Low-molecular-weight heparin for anti-coagulation after left ventricular assist device implantation
Anti-coagulation is required in patients with left ventricular assist devices (LVADs). We evaluated the feasibility of low-molecular-weight heparin (LMWH) for initiation of anti-coagulation and transitioning to oral anti-coagulation after LVAD implantation.
This single-center study included 78 consecutive patients who underwent either Thoratec HeartMate II LVAD (n = 27) or HeartWare ventricular assist device (HVAD, n = 51) implantation. The LMWHs enoxaparin (n = 50) and dalteparin (n = 28) were used. LMWH was started within 24 hours post-operatively in 79.5% of patients. No anti-coagulation was given before starting LMWH therapy. LMWH activity was monitored by determination of anti-factor Xa levels in plasma.
The majority of patients (80.7%) had peak anti-Xa activity within the defined range of efficacy of 0.2 to 0.4 IU/ml by the second day of treatment. Mean effective peak anti-Xa activity was 0.28 ± 0.06 IU/ml. Mean duration of anti-coagulation with LMWH was 25.8 ± 18 days. Ischemic strokes were observed in 3 patients (3.8%), with a total of 4 events. Three events occurred while on LMWH, and 1 event occurred during follow-up on oral anti-coagulation. There was 1 fatal stroke. No pump thrombus was observed. Major bleeding was observed in 5 patients (6.4%), with a total of 6 events. Gastrointestinal bleeding was the most common complication (n = 3). There were no fatal bleeding events.
LMWH in the setting of LVAD shows rapid and constant biologic efficacy. Anti-coagulation with LMWH appears feasible after LVAD implantation. These findings support further evaluation of LMWH as an alternative to unfractionated heparin in this patient cohort.
Available from: Mandeep Mehra
[Show abstract] [Hide abstract]
ABSTRACT: Durable left ventricular assist devices (LVADs) have not only enhanced longevity but also conferred sustained improvements in quality of life, symptom control, and functional capacity in patients with medically refractory advanced heart failure. Problems with device-related infection, bleeding, neurologic events, right-sided heart failure, and device malfunction have dominated the clinical care of patients living on mechanical support. Even as adoption of durable LVADs accelerated globally, we began to encounter a growing dilemma of pump malfunction caused by thrombosis. In early 2011, clinicians began to notice a spike in the incidence of pump thrombosis with the HeartMate II (Thoratec Corp, Pleasanton, CA) LVAD. By 2012, the problem of thrombosis in LVADs began to consume most of the scientific direction as centers and collaborative groups began to dissect this nascent phenomenon. In this perspective, we describe the magnitude and implications of pump thrombosis, discuss secular and management trends in this unique population, attempt to dissect the problem at its root, offer guidance on surveillance and therapeutic principles, and outline issues that deserve our immediate and collaborative attention.
[Show abstract] [Hide abstract]
ABSTRACT: For the majority of patients with heart failure (HF) the management is non-surgical, but for the most advanced subgroup of patients with heart failure and reduced ejection fraction, mechanical circulatory support (MCS) is becoming a more viable treatment option. Heart transplantation is the 'gold standard' for advanced HF therapy, but is limited by donor organ availability. In contrast, MCS utilization has risen exponentially over the past decade. Pump thrombosis is a rare but increasingly recognized cause of morbidity and mortality in this population. In this review, we define the problem of pump thrombosis, discuss diagnostic testing and approaches to the prevention and management of this potentially devastating complication of durable MCS.
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.