Journal of Thrombosis and Thrombolysis

, Volume 47, Issue 1, pp 57–66 | Cite as

Postoperative bridging anticoagulation and left ventricular assist system thrombosis

  • David M. NemerEmail author
  • Garrick C. Stewart
  • Maneka Puligandla
  • Donna S. Neuberg
  • Michael M. Givertz
  • Mandeep R. Mehra
  • Gregory S. Couper
  • Jean M. Connors


Reduced emphasis on early postoperative bridging anticoagulation is one explanation for the increased incidence of HeartMate II (HM II) pump thrombosis. We conducted a single-center analysis of initial postoperative anticoagulation practices and their impact on the incidence of HM II pump thrombosis. Data was collected on 105 patients undergoing primary HM II implant from 2009 to 2014. A parenteral bridge was defined as use of parenteral anticoagulation prior to attainment of an international normalized ratio ≥ 2 on warfarin. A parenteral bridge was further characterized as early if initiated ≤ 3 days of implant and therapeutic if a manufacturer-specified goal partial thromboplastin time (PTT) was achieved during each of the first 3 days of administration. Pump thrombosis was “suspected” based upon suggestive clinical parameters leading to hospital admission with parenteral anticoagulant administration and “confirmed” by direct visualization of thrombus in the device. A majority of patients (70%) were treated with an initial parenteral bridge, which was started within 3 days of device implantation in 68% of cases. Therapeutic PTT levels were achieved in 52% of patients treated with a parenteral bridge. Patients who were bridged had lower Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (p = 0.039) and longer intensive care unit stay (p = 0.005). Pump thrombosis was suspected in 25% and confirmed in 13% of patients within 6 months of implant. Point estimates of pump thrombosis incidence demonstrated a lower event rate at 6 months in patients who received a therapeutic bridge (15.8%, 95% CI 6.3–29.1% for suspected; 7.9%, 95% CI 2.0–19.3% for confirmed) compared to those who did not receive a therapeutic bridge (29.9%, CI 19.3–41.1% for suspected; 16.4%, 95% CI 8.7–26.3% for confirmed). This trend was not sustained at 12 and 24 months. Cumulative incidence analyses showed no significant difference in the overall incidence of pump thrombosis between patients who did and did not receive a parenteral bridge. In patients undergoing HM II implantation, the use of initial postoperative parenteral bridging anticoagulation is common but frequently sub-therapeutic. Use of a parenteral bridge reaching therapeutic targets may decrease the 6-month but not the overall incidence of pump thrombosis.


Left ventricular assist system Thrombosis Bridging Anticoagulation 



The authors would like to thank the Kenneth L. Baughman Master Clinician Scholar Program in Cardiovascular Medicine at Brigham and Women’s Hospital for its support of this research.


This research was supported by the Kenneth L. Baughman Master Clinician Scholar Program in Cardiovascular Medicine at Brigham and Women’s Hospital.

Compliance with Ethical Standards

Conflict of interest

The authors D. M. Nemer, G.C. Stewart, M. Puligandla, D. S. Neuberg, M. M. Givertz and G. S. Couper declare that they have no conflict of interest. M. R. Mehra is a consultant for Abbott, Medtronic, Janssen (a division of Johnson and Johnson), Mesoblast, Portola and NupulaseCV. J. M. Connors reports receiving fees for serving on scientific advisory boards from Boehringer Ingelheim and Bristol Meyers Squibb, consulting fees from Bristol Meyers Squibb, and unpaid consultation for Thoratec Corporation.

