Bridging Anticoagulation Research Articles

Comparison of safety between continued warfarin therapy and bridging anticoagulation therapy in patients undergoing coronary intervention

Objective: To compare the safety of continued warfarin therapy and bridging anticoagulation therapy during hospital stay in patients undergoing percutaneous coronary intervention (PCI). Methods: We retrospectively analyzed patients on warfarin therapy referred for PCI in Beijing Anzhen Hospital from January 2008 to December 2016. The patients were divided into continued warfarin therapy (n=195) or bridging anticoagulation therapy (n=311) groups. After Propensity Score Matching, data from matched patients (n=123 in each group) were analyzed. Bleeding complications and major adverse cardiac events including death, myocardial infarction, target vessel revascularization, and stent thrombosis were assessed. Results: There were no significant difference in the rate of death (2.4%(3/123) vs. 1.6%(2/123),P=0.54), acute myocardial infarction (4.1%(5/123) vs. 4.9%(6/123), P=0.78),re-revascularization (0.8%(1/123) vs. 1.6%(2/123),P=0.16), stent thrombosis (1.6%(2/123) vs. 1.6%(2/123),P=1.00) and stroke between the two groups. Prevalence of minor bleeding complications was significantly higher in the bridging therapy group (15.4%(19/123) vs. 9.8%(12/123),P=0.01). Rate of access-site complications (hematoma:4.1%(5/123) vs. 2.4%(3/123),P=0.20; pseudoaneurysm:2.4%(3/123) vs. 2.4%(3/123),P=1.00; arteriovenous fistula:0.8%(1/123) vs. 1.6%(2/123),P=0.09; and retroperitoneal hematoma:0(0/123) vs. 0.8%(1/123),P=0.23) were similar between the two groups. Conclusion: For patients receiving chronic warfarin therapy, the uninterrupted oral anticoagulant treatment is as safe as bridging therapy in PCI patients.

Bridging anticoagulation in patients receiving vitaminKantagonists : Current status

Approximately 30% of patients receiving oral anticoagulation using vitaminK antagonists (VKA) require surgery within 2years. In this context, aclinical decision on the need and the mode of aperi-interventional bridging with heparin is needed. While afew years ago, bridging was almost considered astandard of care, recent study results triggered adiscussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for arisk-adapted peri-interventional approach to management of patients with aneed for long-term anticoagulation using VKA.

Perioperative hematoma with subcutaneous ICD implantation: Impact of anticoagulation and antiplatelet therapies.

The safety of perioperative anticoagulation (AC) and antiplatelet (AP) therapy with subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is unknown. The purpose of this study was to identify therisk factors associated with hematoma complicating S-ICD implantation. Records were retrospectively reviewed from 200 consecutive patients undergoing S-ICD implantation at two academic medical centers. A hematoma was defined as a device site blood accumulation requiring surgical evacuation, extended hospital stay, or transfusion. Among 200 patients undergoing S-ICD implantation (age 49 ± 17 years, 67% men), 10 patients (5%) had a hematoma, which required evacuation in six patients (3%). Warfarin was bridged or uninterrupted in 12 and 13 patients, respectively (6% and 6.5%). Four of 12 patients with warfarin and bridging AC (33%) and two of 13 patients with uninterrupted warfarin (15%) developed a hematoma. Neither of the two patients with uninterrupted DOAC had a hematoma. No patients on interrupted AC without bridging (n=26, 13 with warfarin, 13 with DOAC) developed a hematoma. A hematoma was also more likely with the use of clopidogrel (n=4/10vs 10/190, 40%vs 5.3%, P<0.0001) in combination with aspirin in 12/14 patients. Any bridging AC (odds ratio [OR] 10.3, 1.8-60.8, P=0.01), clopidogrel (OR 10.0, 1.7-57.7, P=0.01), and uninterrupted warfarin without bridging (OR 11.1, 1.7-74.3, P=0.013) were independently associated with hematoma formation. AC and/or AP therapy with clopidogrel appears to increase the risk for hematoma following S-ICD implantation. Interruption of AC without bridging should be considered when it is an acceptable risk to hold AC.

Barriers to Adherence with Early Postoperative Bridging Anticoagulation Protocols Following LVAS Implantation

Early post-operative bridging anticoagulation is a key component in care pathways to prevent LVAS pump thrombosis. We conducted a single-center analysis of initial post-operative anticoagulation practices to identify barriers to implementation of standard anticoagulation protocols following LVAS.

