Antithrombotics after Intracranial Hemorrhage in Patients with Left Ventricular Assist Devices

Abstract

Decisions regarding if or when to resume antithrombotics (anticoagulation or antiplatelets) after intracranial hemorrhage (ICH) in patients with left ventricular devices (LVADs) remain controversial and available data to guide management is limited. We aim to explore antithrombotic practices following ICH in LVAD patients and identify most effective strategies. Using a retrospective analysis of our institutional LVAD database between 11/2012 and 5/2018, we identified all patients who suffered ICH. We recorded type and timing of antithrombotic resumed following ICH. Primary outcome events included subsequent ischemic stroke or TIA, pump thrombosis, systemic thrombosis, re-hemorrhage, and extracranial bleeding; death was a secondary outcome. Other variables collected included age, sex, and year of LVAD placement. Descriptive and nonparametric survival analyses were performed. A total of 36 adult patients met our criteria. Median age was 54.5 years (IQR 38-56), 28% were women, and 25% non-white. Forty-four percent of procedures occurred after 2014 and ICH occurred a median of 266 days (IQR 110-689) after LVAD implantation. Antiplatelets were held in 83% of patients for a median duration of 20 days (IQR 5.5 days to never restarted) and anticoagulation held in 92% for a median of 5 days (IQR 3-27). After ICH, 19 patients suffered 25 outcome events including 19 primary events (3 ischemic strokes/TIAs, 3 pump thromboses, 4 systemic thrombotic events, 7 re-hemorrhage, and 2 systemic hemorrhages). Kaplan-Meier survival free of a primary outcome was 89%, 72% and 58% at 7, 14 and 30 days post-ICH, respectively. Most of the 36 patients died (n=26, 72%), 12 within 90 days of the index ICH. There were no significant associations between survival free of a primary event and timing of anticoagulation, age > 60, sex, or LVAD placement before vs after 2014. Ischemic and hemorrhagic complications occurred at similar, high rates following intracranial hemorrhage in LVAD patients, with no evidence of increased risk of re-hemorrhage with early anticoagulation. Future study is necessary to identify specific risk factors for rebleeding and re-thrombosis in these patients to reduce levels or morbidity and mortality following intracranial hemorrhage.