Multi-Targeted Antithrombotic Therapy for Total Artificial Heart Device Patients

Abstract

To prevent thrombotic or bleeding events in patients receiving a total artificial heart (TAH), agents have been used to avoid adverse events. The purpose of this article is to outline the adoption and results of a multi-targeted antithrombotic clinical procedure guideline (CPG) for TAH patients. Based on literature review of TAH anticoagulation and multiple case series, a CPG was designed to prescribe the use of multiple pharmacological agents. Total blood loss, Thromboelastograph(®) (TEG), and platelet light-transmission aggregometry (LTA) measurements were conducted on 13 TAH patients during the first 2 weeks of support in our institution. Target values and actual medians for postimplant days 1, 3, 7, and 14 were calculated for kaolinheparinase TEG, kaolin TEG, LTA, and estimated blood loss. Protocol guidelines were followed and anticoagulation management reduced bleeding and prevented thrombus formation as well as thromboembolic events in TAH patients postimplantation. The patients in this study were susceptible to a variety of possible complications such as mechanical device issues, thrombotic events, infection, and bleeding. Among them all it was clear that patients were at most risk for bleeding, particularly on postoperative days 1 through 3. However, bleeding was reduced into postoperative days 3 and 7, indicating that acceptable hemostasis was achieved with the anticoagulation protocol. The multidisciplinary, multi-targeted anticoagulation clinical procedure guideline was successful to maintain adequate antithrombotic therapy for TAH patients.

Keywords: aggregometry; antithrombosis; multi-targeted antithrombotic therapy; thromboelastography; total artificial heart.

Figure 1.

(A) Laboratory values of hemoglobin concentration (HB, gm/dL), platelet count (PLT, 10⁹/L), fibrinogen concentration (FIB, gm/dL), and leukocyte count (LEUK, 10⁹/L). (B) Laboratory values of aPTT (sec), INR, AT (%), and PFOxyHB (mg/dL).

Figure 1.

(A) Laboratory values of hemoglobin concentration (HB, gm/dL), platelet count (PLT, 10⁹/L), fibrinogen concentration (FIB, gm/dL), and leukocyte count (LEUK, 10⁹/L). (B) Laboratory values of aPTT (sec), INR, AT (%), and PFOxyHB (mg/dL).

Figure 2.

Thromboelastography values. Red lines connect median values for heparinase + kaolin TEG values and blue lines connect KTEG values. Points are median values for 5–13 patient results per total artificial heart implant day.

Figure 3.

LTA platelet maximum aggregation by agonists. COLLAG is collagen. Therapeutic target agonist inhibition is less than 50%.

Figure 4.

Chest tube drainage estimated blood loss. Blood loss is mL/kg/day. The median blood loss is denoted by the blue markers and line.