Current Trends in Anticoagulation Bridging for Patients With Chronic Atrial Fibrillation on Warfarin Undergoing Endoscopy

For warfarin-treated patients with atrial fibrillation (AF) at low thromboembolic risk, recent studies have shown harm associated with periprocedural bridging using low-molecular-weight heparin. Clinician surveys have indicated a preference toward excessive bridging, especially among noncardiologists; however, little is known about actual practice patterns in these patients. We performed a retrospective evaluation of bridging in the setting of gastrointestinal endoscopy. We identified 938 patients with AF on warfarin who underwent esophagogastroduodenoscopy or colonoscopy between 2012 and 2016 at a tertiary health center. Urgent, inpatient, or advanced endoscopic procedures were excluded. Clinical variables were abstracted using a predefined data dictionary. Values were expressed as means and compared using a t test or a chi-squared test as appropriate. Three hundred seventy-four patients met criteria for analysis. Twenty-five percent of these patients received bridging therapy, including 11% of patients with CHADS2 scores of 0 to 2 without valvular AF or previous venous thromboembolism. Of the clinical variables assessed, CHADS2, CHA2DS2-VASc, and a history of stroke were the strongest predictors of bridging. Cardiologists were also significantly less likely to prescribe bridging than noncardiology providers (18% vs 30%, p = 0.011); this effect was significant when controlling for CHADS2, CHA2DS2-VASc, or stroke history. In conclusion, patients with AF on warfarin receive excessive low-molecular-weight heparin bridging in the setting of endoscopy; the lower rates of bridging observed among cardiologists suggests a need for their increased involvement in this decision making.

Development of an Outpatient Guideline for Optimal Anticoagulation Bridging in Patients With Durable Mechanical Circulatory Support.

Patients with durable mechanical circulatory support are at increased risk of thromboembolic and bleeding complications. Current guidelines recommend that these patients receive chronic anticoagulation with warfarin to maintain a target international normalized ratio (INR) as specified by device manufacturers. Limited data exist regarding management of subtherapeutic INRs in this setting. To standardize clinical practice at our institution, we assembled a multidisciplinary task force including members from various specialties to develop a guideline for managing subtherapeutic INRs that incorporates published data and expert opinion. In this article, we present our clinical practice guideline as a decision support tool to aid clinicians in developing a consistent strategy for managing subtherapeutic INRs and for safely bridging anticoagulation in patients receiving mechanical circulatory support.

Thromboembolic prophylaxis protocol with warfarin after radiofrequency catheter ablation of infarct-related ventricular tachycardia.

Ablation in the left ventricle (LV) is associated with a risk of thromboembolism. There are limited data on the use of specific thromboembolic prophylaxis strategies postablation. We aimed to evaluate a thromboembolic prophylaxis protocol after ventricular tachycardia (VT) ablation. The index procedures of 217 patients undergoing ablation for infarct-related VT with open irrigated-tip catheters were included. Patients with large LV endocardial ablation area (>3cm between ablation lesions) were started on low-dose, slowly escalating unfractionated heparin (UFH) infusion 8hours after access hemostasis, followed by 3months of anticoagulation. Patients with less extensive ablation were treated only with antiplatelet agents postablation. Postablation bridging anticoagulation was used in 181 (83%) patients. Of them, 11 (6%) patients experienced bleeding events (1 required endovascular intervention) and 1 (0.6%) experienced lower extremity arterial embolism requiring vascular surgery. Systemic anticoagulation was prescribed in 190 (89%) of 214 patients discharged from the hospital (warfarin in 98%), while the rest received single- or dual-antiplatelet therapy alone. Patients treated with an anticoagulant had significantly longer radiofrequency time compared to patients treated with antiplatelet agents only. One (0.5%) of the patients treated with oral anticoagulation experienced major bleeding 2 weeks postablation. No thromboembolic events were documented in either the anticoagulation or the "antiplatelet only" group postdischarge. A slowly escalating bridging regimen of UFH, followed by 3months of oral anticoagulation, is associated with low thromboembolic and bleeding risks after infarct-related VT ablation. In the absence of extensive ablation, antiplatelet therapy alone is reasonable.

