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Jessaca R. Zuidema
College of Nursing and Fishback Honors College
Antithrombic Therapy for Patients with Left
Ventricular Assist Devices: A Literature Review
BACKGROUND RESULTS
• Worldwide, 23 million people have heart • Current practice is heparin until patients can ingest oral • Bivalirudin is novel but has been used to bridge to warfarin 6,12
failure 1 warfarin and aspirin, which they take for the remainder of • Factor Xa inhibitors may be an option for those with warfarin
• Half of those with heart failure will die LVAD placement 1,5,10 resistance 1
within five years of their diagnosis 2 • Despite complications, warfarin is the drug of choice for • More bleeding was seen when aspirin was used with warfarin
• LVADs are mechanical pumps that maintenance, but no ideal internal normalized ratio has been than when warfarin was used alone 1,10,15,17
compensate for the patient’s weakened identified 1,3,9,12,13,16 • Alternate antiplatelets have been used but evidence is very
left ventricle • Heparin bridging is associated with bleeding, but results are limited 1,4,12,13
• Due to clotting risk, antithrombic therapy highly variable 1,2,6,7,10,11 • Few reports of success without antithrombic therapy exist 3
is necessary 9
• Bleeding and clotting complications are
high 5
CONCLUSION SIGNIFICANCE TO NURSING
CLINICAL QUESTION • Warfarin monotherapy is recommended for LVAD maintenance • Nurses are the main educators for those
receiving an LVAD
• INR goals should be individualized
In patients with left ventricle assist devices, • Heparin bridging and bivalirudin must be studied more extensively as • The nurse is often the administrator of
what does literature suggest is the most results are variable antithrombic therapy in the hospital
effective form of antithrombic therapy? • Factor Xa inhibitors and alternate antiplatelets should be studied more • Recognizing the signs of impaired
• Research should continue due to high complication rates; randomized coagulation is very important and often falls to
control trials are necessary the nursing staff
METHODS
• Thirty-one articles from CINAHL and REFERENCES
PubMed
• Search criteria was ("Anticoagulant 1. den Exter, P. L., Beeres, S. L. M. A., Eikenboom, J., Klok, F. A., & Huisman, M. V. (2020). Anticoagulant treatment and bleeding 10. McDavid, A., MacBrair, K., Emani, S., Yu, L., Lee, P., Whitson, B. A., Lampert, B. C., Agarwal, R., & Kilic, A. (2018). Anticoagulation
complications in patients with left ventricular assist devices. Expert Review of Cardiovascular Therapy, 18(6), 363-372. https://doi-
management following left ventricular assist device implantation is similar across all provider strategies. Interactive Cardiovascular and
therapy" OR "Anticoagulants org.excelsior.sdstate.edu/10.1080/14779072.2020.1773803 Thoracic Surgery, 26(1), 60–65. https://doi.org/10.1093/icvts/ivx255
2. Doty, D. (2015). Ventricular Assist Device and Destination Therapy Candidates from Preoperative Selection Through End of
11. Sandica, E., Blanz, U., Mime, L. B., Schultz-Kaizler, U., Kececioglu, D., Haas, N., Kirchner, G., zu Knyphausen, E., Lauenroth, V., &
Therapeutic Use" OR "anticoagulant Hospitalization. Critical Care Nursing Clinics of North America, 27(4), 551-564. https://doi-org.excelsior.sdstate.edu/ Morshuis, M. (2016). Long-Term Mechanical Circulatory Support in Pediatric Patients. Artificial organs, 40(3), 225–232.
10.1016/j.cnc.2015.07.006
https://doi.org/10.1111/aor.12552
treatment") AND (LVAD or "left 3. Elder, T., Raghavan, A., Smith, A., Wright, C. H., Wright, J., Burant, C., Sajatovic, M., & Hoffer, A. (2019). Outcomes After Intracranial 12. Sherwin, J., Thomson, E., Hill, K. D., Wall, K., Hornik, C. P., Lodge, A. J., & Gonzalez, D. (2018). Clinical pharmacology
considerations for children supported with ventricular assist devices. Cardiology in the Young, 28(9), 1082-1090. https://doi-
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ventricular") 4. Gernhofer, Y. K., Ross, M., Khoche, S., & Pretorius, V. (2018). The use of cangrelor with heparin for left ventricular assist device 13. Toeg, H., Ruel, M., & Haddad, H. (2015). Anticoagulation strategies for left ventricular assist devices. Current Opinion in Cardiology,
implantation in a patient with acute heparin-induced thrombocytopenia. Journal of cardiothoracic surgery, 13(1), 30.
30(2), 192-196. https://doi-org.excelsior.sdstate.edu/10.1097/HCO.0000000000000143
• Inclusion criteria was published since https://doi.org/10.1186/s13019-018-0721-x 14. Upshaw, J. N., Kiernan, M. S., Morine, K. J., Kapur, N. K., & DeNofrio, D. (2016). Incidence, Management, and Outcome of
5. John, R., Holley, C. T., Eckman, P., Roy, S. S., Cogswell, R., Harvey, L., Shumway, S., & Liao, K. (2016). A Decade of Experience
Suspected Continuous-Flow Left Ventricular Assist Device Thrombosis. ASAIO journal (American Society for Artificial Internal Organs:
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the United States, human subjects, and 6. Kantorovich, A., Fink J. M., Militello, M. A., Bauer, S. R., Soltesz, E. G., & Moazami, N. (2016). Comparison of Anticoagulation and Aspirin Versus Warfarin Alone for Prevention of Embolic Events in Patients with a HeartMate II Left Ventricular Assist
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Devices. Current Problems in Cardiology, 40(12), 511-540. https://doi:10.1026/j.cpcardiol.2015.03.004
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ventricular assist devices. Artificial organs, 43(8), 736–744. https://doi.org/10.1111/aor.13456
Flow Left Ventricular Assist Devices: Our Clinical Experience With Medical and Surgical Management. Transplantation
• Exclusion criteria included focus on right proceedings, 48(6), 2162–2167. https://doi.org/10.1016/j.transproceed.2016.04.025 17. Yin, M. Y., Ruckel, S., Kfoury, A. G., McKellar, S. H., Taleb, I., Gilbert, E. M., Nativi-Nicolau, J., Stehlik, J., Reid, B. B., Koliopoulou,
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