associated with degree of anticoagulation. Certain baseline characteristics may be more important than anticoagulation intensity to identify patients at risk for bleeding after LVAD implant. Modification of anticoagulation alone is not a sufficient management strategy and early intervention may be required to mitigate bleeding impact.

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Section: Discussionmentioning

confidence: 86%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Treatment Protocolmentioning

confidence: 99%

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Evaluation of anticoagulation and nonsurgical major bleeding in recipients of continuous‐flow left ventricular assist devices

et al. 2019

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Bleeding and thrombosis associated with ventricular assist device therapy

Shah

Tantry

Bliden

et al. 2017

The Journal of Heart and Lung Transplantation

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Choosing the best antithrombotic regimen in patients with ventricular assist devices

Bader

Mallah

Atallah

2020

Current Opinion in Cardiology

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Purpose of review Two major complications compromise the outcomes and quality of life for left ventricular assist device (LVAD) patients. This review aims to discuss the mechanisms of thrombosis and bleeding, recent literature on the optimal approaches for antithrombotic therapy, and novel approaches to prevent bleeding. Recent findings Recent studies with the newly designed LVAD, the fully magnetically levitated rotor, show lower thrombotic risk but sustain similar bleeding risk. Small studies present options for less intense antithrombotic regimens with the newer devices. Bridging anticoagulation when needed in this patient population might require modified regimens and close monitoring to avoid anticoagulation overlap during the bridged periods. The necessity to add an antiplatelet to anticoagulation is particularly being challenged with the recent data. Antiplatelet responsiveness testing is an intriguing approach to customize regimens. In addition, novel approaches that target activation of the angiotensin II receptors and inflammatory responses might offer further protection against bleeding in implanted patients. Summary Close monitoring, novel, and patient-tailored approaches may offer the best antithrombotic strategies for LVAD patients. More clinical and long-term data are needed to establish the potential for less intense regimens particularly with the newly designed devices.

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Assessment of Bleeding and Thrombosis Based on Aspirin Responsiveness after Continuous-Flow Left Ventricular Assist Device Placement

Cited by 6 publications

References 38 publications

Evaluation of anticoagulation and nonsurgical major bleeding in recipients of continuous‐flow left ventricular assist devices

Evaluation of anticoagulation and nonsurgical major bleeding in recipients of continuous‐flow left ventricular assist devices

Bleeding and thrombosis associated with ventricular assist device therapy

Choosing the best antithrombotic regimen in patients with ventricular assist devices

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