Perioperative management of anticoagulant and antiplatelet therapy

### Learning objectives Long-term oral anticoagulant therapy is often used in patients with atrial fibrillation (AF), a mechanical heart valve (MHV) or venous thromboembolism. The perioperative management of patients who...

Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications

Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge and other antithrombotic therapy. We performed a retrospective cohort and case control study at 2 tertiary-care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding. There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14.9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1.19% (95% confidence interval, 0.91%-1.54%) (59/4923). We identified similarly low rates of bleeding in patients taking warfarin (0.66%), clopidogrel (0.84%), and aspirin (0.92%). Patients who bled tended to have larger polyps (13.9 vs 7.3mm; P< .001) and more polyps≥2 cm (41% vs 10%; P< .001). Bleeding risk was increased with restarting antithrombotics within 1 week postpolypectomy (odds ratio [OR] 4.50; P< .001), having polyps≥2 cm (OR 5.94; P< .001), performing right-sided cautery (OR 2.61; P= .004), and having multiple large polyps (OR 2.92; P=.001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P= .0001). We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with patients taking warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk.

Impact of educational intervention on management of periprocedural anticoagulation.

The effect of education regarding new evidence in periprocedural anticoagulation, with a focus on reducing use in patients at only moderate thromboembolic risk, is presented. A retrospective cohort analysis and quasiexperimental design were used. The initial review identified the current state of practice regarding bridging anticoagulation. Education was then provided to primary care providers and pharmacists on recent evidence. A subsequent review was completed to assess the impact of this education on clinical decision-making. Inclusion criteria were adults taking warfarin for an indication of mechanical heart valve, atrial fibrillation (AF), or history of venous thromboembolism (VTE) and required interruption of warfarin therapy to undergo a planned procedure. Patients were excluded if their anticoagulation was managed outside of the Minneapolis Veterans Affairs Anticoagulation Clinic. The overall rate of bridging decreased from 38.8% to 24.8% (14% decrease; 95% confidence interval [CI], 2-26%; p = 0.028) confidence interval [CI], 0.02-0.26; p = 0.026) after educational intervention. This decrease occurred in the moderate thromboembolic risk group, in which the bridging rate decreased from 63.8% to 30.2% (33.6% decrease; 95% CI, 14-53%; p = 0.001). Bleeding complications occurred more frequently in patients who received bridging. There were no thromboembolic complications. The majority of patients at moderate thromboembolic risk were previously receiving bridging until new evidence was released indicating that the risks may outweigh any benefits. The provision of education to primary care physicians and pharmacy staff regarding this new evidence in the area of periprocedural anticoagulation management significantly reduced the amount of bridging used for patients on warfarin for AF or a history of VTE who were at moderate thromboembolic risk.

Bleeding risk of submuscular ICD implantation with continued oral anticoagulation versus heparin bridging therapy.

Recent studies have shown that subcutaneous or subfascial pacemaker- and ICD implantation with continued oral anticoagulation therapy is associated with lower risk for bleeding complications, when compared to heparin bridging strategies. However, ICD generators are often implanted submuscularly. We therefore compared the bleeding risk with continued phenprocoumon therapy vs. heparin bridging in patients receiving submuscular ICD implantation. Between 01/2013 and 12/2013, 104 patients with need for oral anticoagulation received submuscular ICD or CRT-D implantation in our institution. 46 patients were implanted under continued phenprocoumon therapy while 58 patients received heparin bridging for implantation procedure. All ICD generators were placed submuscularly. The primary outcome of the study was clinically significant bleeding or device pocket hematoma with need for surgical revision. Mean patients age was 63.7years, 72.1% were male. In patients with heparin bridging therapy, preoperative INR prior to ICD implantation was 1.2±0.31 while in the group of patients on continued phenprocoumon therapy, mean pre-OP INR was 2.4±0.47. In heparin bridging group, 8 (13.8%) patients experienced a clinically relevant pocket hematoma, while only 1 (2.2%) patient on continued phenprocoumon therapy needed surgical revision for pocket hematoma (P=0.04). No further bleeding complications or clinically relevant pericardial effusion was observed in any of the groups and no perioperative thromboembolic event occurred. Submuscular ICD implantation under continued phenprocoumon therapy was safe and feasible. Compared to patients with heparin bridging therapy, those with continued phenprocoumon therapy had a lower incidence of clinically relevant bleeding complications.

