Abstract
BackgroundThrombotic events are a common complication of left ventricular assist device placement and warrant prophylactic anticoagulation. Heparin is the most common anticoagulant used for prophylaxis of thrombotic events in left ventricular assist device patients as a transition to oral anticoagulants but carries the risk of heparin-induced thrombocytopenia. Limited data is available for the treatment of heparin-induced thrombocytopenia in this patient population. We report an evaluation of 8 left ventricular assist device patients with suspected or confirmed HIT started on fondaparinux at the time of heparin-induced platelet-factor-4 antibody positivity.MethodsAdult patients were reported if they were heparin-induced platelet antibody positive, tested via enzyme-linked immunusorbent assay, post-operative after left-ventricular assist device, and were initiated on fondaparinux at the time of heparin-induced platelet antibody positivity. Waiver of informed consent was granted from the institutional review board. Baseline demographics, clinical course of HIT, safety and efficacy variables were collected.ResultsEight patients receiving fondaparinux were identified and included in this report. The patient group was on average 49 years old, weighing 95 kg, with calculated BMI 28.8 and consisted primarily of Caucasian males. Three patients developed new thromboses after initiation of fondaparinux for heparin-induced thrombocytopenia. Only one patient had a major bleeding event of an overt bleed after initiation of fondaparinux therapy.ConclusionsGiven the lack of major bleeding in this evaluation, fondaparinux could be a potentially safe treatment option for left ventricular assist device patients that are heparin-induced platelet antibody positive pending confirmatory testing results. Given the development of new thromboses in 3 of 8 patients, concern exists about the efficacy of fondaparinux in this patient population. Significant limitations exist regarding these conclusions in this evaluation. Controlled, systematic evaluations are necessary to delineate safety and efficacy of fondaparinux for heparin-induced thrombocytopenia in this population.
Highlights
Thrombotic events are a common complication of left ventricular assist device placement and warrant prophylactic anticoagulation
Thrombotic events in Ventricular assist device (VAD) patients occur at a reported incidence ranging up to 26% and because of this, all Left ventricular assist device (LVAD) patients will be transitioned to long-term anticoagulation unless contraindicated [11]
We investigated our institutional experience utilizing fondaparinux in LVAD patients with suspected or confirmed heparin-induced thrombocytopenia (HIT)
Summary
Thrombotic events are a common complication of left ventricular assist device placement and warrant prophylactic anticoagulation. Heparin is the most common anticoagulant used for prophylaxis of thrombotic events in left ventricular assist device patients as a transition to oral anticoagulants but carries the risk of heparin-induced thrombocytopenia. According to the Centers for Disease Control and Prevention, an estimated 5.8 million people in the United States have heart failure and 550,000 are newly diagnosed with end stage heart failure each year [1]. Because of this burden, there has been an increased utilization of LVADs [2]. It is recommended that LVAD patients be bridged with intravenous heparin to warfarin beginning as early as postoperative day 1 until therapeutic international normalized ratio (INR) is reached [12]
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