Reversal and Resumption of Antithrombotic Therapy in LVAD-Associated Intracranial Hemorrhage.

Abstract

BACKGROUND:

Little data exist regarding reversal and resumption of antithrombotics after left ventricular assist device (LVAD)-associated intracranial hemorrhage.

METHODS:

Prospectively collected data of LVAD patients with intracranial hemorrhage were reviewed. Coagulopathy reversal agents, antithrombotic regimens, and thrombotic (venous thromboembolism, ischemic stroke, myocardial infarction) and hemorrhagic (recurrent intracranial hemorrhage, gastrointestinal bleed, anemia requiring transfusion) complications were recorded.

RESULTS:

Of 405 patients, intracranial hemorrhage occurred in 39 (10%): 23 intracerebral hemorrhages, 10 subarachnoid hemorrhages, and 6 subdural hematomas. Of 27 patients who received antithrombotic reversal, 8 (30%) had inadequate coagulopathy reversal, and 3 of these patients had hemorrhage expansion or died before repeat imaging. One (4%) patient had a thrombotic complication (deep vein thrombosis). Antithrombotic therapy was resumed in 17 (100%) survivors in a median time 8 days for antiplatelet agents and 14 days for warfarin. Recurrent intracranial hemorrhage occurred within a median of 7 days of antithrombotic resumption, while ischemic stroke occurred in a median of 428 days. Patients who resumed antiplatelets alone (n = 4) had a trend toward more thrombotic events (1.37 versus 0.14 events/patient-year [EPPY]; p = 0.08), including more fatal thrombotic events (0.34 EPPY versus 0.08 EPPY; p = 0.89) compared with those resuming warfarin ± antiplatelet (n = 14). Nonfatal hemorrhage event rates were 0.34 EPPY in the warfarin ± antiplatelet versus 0 EPPY in the antiplatelet-alone group (p = 0.16). No fatal hemorrhagic events occurred.

CONCLUSIONS:

Reversal of anticoagulation appears safe after LVAD-associated intracranial hemorrhage, though inadequate reversal was common. Resumption of warfarin ± antiplatelet was associated with fewer fatal and nonfatal thrombotic events compared with antiplatelets alone, though more nonfatal hemorrhage events occurred.

• Authors: Sung-Min Cho, Nader Moazami, Stuart Katz, Randall Starling, Jennifer A Frontera
• Journal: The Annals of thoracic surgery (Ann Thorac Surg) Vol. 108 Issue 1 Pg. 52-58 (07 2019) ISSN: 1552-6259 [Electronic] Netherlands
• PMID: 30763560 (Publication Type: Journal Article)
• Copyright: Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Chemical References

• Fibrinolytic Agents

Topics

• Adult
• Aged
• Female
• Fibrinolytic Agents (therapeutic use)
• Heart-Assist Devices (adverse effects)
• Humans
• Intracranial Hemorrhages (drug therapy, mortality)
• Male
• Middle Aged
• Prospective Studies
• Recurrence