Efficacy and safety of Rivaroxaban anticoagulant therapy in the treatment of atrial fibrillation cryoablation

Objective: To observe the efficacy and safety of the novel oral anticoagulant Rivaroxaban for anticoagulation therapy in patients with nonvalvular atrial fibrillation (AF) during cryoablation. Methods: A total of 137 AF patients from October 2013 to December 2016 underwent cryoablation were divided into two groups according to the application of anticoagulant drugs: Rivaroxaban group (65 cases) and Heparin group (72 cases). Rivaroxaban group: oral administration of Rivaroxaban 20 mg, once a day, was started 3 days before the cryoablation, no anticoagulant was additionally added during cryoablation, the activated clotting time (ACT) was measured, and oral administration of Rivaroxaban was continued for 3 months after cryoablation. Heparin group: oral administration of Rivaroxaban 20 mg, once a day, was stopped 24 hours before the cryoablation, heparin (100 U/kg) anticoagulation was given during cryoablation, ACT was controlled between 250 and 300 seconds, and oral administration of Rivaroxaban was continued for 3 months after cryoablation. The ACT results, the incidence of bleeding and thromboembolic events between the two groups were compared. Results: The ACT result between the two groups were with statistically significance[(110±16) vs (323±61) seconds, P=0.000)]. The bleeding events for Rivaroxaban group were two cases of local hematoma of the femoral vein puncture site, with the incidence rate of 3.1%(2/65); Heparin group were two cases of local hematoma of the femoral vein puncture site, and one case of epistaxis, with the incidence rate of 4.2%(3/72), with no statistical significance(P=0.549) between the two groups. No thromboembolic event occurred in the Rivaroxaban group, one cerebellar thromboembolic event occurred in the Heparin group during anticoagulant bridging phase after cryoablation. Conclusion: Rivaroxaban is safe and effective for anticoagulation therapy in patients with atrial fibrillation cryoablation.

Evaluation of a Standardized Perioperative Management Protocol in the Adult Hematology Anticoagulation Management Service.

In North America, 250,000 patients on vitamin K antagonists require surgical procedures each year. Temporary interruption of oral anticoagulation and perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin are recommended by the American College of Chest Physicians 2012 for select patients. The study objectives are to evaluate adherence and nonadherence to the Johns Hopkins clinic guidelines for perioperative management of anticoagulation and identify bleeding or thromboembolic events during perioperative management of anticoagulation. This is a retrospective study of patients who required perioperative management of anticoagulation for an invasive procedure from May 2009 to March 2014. Individualized perioperative anticoagulation management plans were prospectively developed for each patient according to the standardized Johns Hopkins perioperative bridging recommendations and documented in the medical record. Adherence to these standardized Johns Hopkins clinic guidelines, the incidence of thromboembolic events, and bleeding and adverse events during perioperative management were retrieved from the medical record. In 294 perioperative management cases, there was 1 (0.3%) thromboembolism, 3 (1%) major bleeds, and 21 (7%) minor bleeds. One patient experienced facial swelling after starting enoxaparin. There was no difference in thromboembolic (0 vs 1, P = 1.00), major (1 vs 2, P = 1.00), or minor bleeding (14 vs 7, P = 1.00) events in patients managed by providers who were adherent to guidelines when compared with providers who were nonadherent. Our study shows that using a standardized guideline for perioperative management of anticoagulation to inform but not to dictate clinical practice leads to low rates of both thromboembolism and bleeding.

Management of Supratherapeutic International Normalized Ratio without Bleeding after Warfarin Use: An Evaluation of Vitamin K Administration (SUPRA-WAR-K Study).

