Argatroban as an Alternative Anticoagulant in Impella Supported Patients

Abstract

<h3>Purpose</h3> To investigate the safety and efficacy of argatroban in preventing thrombotic complications in patients with suspected heparin-induced thrombocytopenia (HIT) treated with axillary flow left ventricular assist device (Impella). <h3>Methods</h3> We performed a retrospective observational case-series of patients who were supported on Impella and anticoagulated with argatroban due to suspected HIT. The electronic medical record was reviewed for safety events including hemorrhagic or embolic stroke, bleeding and Impella motor thrombosis. <h3>Results</h3> We identified six patients who met inclusion criteria. Three patients were definitively diagnosed with HIT. In each case argatroban was used as the Impella purge solution and intravenous argatroban was administered as needed to maintain a PTT target of 50-80 seconds. The purge solution was formulated as argatroban 25mg in 500mL of dextrose 5% water. The Impella controller was programmed to a heparin purge fluid concentration of "0 IU/ml". Only one patient had a bleeding event; this involved minor bleeding from the endotracheal tube. Prior to initiation of argatroban; the PTT in this patient was elevated secondary to hepatic dysfunction which likely predisposed to bleeding. No patient developed a hemorrhagic or embolic stroke, or Impella motor thrombosis. <h3>Conclusion</h3> In this case series, the use of argatroban was a safe and effective alternative to heparin in patients with suspected HIT supported with Impella. Only one patient had a bleeding event that was attributed to underlying coagulopathy secondary to hepatic dysfunction and not from argatroban. In all patients argatroban was effective in preventing Impella motor thrombosis. Currently, the Impella console can only be programmed to administer heparinized purge solution which is a barrier to the use of alternative anticoagulants. Further investigation is needed to support the use of alternative anticoagulants in patients treated with Impella.