Anticoagulation Strategy in Patients with HeartMate II Undergoing Elective Surgery

Abstract

Introduction Management of anticoagulation in patients with left ventricular assist devices (LVADs) undergoing elective invasive procedures or surgeries is challenging. We studied the patterns and outcomes of management of anticoagulation in patients with HeartMate II. Methods We prospectively included patients with HeartMate II, followed at our institution, who were scheduled for elective invasive procedures or surgeries, and recorded anticoagulation management. Primary outcome was bleeding or pump thrombosis within 3 months following the procedure. Chi square test was used to calculate statistical significance. Results A total of 29 patients underwent 41 elective procedures. Before procedure, all were taking warfarin. Their mean INR was 2.3±0.9, and mean dose of warfarin was 4.9±2 mg/day. Five patients had more than one procedure. Out of them, 21 had 34 elective invasive procedures or surgeries raging from endoscopy and dental extraction to ileostomy reversal. There was no significant blood loss, with hematocrit 32.1±6.4 and 32.2±6.0 before and after procedure, respectively. INR on the day of the procedure was 1.6±0.4. Bleeding or thrombotic events within three months of the procedure occurred in 5 cases (16.1%). Anticoagulation was continued without interruption in 9 (26.4%) cases, interrupted without bridging in 16 (52.8%), and interrupted with bridging with heparin/low molecular weight heparin in 9 (26.4%) cases. In those who had uninterrupted anticoagulation during the procedure, one patient (11.1%) had oral bleeding requiring hospitalization after teeth extraction. There were no thromboembolic events. In patients with interruption of warfarin but no bridging there were no bleeding complications but there was one pump thrombosis requiring the device exchange (6.3%). Patients who were bridged had 4 bleeding events and no thrombosis (44.4%), p Additionally, 10 patients had procedures in the catheterization laboratory, including right heart catheterization and cardiomems implantation. All of them continued routine anticoagulation with warfarin. Only one patient with history of recurrent gastrointestinal bleeding was admitted for GI bleeding one month after cardiomems implantation. Conclusions In patients with HeartMate II, bridging with low molecular weight heparin results in more bleeding events than continuing anticoagulation without interruption or interrupting warfarin without bridging.