Antithrombotic strategies in children receiving long-term Berlin Heart EXCOR ventricular assist device therapy

Rutledge, John; Chakravarti, Sujata; Massicotte, M. Patricia; Buchholz, Holger; Ross, David B.; Joashi, Umesh

doi:10.1016/j.healun.2013.01.1056

Cited by 45 publications

(32 citation statements)

References 20 publications

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“…It has been used in ventricular assist device patients in an effort to reduce pump thrombosis [103,104]. Small subsets of patients receiving clopidogrel in addition to other anticoagulants while on ECMO have also been reported [105,106].…”

Section: Clopidogrelmentioning

confidence: 99%

“…Like aspirin therapy, it has been extensively used in the realms of synthetic vascular graft, stent and valve therapies [111,118] as well as ventricular assist devices, particularly in the development of the Berlin Heart protocols [91,104,114,119]. The use of dipyridamole in the setting of ECMO has been reported in single-center studies aimed at demonstrating safety [96].…”

Section: Dipyridamolementioning

confidence: 99%

See 1 more Smart Citation

ECMO Biocompatibility: Surface Coatings, Anticoagulation, and Coagulation Monitoring

Maul¹,

Massicotte²,

Wearden³

2016

Extracorporeal Membrane Oxygenation: Advances in Therapy

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The interaction between the patient and the ECMO (extracorporeal membrane oxygenation) circuit initiates a significant coagulation and inflammatory response due to the large surface area of foreign material contained within the circuit. This response can be blunted with the appropriate mix of biocompatible materials and anticoagulation therapy. The use of anticoagulants, in turn, requires appropriate laboratory testing to determine whether the patient is appropriately anticoagulated. Physicians must balance the risks of bleeding with the risks of thrombosis; the proper interpretation of these tests is often shrouded in mystery. It is the purpose of this chapter to help demystify the coagulation system, anticoagulants, biocompatible surfaces, and coagulation testing so that ECMO practitioners can make informed decisions about their patients and to spur coordinated efforts for future research to improve our understanding of these complex processes.

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Section: Clopidogrelmentioning

confidence: 99%

Section: Dipyridamolementioning

confidence: 99%

ECMO Biocompatibility: Surface Coatings, Anticoagulation, and Coagulation Monitoring

Maul¹,

Massicotte²,

Wearden³

2016

Extracorporeal Membrane Oxygenation: Advances in Therapy

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“…One study found success while utilizing argatroban to manage HIT in VAD patients without an increased risk of bleeding [15]. Bivalirudin has been used during cardiac surgery in patients with a history of HIT, but its use in the treatment of HIT in LVAD patients has been shown only in case reports [16-18]. Fondaparinux has only one published case specifically in VAD patients (biventricular VAD only), no published cases with LVADs, but experience is growing in cardiac surgery patients [19-21].…”

Section: Introductionmentioning

confidence: 99%

A retrospective evaluation of fondaparinux for confirmed or suspected heparin-induced thrombocytopenia in left-ventricular-assist device patients

Benken

Tillman

Dajani

et al. 2014

J Cardiothorac Surg

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BackgroundThrombotic events are a common complication of left ventricular assist device placement and warrant prophylactic anticoagulation. Heparin is the most common anticoagulant used for prophylaxis of thrombotic events in left ventricular assist device patients as a transition to oral anticoagulants but carries the risk of heparin-induced thrombocytopenia. Limited data is available for the treatment of heparin-induced thrombocytopenia in this patient population. We report an evaluation of 8 left ventricular assist device patients with suspected or confirmed HIT started on fondaparinux at the time of heparin-induced platelet-factor-4 antibody positivity.MethodsAdult patients were reported if they were heparin-induced platelet antibody positive, tested via enzyme-linked immunusorbent assay, post-operative after left-ventricular assist device, and were initiated on fondaparinux at the time of heparin-induced platelet antibody positivity. Waiver of informed consent was granted from the institutional review board. Baseline demographics, clinical course of HIT, safety and efficacy variables were collected.ResultsEight patients receiving fondaparinux were identified and included in this report. The patient group was on average 49 years old, weighing 95 kg, with calculated BMI 28.8 and consisted primarily of Caucasian males. Three patients developed new thromboses after initiation of fondaparinux for heparin-induced thrombocytopenia. Only one patient had a major bleeding event of an overt bleed after initiation of fondaparinux therapy.ConclusionsGiven the lack of major bleeding in this evaluation, fondaparinux could be a potentially safe treatment option for left ventricular assist device patients that are heparin-induced platelet antibody positive pending confirmatory testing results. Given the development of new thromboses in 3 of 8 patients, concern exists about the efficacy of fondaparinux in this patient population. Significant limitations exist regarding these conclusions in this evaluation. Controlled, systematic evaluations are necessary to delineate safety and efficacy of fondaparinux for heparin-induced thrombocytopenia in this population.