Supplementary material

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Supplemental material 1 (pptx 206 KB)
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Supplementary material 2 (docx 16 KB)


  1. 1.
    Slaughter MS, Rogers JG, Milano CA et al (2009) Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 36:2241–2251CrossRefGoogle Scholar
  2. 2.
    Jorde UP, Kushwaha SS, Tatooles AJ et al (2014) Results of the destination therapy post-food and drug administration approval study with a continuous flow left ventricular assist device: a prospective study using the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol 63:1751–1757CrossRefGoogle Scholar
  3. 3.
    Kirklin JK, Pagani FD, Kormos RL et al (2017) Eighth annual INTERMACS report: special focus on framing the impact of adverse events. J Heart Lung Transplant 36:1080–1086CrossRefGoogle Scholar
  4. 4.
    Patel CB, Cowger JA, Zuckermann A (2014) A contemporary review of mechanical circulatory support. J Heart Lung Transplant 33:667–674CrossRefGoogle Scholar
  5. 5.
    Starling RC, Moazami N, Silvestry SC et al (2014) Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med 370:33–40CrossRefGoogle Scholar
  6. 6.
    Kirklin JK, Naftel DC, Kormos RL et al (2014) Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) analysis of pump thrombosis in the HeartMate II left ventricular assist device. J Heart Lung Transplant 33:12–22CrossRefGoogle Scholar
  7. 7.
    Kirklin JK, Naftel DC, Pagani FD et al (2015) Pump thrombosis in the Thoratec HeartMate II device: an update analysis of the INTERMACS Registry. J Heart Lung Transpl 34:1515–1526CrossRefGoogle Scholar
  8. 8.
    Mehra MR, Stewart GC, Uber PA (2014) The vexing problem of thrombosis in long-term mechanical circulatory support. J Heart Lung Transplant 33:1–11CrossRefGoogle Scholar
  9. 9.
    Miller LW, Pagani FD, Russell SD et al (2007) Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 357:885–896CrossRefGoogle Scholar
  10. 10.
    Boyle AJ, Russell SD, Teuteberg JJ et al (2009) Low thromboembolism and pump thrombosis with the HeartMate II left ventricular assist device: analysis of outpatient anti-coagulation. J Heart Lung Transplant 28:881–887CrossRefGoogle Scholar
  11. 11.
    Slaughter MS, Naka Y, John R et al (2010) Postoperative heparin may not be required for transitioning patients with a HeartMate II left ventricular assist system to long-term warfarin therapy. J Heart Lung Transplant 29:616–624CrossRefGoogle Scholar
  12. 12.
    Slaughter MS, Pagani FD, Rogers JG et al (2010) Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant 29:S1–S39CrossRefGoogle Scholar
  13. 13.
    HeartMate II Left Ventricular Assist System (2017) Instructions for use. 10006960.B.
  14. 14.
    John R, Kamdar F, Liao K et al (2008) Low thromboembolic risk for patients with the Heartmate II left ventricular assist device. J Thorac Cardiovasc Surg 136:1318–1323CrossRefGoogle Scholar
  15. 15.
    Maltais S, Kilic A, Nathan S et al (2017) PREVENtion of HeartMate II Pump thrombosis through clinical management: the PREVENT multi-center study. J Heart Lung Transplant 36:1–12CrossRefGoogle Scholar
  16. 16.
    Taghavi S, Ward C, Jayarajan SN, Gaughan J, Wilson LM, Mangi AA (2013) Surgical technique influences HeartMate II left ventricular assist device thrombosis. Ann Thorac Surg 96:1259–1265CrossRefGoogle Scholar
  17. 17.
    Uriel N, Han J, Morrison KA et al (2014) Device thrombosis in HeartMate II continuous-flow left ventricular assist devices: a multifactorial phenomenon. J Heart Lung Transplant 33:51–59CrossRefGoogle Scholar
  18. 18.
    Mehra MR, Naka Y, Uriel N et al (2017) A fully magnetically levitated circulatory pump for advanced heart failure. N Engl J Med 376:440–450CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Cardiovascular MedicineCleveland Clinic FoundationClevelandUSA
  2. 2.Division of Cardiovascular Medicine, Department of MedicineBrigham and Women’s HospitalBostonUSA
  3. 3.Department of Biostatistics and Computational BiologyDana-Farber Cancer InstituteBostonUSA
  4. 4.Department of Cardiothoracic SurgeryTufts Medical CenterBostonUSA
  5. 5.Division of Hematology, Department of MedicineBrigham and Women’s HospitalBostonUSA

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