Upcoming prospective, randomized, controlled studies have yet to verify this observation

Upcoming prospective, randomized, controlled studies have yet to verify this observation. In individuals with heavy bleeding complications, anticoagulant therapy ought to be discontinued or adjusted. experience an obtained coagulopathy, including platelet dysfunction and impaired von Willebrand aspect activity, leading to obtained von Willebrand symptoms. Within this educational manuscript, the epidemiology, etiology, and pathophysiology of bleeding in sufferers with LVAD will be discussed. Because hematologist are generally consulted in situations of bleeding complications in they in a crucial care setting, the noticed kind of bleeding problems and administration strategies to treat bleeding are also reviewed. Learning Objectives Learn that bleeding is a frequent and severe complication after implantation of left ventricular assist devices (LVADs) Understand that acquired von Willebrand syndrome (AVWS) is found in nearly all patients with LVAD implants and may influence bleeding episodes Understand that recurrent gastrointestinal bleeding is frequently observed and may be caused by the combination of angiodysplasia and AVWS Introduction In patients admitted to the critical care unit, bleeding is a frequently encountered complication. Over the years, the causes of bleeding have changed, and nowadays, many of these bleeding episodes are observed in patients receiving new devices used to support the circulatory system or the pulmonary system, including left ventricular assist devices (LVADs) and extracorporal membrane oxygenation (ECMO). In this case-based article, the epidemiology, pathophysiology, and management of bleeding problems that are observed in patients in whom an LVAD has been implanted to improve cardiac function will be discussed. Case 1 This is a 57-year-old male who developed cardiac failure owing to severely reduced left ventricular function after a large anterior myocardial. Four months after the infarction in 2015, he was transferred to our cardiology department, and a HeartMate II LVAD was implanted as a bridge to heart transplantation. Anticoagulation was initiated according to local protocols, including aspirin and vitamin K antagonists (acenocoumarol) (Table 1). A week after LVAD implantation, he developed regular nose bleeds, for which cautery by the otolaryngologist was performed. One month later, he was admitted with collapse, dizziness, and melena. During hospitalization, he developed hypotension and was transmitted to the intensive care unit (ICU). Endoscopy showed no bleeding focus in stomach or colon. He received several transfusions, Thiotepa and anticoagulation was temporarily stopped for a few days and resumed after cessation Thiotepa of bleeding. In the year after LVAD implantation, he was admitted 4 times with hemoglobin levels between 3.2 and 5.5 mmol/L owing to gastrointestinal (GI) bleeding, for which transfusion with packed red cells was needed. The bleeding could not be stopped by local measures because no bleeding focus was found. Table 1. Recommendations for the use of anticoagulation and postoperative management NFBD1 thead valign=”bottom” th rowspan=”1″ colspan=”1″ Time course and events /th th align=”center” rowspan=”1″ colspan=”1″ Management strategies /th /thead Intraoperative period?If intraoperative extracorporeal life support or off-pump implantation is performed, administration of a reduced dose of heparin may be consideredEarly postoperative period?Direct postoperativeComplete reversal of heparin?First 24 hNo action required, consider acetylsalicylic acid?Postoperative days 1 and 2IV heparin or alternative anticoagulation if no evidence of bleeding?Postoperative days 2 and 3Continue heparin and start warfarin and aspirin (81-325 mg daily) after removal of chest tubes; the use of LMWH for bridging during long-term support is recommendedDuring LVAD support?A postoperative INR target between 2.0 and 3.0 is recommended?AnticoagulationAnticoagulation with warfarin to maintain an INR within a range as specified by each devices manufacturer is recommended?Antiplatelet therapyChronic antiplatelet therapy with aspirin (81-325 mg daily) may be used in addition to warfarin, and additional antiplatelet therapy may be added according to the recommendations of specific device manufacturersComplications?Early postoperative bleedingUrgently evaluate necessity of lowering, discontinuation, and/or Thiotepa reversal of anticoagulation and antiplatelet medications; in all cases of bleeding, exploration and treatment of a bleeding site should be considered?Gastrointestinal bleedingAnticoagulation and antiplatelet therapy should be held in the setting of clinically significant bleeding; anticoagulation should be reversed in the setting of an elevated INR, and careful monitoring of the devices parameters is warranted?Neurologic event/deficitDiscontinuation or reversal of anticoagulation in the setting of hemorrhagic stroke is recommended?HemolysisHemolysis in the presence of altered pump function should prompt admission for optimization of anticoagulation and antiplatelet management and possible pump exchange?Pump thrombosisHeparin, GPIIb/IIIa inhibitors, and thrombolytics, either alone or in combination, have been proposed as treatment option for pump thrombosis; however, definitive therapy for pump stoppage is surgical pump exchange?Cessation of acetylsalicylic acidAfter resolution of the first bleeding episode, discontinuation of long-term acetylsalicylic acid should be considered?DOACThe use of novel oral anticoagulants is not recommended Open in a separate window Modified from the 2013 International.