Warfarin Discontinuation in Patients with HeartMate3 Left Ventricular Assist Device

Abstract

<h3>Purpose</h3> The standard of care for management in patients with Heartmate 3 (HM3) left ventricular assist devices (LVAD) involves anticoagulation with warfarin for thromboprophylaxis. To date, there have been no major prospective studies that evaluate outcomes of patients with HM3 LVAD off anticoagulation. We aimed to review cases of patients with HM3 LVAD in which warfarin was discontinued for various reasons. <h3>Methods</h3> A multicenter retrospective review was done of patients implanted with a HM3 LVAD. Patients who were initially on anticoagulation after implantation but later discontinued were identified. The primary outcome evaluated was the presence of a pump related thrombotic adverse event defined as pump thrombosis, stroke, or systemic embolism. Additional characteristics including echocardiographic parameters, hematologic lab values, and LVAD parameters were assessed. <h3>Results</h3> A total of eight patients were identified at three advanced heart failure centers. LVAD therapy was implemented for a median of 556 days (67-1113 days, range). Warfarin was discontinued in five patients due to substantial bleeding (recurrent GI bleeds, intracranial bleeds/subdural hematoma) and discontinued in the other three patients due to self-discontinuation/non-adherence. Warfarin was discontinued for a median of 180 days (43-567 days, range). Of the identified patients, 50% of the patients were not on aspirin. None of the patients reviewed had pump related thromboembolic or thrombotic events after discontinuing warfarin. One patient died due to cirrhosis and right ventricular failure. There was no observed change in echocardiographic parameters, lab values, or LVAD parameters after cessation of warfarin. <h3>Conclusion</h3> In this multicenter case review, warfarin discontinuation in patients with HM3 LVAD did not result in an increase of pump related thrombotic events. In select cases, it is reasonable to discontinue anticoagulation however close monitoring is required. Further investigation is required to understand the long term safety and hemocompatibility of discontinuing anticoagulation in patients with HM3 LVAD.