Development of Multidisciplinary Anticoagulation Management Guidelines for Patients Receiving Durable Mechanical Circulatory Support

Abstract

Patients receiving durable mechanical circulatory support (MCS) require life-long anticoagulation with a vitamin K antagonist (VKA). Due to alternations in hemostasis, concomitant therapy with antiplatelet agents and critical illness, they are at increased risk of thromboembolic and bleeding complications compared with the general population managed on VKAs. To prevent thrombotic events, current guidelines recommend that patients with MCS receive long-term anticoagulation with a VKA to maintain a target international normalized ratio (INR) as specified by device manufacturers, but limited data exist regarding specific routine management of anticoagulation therapy and its potential complications. To optimize anticoagulation management and minimize risk in these patients, we have centralized anticoagulation management in a collaborative approach between the inpatient hemostatic and antithrombotic (HAT) stewardship service and between ambulatory anticoagulation management service (AMS) and the advanced heart disease team. Patients are followed by these three services beginning when the device is implanted and extending the duration that patients have the device. The teams include multiple clinicians from cardiac surgery, cardiology, hematology, pharmacy, nursing, case management, nutrition, and psychiatry, therefore, in order to standardize practice among clinicians without compromising patient centered decision making, we assembled an interdisciplinary team to create multiple treatment guidelines. In addition to a centralized and collaborative approach, our guidelines ensure seamless transitions of care between the inpatient and outpatient settings. We believe our approach has demontrated a positive improvement in the care of these challenging patients. In this article, we present our comprehensive centralized anticoagulation management approach for patients with left ventricular assist systems (LVAS).

Heart Failure Association of the European Society of Cardiology position paper on the management of left ventricular assist device‐supported patients for the non‐left ventricular assist device specialist healthcare provider: Part 2: at the emergency department

“…Detailed guidelines on the management of oral anticoagulation in this population are available. 45,46 Coumarin oral anticoagulants such as warfarin are metabolized via the CYP2C9, 47 which is also a common pathway for several other drugs commonly used in this patient population (antidiabetic medication, angiotensin receptor blockers, anticonvulsive medication, etc. ).…”

“…green and leafy vegetables). Detailed guidelines on the management of oral anticoagulation in this population are available 45,46 …”

A Multidisciplinary Educational Approach to Anticoagulation Management for a Percutaneous Endovascular Mechanical Circulatory Support Device

“…10 The involvement of experts representing multiple disciplines allows for the development of a more comprehensive assessment of the practice problem. In 2019, Levesque and others 11 described an interdisciplinary team comprised of inpatient and ambulatory care providers enacted to restructure AC management for patients with durable VADs. This collaboration was successful in streamlining transitions of care, standardizing practice guidelines and improving documentation.…”

Hemostatic Challenges in Pediatric Critical Care Medicine—Hemostatic Balance in VAD

“…In adults, major bleeding events are the most common adverse event within the first 3–12 months of continuous flow LVAD implantation. Gastrointestinal hemorrhage was the most common site of bleeding (up to 40%, particularly after 3 months) ( 45 , 46 ). Based on the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS) report for outcomes of children supported with temporary devices, the most frequent early adverse events were bleeding (28%) ( 13 ).…”