Interruption of Anticoagulation in Patients with HeartMate 3 - A Safety Analysis

Objectives: To prevent thrombotic device-related complications, patients with left ventricular assist devices (LVAD) require anticoagulation and antiplatelet therapy. However, if these patients require interventional procedures or present other conditions with increased bleeding risk, anticoagulation poses a central problem. The HeartMate 3 LVAD was recently introduced into clinical practice. It is designed to stimulate endothelialization on its internal surfaces with the goal to reduce risk of thrombotic risk. So far, data for interrupting or reducing anticoagulation are rare. We report a case series where anticoagulation had to be temporarily discontinued.

Methods: We analyzed all cases of HeartMate 3 implantations performed in our clinic since 11/2015. Anticoagulation was performed as recommended, initially heparin and later oral anticoagulation and antiplatelet therapy.

Results: HeartMate 3 was implanted in 42 patients (39 male, 3 female), 54.8% were implanted as a bridge to transplantation and 31.0% as destination therapy, 14.3 as bridge to decision. Patients' INTERMACS profiles were: 1 (21.4%), 2 (19%), 3 (31%), 4 (28.6%). Mean age was 59 ± 11.4 years. Thirty day survival was 90%. In 25 cases (16 patients), discontinuation of oral anticoagulation was deemed necessary with a mean duration of 43.52 ± 61.9 hours. The longest case without any anticoagulation was 12 days and 3 hours. Before discontinuation 85% of the patients were anticoagulated with heparin and 16% with vitamin K antagonists. None of the patients had any other anticoagulants during the interruption, except aspirin in 2 cases. In the heparin group, partial thromboplastin time fell from 61.1 ± 18.6 second to 30.9 ± 8.29 second after discontinuation (p < 0.001). In the patients with vitamin K antagonists INR fell from 2.3 ± 0.7 to 1.57 ± 0.18. The main interventions performed were thoracocentesis and chest tube insertion (n = 11; 45.8%). Others reasons included ICD battery exchange, reexploration for thoracic bleeding, risk of brain bleeding and hematuria. There were no bleeding or any other complications associated when interventions were performed. Importantly, there were no strokes or other signs of thrombotic events and pump thrombosis. LVAD parameters remained stable during the episodes of anticoagulant discontinuation.

Conclusion: Short-term discontinuation of anticoagulation may be safe in HeartMate 3 recipients and appear to reduce bleeding complications without increasing thrombotic risk.

No conflict of interest has been declared by the author(s).