Argatroban Bridging in the Immediate Post-Operative Period in Recipients of Durable Left Ventricular Assist Devices

Abstract

Purpose In recipients of durable LVADs, the development of heparin induced thrombocytopenia threatens the integrity of the pump circuit and thus the life of the patient. In hospitalized HF patients, the exposure to heparin is frequent and often prolonged. We set out to change our immediate bridging protocol post-LVAD to decrease heparin exposure and evaluate the bleeding and thromboembolic consequences of these 2 different bridging strategies. Methods This is a single center retrospective study of consecutive patients implanted with a durable LVAD. Heparin (HEP) bridging was utilized in patients from Jan 2016 to June 2017 (n=30) and argatroban (ARG) bridging was utilized in patients from July 2017 through June 2018. Patients that received an RVAD at time of LVAD implantation were excluded from the analysis. Patients were started on intravenous anticoagulation the morning of POD#1 and were titrated to goal (heparin anti-factor Xa levels 0.3 to 0.5; argatroban PTT 50-70 s.) Aspirin and warfarin were also initiated on POD#1. Events were tracked 6 months post-implant. Results Device selection between the two groups was different with the following breakdown; HEP group with 27 HM2 and 3 HVADs compared to the ARG group with 11 HM2, 15 HVADs and 3 HM3. The need to return to the OR from bleeding was lower in the ARG group (6.4% vs 23.3%, p=0.27). The mean number of red blood cell transfusions was statistically lower in the ARG group (1.5 vs 2.7 units, p=0.02). There was no difference observed between the platelet counts on POD#3 or POD#7. A nonsignificant reduction in major hemolysis between the two groups was noted (HEP 20.0% vs ARG 3.2%, p=0.10). There was 1 patient with pump thrombosis in the ARG group compared to 2 patients in the HEP group. A nonsignificant increase in strokes was observed in the ARG group (overall 25.8% - 19.3% ischemic stroke; 6.5% hemorrhagic stroke) compared to the HEP group (overall 16.6% - 13.3% ischemic; 3.3 hemorrhagic stroke; p=0.58) Conclusion Argatroban bridging in the immediate post-operative period is safe in recipients of durable LVADs. There were fewer bleeding events in the ARG bridged group. Though not meeting statistical significance, there were numerically more episodes of major hemolysis and pump thrombosis in the HEP group which contrasted with more stroke events in the ARG group.