For patients with supratherapeutic international normalized ratio (INR) and no evidence of bleeding, the 2012 guidelines of the American College of Chest Physicians discourage administration of vitamin K. At the study hospital, it was observed that vitamin K was frequently prescribed for patients with INR of 4.5 or higher and no bleeding. To compare efficacy and safety outcomes between holding warfarin alone and holding warfarin with administration of vitamin K and to compare these outcomes among various doses and routes of vitamin K administration in non-critical care inpatients experiencing supratherapeutic INR without evidence of bleeding. This single-centre retrospective chart review involved noncritical care inpatients with supratherapeutic INR (4.5-8.9) without evidence of bleeding. The primary outcomes were the change in INR 1 day after implementation of supratherapeutic INR management and the time to reach INR less than 3.0. The secondary outcomes were length of stay, frequency of warfarin resistance, incidence and duration of bridging anticoagulation, incidence of thromboembolism and major bleeding, and death. Regardless of vitamin K dose, the administration of vitamin K combined with holding warfarin, relative to holding warfarin alone, was associated with a greater INR decrease 1 day after the intervention (mean ± standard deviation -3.2 ± 1.9 versus -0.9 ± 1.0, p < 0.001) and a shorter time to reach INR below 3.0 (1.9 ± 1.0 days versus 2.6 ± 1.4 days, p = 0.003). No statistically significant differences in any other outcomes were observed. In hospitalized non-critical care patients with INR between 4.5 and 8.9 without evidence of bleeding, the combination of holding warfarin and administering vitamin K was associated with greater and faster decreases in INR than holding warfarin alone. No significant differences were found in clinically important outcomes. The practice of administering vitamin K in this population warrants further study and re-evaluation.

Safety and Efficacy of Rivaroxaban in Patients With Cardiac Implantable Electronic Devices: Observations From the ROCKET AF Trial.

BackgroundAlthough implantation of cardiac implantable electronic devices (CIEDs) in patients receiving warfarin is well studied, limited data are available on the use of oral factor Xa inhibitors in this setting.Methods and ResultsUsing data from Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) (n=14 264), we compared baseline characteristics and clinical outcomes in patients with atrial fibrillation randomized to rivaroxaban versus warfarin who did and did not undergo CIED implantation or revision. In this post‐hoc, postrandomization, on‐treatment analysis, only the first intervention per patient was analyzed. During a median follow‐up of 2.2 years, 453 patients (242 rivaroxaban group; 211 warfarin group) underwent de novo CIED implantation (64.2%) or revision procedures (35.8%). Patients who received CIEDs were older, more likely to be male, and more likely to have past myocardial infarction, but had similar stroke risk compared to patients who did not receive CIEDs. Most patients who received a device had study drug interrupted for the procedure and did not receive bridging anticoagulation. During the 30‐day postprocedural period, 11 patients (4.55%) in the rivaroxaban group experienced bleeding complications compared with 15 (7.13%) in the warfarin group. Thromboembolic complications occurred in 3 patients (1.26%) in the rivaroxaban group and 1 (0.48%) in the warfarin group. Event rates were too low for formal hypothesis testing.ConclusionsBleeding and thromboembolic events were low in both rivaroxaban‐ and warfarin‐treated patients. Periprocedural use of oral factor Xa inhibitors in CIED implantation requires further study in prospective, randomized trials.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00403767.

Anticoagulation Bridge Therapy in Patients with Atrial Fibrillation: Recent Updates Providing a Rebalance of Risk and Benefit.

In 2011 we reviewed clinical updates and controversies surrounding anticoagulation bridge therapy in patients with atrial fibrillation (AF). Since then, options for oral anticoagulation have expanded with the addition of four direct oral anticoagulant (DOAC) agents available in the United States. Nonetheless, vitamin K antagonist (VKA) therapy continues to be the treatment of choice for patients who are poor candidates for a DOAC and for whom bridge therapy remains a therapeutic dilemma. This literature review identifies evidence and guideline and consensus statements from the last 5 years to provide updated recommendations and insight into bridge therapy for patients using a VKA for AF. Since our last review, at least four major international guidelines have been updated plus a new consensus document addressing bridge therapy was released. Prospective trials and one randomized controlled trial have provided guidance for perioperative bridge therapy. The clinical trial data showed that bridging with heparin is associated with a significant bleeding risk compared with not bridging; furthermore, data suggested that actual perioperative thromboembolic risk may be lower than previously estimated. Notably, patients at high risk for stroke have not been adequately represented. These findings highlight the importance of assessing thrombosis and bleeding risk before making bridging decisions. Thrombosis and bleeding risk tools have emerged to facilitate this assessment and have been incorporated into guideline recommendations. Results from ongoing trials are expected to provide more guidance on safe and effective perioperative management approaches for patients at high risk for stroke.

Oral anticoagulation management in patients with atrial fibrillation undergoing cardiac implantable electronic device implantation.

