Management of Bleeding Associated with Durable Mechanical Circulatory Support

Abstract

Heart failure patients that require mechanical circulatory support with a ventricular assist device (VAD) are at a high risk of bleeding due to the underlying physiology of their disease, the physical presence of the VAD, and the requirement of antithrombotic therapy. The VAD pump itself can influence hematologic, inflammatory, and immunologic parameters that can disrupt the hemostatic process. Continuous flow VADs are now more frequently used compared to the older, pulsatile flow devices due to their smaller size and reduced risk of thrombosis. These benefits are marginally offset by the higher risk of gastrointestinal bleeding seen in patients using continuous flow devices. It is important that healthcare providers responsible for the management of these patients be prepared to deal with potential bleeding events appropriately.

Management of bleeding in this specific patient population is difficult due to their high risk of thrombosis and frequency of rebleeding. Characteristics of the bleed such as the type, severity, and location need to be considered before any therapeutic interventions are made. Gastrointestinal bleeding and hemorrhagic cerebral vascular events are the most common types of bleeds in the VAD population and are associated with high rates of morbidity and mortality. Techniques to manage and prevent bleeding can include medical therapy, procedural diagnostic interventions, changes to the intensity of anticoagulation or antiplatelet therapy, and reduction of VAD speed. Major bleeding frequently results in discontinuation of an antiplatelet agent or a reduction in target INR range. Antithrombotic therapy should be resumed as soon as bleeding has resolved and baseline hemostasis has been achieved. In general, all patients that experience a bleeding event should be evaluated and treated on an individualized basis based on the patient and event specific factors.