Preoperative Bleeding and Blood Product Transfusion Association with the Preoperative Use of Aspirin and Heparin in Left Ventricular Assist Device Implantation

Abstract

Introduction Perioperative bleeding in the setting of LVAD implantation adversely impact outcomes. Hypothesis This project aims to determine pre-operative and intraoperative risk factors for this complication. Methods A retrospective cohort study was conducted including 90 consecutive advanced heart failure patients who underwent LVAD implantation as a bridge to transplantation or destination therapy from 2008 to 2017. By protocol, all anti-platelet therapies other than aspirin were discontinued 7 days pre-implantation. Aspirin was continued if clinically indicated. Additionally, any patients on anti-coagulant therapy were transitioned to intravenous heparin. Heparin infusion was discontinued 6 hours pre-operatively. Perioperative hemodynamics, laboratory values, cardiopulmonary bypass parameters, and blood product utilization were collected. Results Observable bleeding within 7 days of implant occurred in 15 patients (16%). This was significantly associated with the pre-operative use of heparin (OR 6.4; 95% CI 1.8-23.2; p=0.005) and its incidence increased for each 1 mmHg increase in right atrial pressure during pre-operative right heart catheterization (OR 1.1; 95% CI 1.0-1.2; p=0.03). Aspirin use within 3 days of implant increased the need of packed RBC transfusion both intra-operatively (OR 3.2; 95% CI 1.3-8.2; p=0.01) and post-operatively (OR 3.0; 95% CI 1.1-8.4; p=0.04) as well as increased the risk of hemoglobin drop ≥3 gm/dl on post-operative day 1 or the need of more than 2 packed RBC units peri-operatively (OR 4.2; 95% CI 1.6-11.4; p=0.004). Cardiopulmonary bypass time > 60 minutes increased the need for packed RBC transfusion post-operatively (OR 3.07; 95% CI 1.05-9.01; p=0.04). Conclusions Pre-operative aspirin and heparin are reversible factors that may affect the need for peri-operative blood products transfusion. This may indicate that these agents may need to be withheld longer or alternative antithrombotic preoperative agents should be considered.