Risk Of Pump Thrombosis With Once Daily Enoxaparin For Anticoagulation Bridging In Patients With Heartmate III

Purpose Most centers bridge patients with Left Ventricular Assist Device (LVAD) with heparin drip to avoid thromboembolic complications including stroke and pump thrombosis based on data from HeartMate II. Because of improved hemocompatibility of third generation HeartMateIII (HM3), particularly the decreased risk of in-pump thrombosis, outpatient treatment dose of low molecule weight heparin (LWMH) like Enoxaparin has been used to bridge to warfarin when the INR is subtherapeutic. Once daily dosing has been used in select patients with higher bleeding risk. However, data supporting this approach is limited. We investigate the safety of using once daily Enoxaparin dosing to bridge subtherapeutic warfarin in patients on HMIII LVAD. Methods We conducted a retrospective review of patients who underwent HMIII LVAD implantation from 2018 to 2020. We identified 104 patients who received Enoxaparin 1mg/kg subcutaneous once a day bridging after LVAD implantation. A detailed chart review was performed. We investigated complications related to Enoxaparin use and necessary data parameters to determine the safety profile of once daily Enoxaparin use. The primary outcome was in-pump thrombosis. Secondary outcomes included ischemic stroke, embolic phenomenon, acute kidney injury and bleeding events. Results 232 patients were screened, 104 patients of which bridged at least once with Enoxaparin. Multiple patients received multiple rounds of Enoxaparin bridging over their course of follow up. The average Enoxaparin course was 3-5 days and extended only if INR remains below 1.6. Enoxaparin was held once the INR reaches 1.8. There was no incidence of pump thrombosis or ischemic stroke. Conclusion Once daily Enoxaparin dosing as a bridge to subtherapeutic anticoagulation with warfarin for Heartmate 3 patients is a safe and effective method for preventing pump thrombosis. Most centers bridge patients with Left Ventricular Assist Device (LVAD) with heparin drip to avoid thromboembolic complications including stroke and pump thrombosis based on data from HeartMate II. Because of improved hemocompatibility of third generation HeartMateIII (HM3), particularly the decreased risk of in-pump thrombosis, outpatient treatment dose of low molecule weight heparin (LWMH) like Enoxaparin has been used to bridge to warfarin when the INR is subtherapeutic. Once daily dosing has been used in select patients with higher bleeding risk. However, data supporting this approach is limited. We investigate the safety of using once daily Enoxaparin dosing to bridge subtherapeutic warfarin in patients on HMIII LVAD. We conducted a retrospective review of patients who underwent HMIII LVAD implantation from 2018 to 2020. We identified 104 patients who received Enoxaparin 1mg/kg subcutaneous once a day bridging after LVAD implantation. A detailed chart review was performed. We investigated complications related to Enoxaparin use and necessary data parameters to determine the safety profile of once daily Enoxaparin use. The primary outcome was in-pump thrombosis. Secondary outcomes included ischemic stroke, embolic phenomenon, acute kidney injury and bleeding events. 232 patients were screened, 104 patients of which bridged at least once with Enoxaparin. Multiple patients received multiple rounds of Enoxaparin bridging over their course of follow up. The average Enoxaparin course was 3-5 days and extended only if INR remains below 1.6. Enoxaparin was held once the INR reaches 1.8. There was no incidence of pump thrombosis or ischemic stroke. Once daily Enoxaparin dosing as a bridge to subtherapeutic anticoagulation with warfarin for Heartmate 3 patients is a safe and effective method for preventing pump thrombosis.