Is anti-platelet therapy needed in continuous flow left ventricular assist device patients? A single-centre experience

Litzler, Pierre‐Yves; Smail, Hassiba; Barbay, Virginie; Nafeh-Bizet, Catherine; Bouchart, F; Baste, Jean-Marc; Abriou, Caroline; Bessou, Jean–Paul

doi:10.1093/ejcts/ezt228

Cited by 38 publications

(31 citation statements)

References 18 publications

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“…However, in this analysis, the observed rates of thrombotic events with ASA 325 mg were similar to those seen with ASA 81 mg+DPE and ASA 81 mg. Our findings are similar to another investigation conducted with the HM II device in which patients off ASA therapy showed no change in thromboembolic events. 13 Moreover, preliminary results of the European cohort of the Study of Reduced Anti-coagulation/Antiplatelet Therapy in Patients With the HeartMate II Left Ventricular Assist System (TRACE) study indicate that an a priori antiplatelet therapy free regimen may reduce GIB rates without increasing thromboembolic event rates in HM II patients. 14 The final analyses of this multicenter trial may shed further light on the effect of reduced antithrombotic therapy on AEs.…”

Section: Discussionmentioning

confidence: 99%

Antiplatelet Therapy and Adverse Hematologic Events During Heart Mate II Support

Saeed

Shah

Kargoli

et al. 2016

Circ: Heart Failure

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Background — Hematologic adverse events are common during continuous flow left ventricular assist device support; yet, their relation to antiplatelet therapy, including aspirin (ASA) dosing, is uncertain. Methods and Results— A single-center retrospective review of all patients supported by a continuous flow left ventricular assist device (Heart Mate II) from June 2006 to November 2014 was conducted. Patients were categorized into 3 groups: (1) ASA 81 mg+dipyridamole 75 mg daily (n=26) with a target international normalized ratio (INR) of 2 to 3 from June 2006 to August 2009; (2) ASA 81 mg daily (n=18) from September 2009 to August 2011 with a target INR of 1.5 to 2; and (3) ASA 325 mg daily from September 2011 to November 2014 with a target INR of 2 to 3 (n=70). Hemorrhagic and thrombotic outcomes were retrieved ≤365 days after implantation. Cumulative survival free from adverse events was calculated using Kaplan–Meier curves and Cox proportional hazard ratios were generated. Hemorrhagic events occurred in 6 patients on ASA 81 mg+dipyridamole (26%; 0.42 events per patient year; mean INR at event, 2.2), 4 patients on ASA 81 mg (22%; 0.38 events per patient year; mean INR at event, 2.0), and in 38 patients on ASA 325 mg (54%; 1.4 events per patient year; mean INR at event, 2.2); P =0.004. Patients on ASA 325 mg had a higher adjusted hazard ratio of 2.9 (95% confidence interval, 1.2–7.0 versus ASA 81 mg+dipyridamole; P =0.02) and 3.4 (95% confidence interval, 1.2–9.5 versus ASA 81 mg; P =0.02) for hemorrhagic events. Thrombotic events rates were not different between groups. Conclusions— High-dose ASA in Heart Mate II patients treated concomitantly with warfarin is associated with an increased hazard of bleeding but does not reduce thrombotic events.

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Section: Discussionmentioning

confidence: 99%

Antiplatelet Therapy and Adverse Hematologic Events During Heart Mate II Support

Saeed

Shah

Kargoli

et al. 2016

Circ: Heart Failure

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“…Despite a fairly rigid regimen of anticoagulation and antiplatelet measures, pump thrombosis still occurs and has devastating consequences [23], [24], [25], [26], [27]. In addition to the existing routinely used regimens, other anticoagulants/antiplatelet agents reported in the literature include dipyridamole, pentoxifylline, dextran, and fluindione [28], [29], [30], [31].…”

