145: SUCCESSFUL MANAGEMENT OF LEFT VENTRICULAR ASSIST DEVICE OFF ANTICOAGULATION FOR 30 DAYS

Abstract

Introduction: Ventricular assist devices (VAD) have revolutionized the management of heart failure. However, risk of thromboembolic events is a concern. This is addressed by anticoagulation protocol to keep international normalized ratio between 2-3. We present a case of left and right ventricular assist devices (LVAD and RVAD) recipient successfully managed off anticoagulation for 30 days without thromboembolic events. Description: 72-year-old male presented with worsening shortness of breath for a month. Past medical history is significant for non-ischemic cardiomyopathy, Stage-D, NYHA-FC-4, Intermacs-2. Patient was admitted with acute decompensated heart failure. Echocardiogram showed left ventricular ejection fraction of 15% and right systolic ventricular pressure of 80 mmHg. Despite maximum medical management, patient decompensated requiring impella support bridge to LVAD, Heartmate-III and RVAD, Protek duo. Patient was started on heparin and bridged to warfarin and aspirin per anticoagulation protocol with goal INR of 2- 3. Post-op course was complicated by massive pulmonary hemorrhage requiring placement of bronchial blocker and a large episode of melena in the first two weeks, prompting us to hold warfarin and aspirin. Thereafter, patient was managed off anticoagulation to prevent further bleeding episodes. Coagulation profile was negative. RVAD was removed on day-27 and anticoagulation was resumed on day-30. During this time patient did not experience any thromboembolic events despite no anticoagulation. Patient was weaned off ventilatory support, transitioned out of intensive care unit, and subsequently discharged home on LVAD. Discussion: Since the introduction of centrifugal non-pulsatile LVADs, incidence of thromboembolic events, including pump thrombosis, has decreased but at expense of increased gastrointestinal bleeds. This shift brings up need to revise current anticoagulation strategies. In our case, management off anticoagulation prevented further bleeding episodes without any thromboembolic events. Although thrombosis prevention is important while on VAD, clinicians can find comfort in knowing that anticoagulation may be safely withheld when bleeding complications arise. Of point, focus must be maintained on VAD flows to help reduce stagnant blood.