Anticoagulation strategies for left ventricular assist devices.

Abstract

Pump thrombosis can be a devastating complication in patients with a left ventricular assist device (LVAD). Treatment options with intravenous anticoagulation can lead to further complications. The present review discusses the current antithrombotic and anticoagulation strategies following LVAD implantation and during suspected pump thrombosis. Recently, a significant increase in pump thrombosis (HeartMate II) at 3 months after LVAD implantation starting in March 2011 has been observed. This observation is likely multifaceted; however, recent changes in perioperative anticoagulation, accepting lower target international normalized ratios and lack of heparin bridging may play a substantial role. The International Society for Heart and Lung Transplantation published guidelines surrounding LVAD anticoagulation and management options in the setting of pump thrombosis. Recommendations for thromboprophylaxis in patients with LVADs are scarce. The International Society for Heart and Lung Transplantation has put together minimum criteria for perioperative anticoagulation; however, this is on the basis of poor level of evidence (observational studies and expert opinion). Ultimately, clinicians will need to individualize the intensity and timing of anticoagulation following LVAD implantation to ensure adequate thromboprophylaxis while simultaneously minimizing bleeding.