Seven Years of Ventricular Assist Device Support on Dabigatran

Abstract

Introduction Currently, left ventricular assist device (LVAD) support mandates anticoagulation with coumarin derivatives such as warfarin and acenocoumarol as well as antiplatelet therapy with low-dose aspirin, for the prevention of thromboembolic events. Bleeding remains a major concern in LVAD recipients and is mainly attributed to the acquired von Willebrand factor deficiency exhibited in such patients. In addition, proper anticoagulation with vitamin K antagonists depend on targeted levels of international normalized ratio (INR) which can be influenced by several factors such as diet and liver function. Case Report A 64-year-old male patient underwent LVAD implantation as destination therapy 13 years ago due to end-stage heart failure caused by ischemic cardiomyopathy. The device used was the HeartMate II ventricular assist device. As per recommended guidelines, the patient was started on anticoagulation treatment using acenocoumarol and low-dose aspirin. The patient reports difficulty reaching therapeutic INR levels, necessitating very frequent coagulation blood tests. After six years on LVAD support, the patient presented to the emergency department with major intramuscular bleeding leading to compartment syndrome after a bicycle accident, necessitating transfusion of more than 2 units of packed red blood cells. His INR levels was within therapeutic range at the incident. The LVAD team then decided to change acenocoumarol to dabigatran exetilate, at the standard dose of 150mg bid as used in the prevention of thromboembolic disease in atrial fibrillation patients. Since then, after seven years of ventricular assist device support with dabigatran exetilate used for anticoagulation, the patient is still alive and has not had any bleeding or thromboembolic events. Summary The use of dabigatran exetilate as a second-line therapy in patients who have exhibited at least one major bleeding event on vitamin K antagonists seems intriguing.