Section: Introductionmentioning

confidence: 99%

Thrombolytics in VAD management — A single-center experience

Nair

Schmitt

Rau

et al. 2016

IJC Heart & Vasculature

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BackgroundWith continued increase in the use of mechanical circulatory support, the incidence of device thrombus remains a challenge. This study is a retrospective analysis of data at a single center to assess the safety and efficacy of thrombolytic use in durable mechanical assist devices.MethodsData was analyzed retrospectively from 154 patients who underwent left ventricular assist device (LVAD) implantation from 1/1/2005 to 6/30/2014. The HMII device was implanted in 131 patients while 23 received the HVAD. LVAD thrombus was diagnosed when lactate dehydrogenase levels exceeded 1000 units/l accompanied by clinical signs of hemolysis and heart failure, echocardiographic data and surges in pump power. TPA (tissue plasminogen activator) protocol consisted of a 5 mg intravenous bolus followed by 3 mg/h infusion in normal saline for 10 h. If symptoms persisted another cycle of TPA at 1 mg/h was continued up to 48 h.ResultsThe TPA group had a 70% success rate. Success was defined as complete resolution of hemolysis and clinical symptoms with no requirement for LVAD exchange at 30 days. 95% survival was noted at 30 days and 90% were free of a hemorrhagic stroke in the TPA group. The rates of hemorrhagic strokes in the TPA group and the control group were not different (OR = 0.92).ConclusionThe TPA protocol described here was successful consistently. Though this study is limited by its size and retrospective nature it leads the way for larger studies to generate more robust comparisons between different types of mechanical assist devices as well as the tailored use of thrombolytics in this patient population.

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“…34 In a group of patients receiving only VKA therapy, the event rate of stroke (ischemic and hemorrhagic) per patient-year was 0.059 among the patients. 34 Evaluation of the clinical decision to withdraw aspirin therapy in MCS patients showed that VKA without aspirin in MCS patients did not increase thromboembolic events and could lead to a diminished risk of bleeding events. 34 Different types of MCS devices are available, making a universally applicable anticoagulation strategy improbable.…”

Section: Thoracic and Cardiovascular Surgeonmentioning

confidence: 97%

“…Some authors showed that VKA therapy without aspirin seems safe in regards to adverse ischemic/thromboembolic events. 34 Litzler et al described their experience with excluding the antiplatelet therapy in MCS patients. 34 In a group of patients receiving only VKA therapy, the event rate of stroke (ischemic and hemorrhagic) per patient-year was 0.059 among the patients.…”

Section: Thoracic and Cardiovascular Surgeonmentioning

confidence: 99%

“…34 Litzler et al described their experience with excluding the antiplatelet therapy in MCS patients. 34 In a group of patients receiving only VKA therapy, the event rate of stroke (ischemic and hemorrhagic) per patient-year was 0.059 among the patients. 34 Evaluation of the clinical decision to withdraw aspirin therapy in MCS patients showed that VKA without aspirin in MCS patients did not increase thromboembolic events and could lead to a diminished risk of bleeding events.…”

Section: Thoracic and Cardiovascular Surgeonmentioning

confidence: 99%

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Bleeding and Thrombotic Events in Patients Undergoing Mechanical Circulatory Support: A Review of Literature

Petričević

Miličić

Boban

et al. 2015

Thorac cardiovasc Surg

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Bleeding and thrombotic events are among the most common complications detected in patients with mechanical circulatory support (MCS). Herein, we reviewed the available evidence on the prevalence, etiology, and management of bleeding and thrombotic events in patients following MCS procedures, such as implantation of both intra- and paracorporeal devices that generate either pulsatile or nonpulsatile flow. Extracorporeal life support procedures providing support to the failing heart and lungs were also reviewed. Most bleeding and thromboembolic events occur despite appropriate hemostatic and anticoagulation management based on conventional coagulation laboratory parameters. Prevalence of bleeding events in this population ranges between 5 and 81%. Wide range in prevalence of bleeding reported in literature may be explained by different devices with different anticoagulation protocols being used, as well as different definitions of bleeding outcomes. Although bleeding events are more common than thromboembolic events, the consequences of thrombotic events are often detrimental. Management of bleeding events remains challenging and measures to prevent and treat bleeding events are often followed by thromboembolic events. Therefore, a personalized approach based on point-of-care hemostatic tests and adjusted to device type and patient comorbidities is therefore warranted. To provide advanced understanding of hemostatic disturbances during MCS, prospective trials focused on bleeding and thromboembolic events as primary endpoints should be conducted. Better understanding of the underlying pathophysiology and a shift towards a personalized approach based on functional point-of-care hemostatic properties assessment may provide more favorable clinical outcomes. This should, however, be coupled with further technological improvements providing better device surface hemocompatibility as interaction between blood and device surface affects the hemostatic equilibrium.

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Is anti-platelet therapy needed in continuous flow left ventricular assist device patients? A single-centre experience

Abstract: A fluindione regimen without aspirin in long-duration LVAD support appears to not increase thromboembolic events and could lead to a diminished risk of haemorrhagic stroke.

Cited by 38 publications

References 18 publications

Antiplatelet Therapy and Adverse Hematologic Events During Heart Mate II Support

Antiplatelet Therapy and Adverse Hematologic Events During Heart Mate II Support

Thrombolytics in VAD management — A single-center experience

Bleeding and Thrombotic Events in Patients Undergoing Mechanical Circulatory Support: A Review of Literature

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