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“…Mechanical assistance in pediatrics has considerably evolved over a decade, providing excellent results, even for small children . However, device and/or systemic thrombosis and hemorrhagic events remain the major causes of mortality and morbidity with complication rates (mainly neurologic) ranging from 20% to 60% …”

mentioning

confidence: 99%

“…The hemostatic changes associated with BH implantation are complex and require a challenging antithrombotic treatment . Thus, an antithrombotic protocol combining anticoagulant and antiplatelet molecules is recommended .…”

mentioning

confidence: 99%

Platelet‐mapping assay for monitoring antiplatelet therapy during mechanical circulatory support in children: A retrospective observational study

Giorni¹,

Costopoulos

Bachelot‐Loza

et al. 2017

Research and Practice in Thrombosis and Haemostasis

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Essentials Thromboelastography (TEG)‐platelet mapping (PM) assay is used for antiplatelet‐drug monitoring.The TEG‐PM was evaluated for dypiridamole and aspirin monitoring in 4 BH‐implanted children.Some TEG‐PM tracings were atypical leading to wrong results.The TEG‐PM has to be improved for antiplatelet‐drug monitoring during ventricular assistance. IntroductionThe complex hemostatic changes associated with Berlin Heart (BH) implantation in children require a challenging antithrombotic treatment. The aim of this retrospective analysis was to evaluate the thromboelastography (TEG)‐platelet mapping (PM) assay to monitor antiplatelet therapy in children implanted with a BH.Methods TEG‐PM was performed in 4 BH‐implanted patients receiving dipyridamole and aspirin, and 9 healthy volunteers. Patients’ antiplatelet therapy was adjusted to TEG‐PM results. Light transmission aggregometry (LTA) was also available for 2 of these patients.ResultsBetween 2009 and 2014, 4 BH‐implanted patients received a dual antiplatelet therapy monitored by TEG‐PM. In 2 patients, 18 of 34 tracings were atypical, because the maximum amplitude due to fibrin never stabilized, which made difficult antiplatelet therapy adjustment as recommended by BH's guidelines. To overcome this difficulty, TEG‐PM and LTA were next performed in parallel. However, both methods led to different decisions to adjust antiplatelet therapy in 57% of the cases. In order to better understand this atypical tracing, TEG‐PM was also performed in 9 volunteers and surprisingly 3 of them had the same atypical tracing. This atypical tracing was corrected by adding apyrase, suggesting that adenosine diphosphate (ADP) participates to spontaneous platelet activation in heparinized samples. In addition, we evidenced a high variability in the responses of TEG‐PM with ADP in volunteers.ConclusionsAntiplatelet therapy monitoring in BH‐implanted children remains challenging, as TEG‐PM is sensitive to several preanalytical and analytical conditions.

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Antithrombotic strategies in children receiving long-term Berlin Heart EXCOR ventricular assist device therapy

Cited by 45 publications

References 20 publications

ECMO Biocompatibility: Surface Coatings, Anticoagulation, and Coagulation Monitoring

ECMO Biocompatibility: Surface Coatings, Anticoagulation, and Coagulation Monitoring

A retrospective evaluation of fondaparinux for confirmed or suspected heparin-induced thrombocytopenia in left-ventricular-assist device patients

Platelet‐mapping assay for monitoring antiplatelet therapy during mechanical circulatory support in children: A retrospective observational study

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