Purpose: We report our experience of discontinuation of warfarin due to bleeding and ineffective international normalized ratio (INR) in patients with LVAD.
Methods: From June 2013 to October 2017, hundred and sixteen patients that underwent LVAD implantation at our department. We analyzed outcomes of patients in whom warfarin therapy had to be discontinued due to intracranial hemorrhage (ICH), gastrointestinal (GI) bleeding and massive subconjunctival hematoma during ongoing support with LVAD. Outcomes of the patients with temporary warfarin resistance due to antibiotic therapy during LVAD therapy were also evaluated. None of these patients received any anticoagulation therapy until their bleeding event was over. Intravenous infusion of heparin was started according to activated clotting time and activated partial thromboplastin time in patients after ICH was controlled or in patients with ineffective INR until effective INR . We checked revolutions per minute (RPM), flow rates and power consumption parameters of pump, lactate dehydrogenase (LDH) level daily.
Results: Of twelve patients, mean age was 41 ± 16.7 (19-59) years, mean follow up time was 645.7 ± 430 (52-1315) days. Seven patients had to discontinue warfarin due to bleeding (ICH in 5, GI bleeding in 1, subconjunctival hemorrhage in 1) and ineffective INR due to warfarin resistance in five patients. Mean duration of ineffective INR was 24.5 ± 12.1 (9-45) days. In one of the patient with ICH, pump thrombosis was encountered, and his pump had to be exchanged with an urgent operation. There were not any other adverse events in this patient population. Mean follow-up time after pump complication was 344 ± 417 (94-1240) days. No delayed rehemorrhages or pump complications were observed after resuming aspirin and warfarin therapy.
Conclusion: Few data are available to guide decision making for the management of patients in whom ICH develop in the setting of LVAD therapy, particularly with regard to management of antiplatelet and anticoagulation medications. Clinical trials will be required to address the use of an altered anticoagulation regimen in these patients.