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

Abstract

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.

Pharmacotherapy for durable left ventricular assist devices

“…Older age and specifically age >65 at time of device implant 70–74 has been identified most frequently as a major risk factor for bleeding complications. Other risk factors identified include RVF 72,74,75 and renal dysfunction 74,76 . The effect of anticoagulation on risk of bleeding is less clear, with some reports identifying a higher baseline INR 73 or concurrent aspirin at 325 mg daily 51 as predictive of bleeding while others 76,77 found no correlation with INR and bleeding events.…”

Artificial Organs 2019: A year in review

“…Tara M. Veasey et al of the Allegheny General Hospital, Pittsburgh, PA, USA investigated anticoagulation and nonsurgical major bleeding in recipients of continuous‐flow LVAD in 85 adults implanted with a HeartMate II. 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.…”

Shear‐dependent platelet aggregation size

“…1,2 Despite the enormous benefits of LVAD, bleeding remains the major cause of morbidity, mortality, and cost during LVAD support, 3,4 which cannot be attributed to anticoagulation alone. 5,6 The pathophysiologic mechanisms responsible for the bleeding diathesis in these patients have shown to be complex and poorly understood.…”

“…Left ventricular assist device (LVAD) is a life‐saving tool for providing hemodynamic support in patients with advanced, refractory left ventricular heart failure, either for temporary support (eg, bridge to cardiac transplantation), or as permanent destination therapy 1,2 . Despite the enormous benefits of LVAD, bleeding remains the major cause of morbidity, mortality, and cost during LVAD support, 3,4 which cannot be attributed to anticoagulation alone 5,6 . The pathophysiologic mechanisms responsible for the bleeding diathesis in these patients have shown to be complex and poorly understood.…”