BackgroundOral anticoagulation (OAC) therapy is associated with increased periprocedural risks after cardiac implantable electronic device (CIED) implantation. Patterns of anticoagulation management involving non–vitamin K antagonist oral anticoagulants (NOACs) have not been characterized.HypothesisAnticoagulation strategies and outcomes differ by anticoagulant type in patients undergoing CIED implantation.MethodsUsing the nationwide Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we assessed how atrial fibrillation (AF) patients undergoing CIED implantation were cared for and their subsequent outcomes. Outcomes were compared by oral anticoagulant therapy (none, warfarin, or NOAC) as well as by anticoagulation interruption status.ResultsAmong 9129 AF patients, 416 (5%) underwent CIED implantation during a median follow‐up of 30 months (interquartile range, 24–36). Of these, 60 (14%) had implantation on a NOAC. Relative to warfarin therapy, those on a NOAC were younger (70.5 years [range, 65–77.5 years] vs 77 years [range, 70–82 years]), had less valvular heart disease (15.0% vs 31.3%), higher creatinine clearance (67.3 [range, 59.7–99.0] vs 65.8 [range, 50.0–91.6]), were more likely to have persistent AF (26.7% vs 22.9%), and use concomitant aspirin (51.7% vs 35.2%). OAC therapy was commonly interrupted for CIED in 64% (n = 183 of 284) of warfarin patients and 65% (n = 39 of 60) of NOAC patients. Many interrupted patients received intravenous bridging anticoagulation: 33/183 (18%) interrupted warfarin and 4/39 (10%) interrupted NOAC patients. Thirty‐day periprocedure bleeding and stroke adverse events were infrequent.ConclusionsManagement of anticoagulation among AF patients undergoing CIED implantation is highly variable, with OAC being interrupted in more than half of both warfarin‐ and NOAC‐treated patients. Bleeding and stroke events were infrequent in both warfarin and NOAC‐treated patients.

Abstract 154: Bridging to Warfarin With Direct Oral Anticoagulant Agents

Background: Anticoagulation bridging using LMWH remains a common practice to mitigate the Warfarin’s delayed onset of action. However, LMWH often creates resistance from patients given cost, fear to injections, or in patients already on direct oral anticoagulant agents (DOACs), cost coverage that demand agent change. In such circumstances, the possibility of bridging using DOACs has been adopted. Aim: To characterize the outcomes and cost benefit for patients who were bridged to Warfarin using a DOAC. Methods: We identified a case series of patients who used DOACs for bridging to Warfarin. Primary outcome was major hemorrhage and thrombosis recurrence identified 30 and 60 days after initial bridging therapy was initiated. Categorical variables were presented as percentages, continuous variables as median and range. Chi Square or Student T were used as appropriate. Results: A total of nineteen patients were included (Men = 42%, Age = 66.3 (32-93), BMI = 29 (19.5-44.6)). Twelve patients received Apixaban (63%), and seven patients received Rivaroxaban (37%). Reasons to avoid low molecular weigh heparin were patient’s preference (53%), changing indication (32%), interaction (10%), and cost (5%) The average time for successful bridging was 13.2 days (5-29). No episodes of major bleeding, deep venous thrombosis, pulmonary embolism or minor bleeding were registered after 30 and 60 days of initiation of bridging therapy. Average cost of bridging therapy with DOAC was 158.3 USD (Range 21.1-407.9). Estimated cost of bridging therapy with LMWH and current pricing would have been 652.4 US dollars (294-1421). Conclusion: Bridging strategy with direct oral anticoagulant agents seems to be a safe, cost-effective approach in patients receiving oral Warfarin. Moreover, this alternative is reasonable for patients with aversion or lack of social support to administer injections. A larger study is necessary to further explore these findings.

(666) - Post-Operative Bridging Anticoagulation and HeartMate II Pump Thrombosis

(666) - Post-Operative Bridging Anticoagulation and HeartMate II Pump Thrombosis

(654) - Bridging Anti-Coagulation with Low-Molecular-Weight Heparin in HVAD Patients - A Safe and Effective Option

Anti-coagulation with Vitamin-K-antagonists is imperatively required to prevent thrombotic events in patients on left ventricular assist devices (LVAD). In the case of sub-therapeutic INR, Heparin is commonly used to bridge anticoagulation. However, its short half-life, instable metabolism and the need for intravenous treatment are major drawbacks of this approach which may lead to bleeding or insufficient anticoagulation. In this study, we sought to analyse the safety and efficacy of anti-coagulation bridging with low-molecular-weight Heparin (LMWH) as an alternative for HVAD patients.