Recommendations for the use of anticoagulation and postoperative management
| Time course and events . | Management strategies . |
|---|---|
| Intraoperative period | |
| If intraoperative extracorporeal life support or off-pump implantation is performed, administration of a reduced dose of heparin may be considered | |
| Early postoperative period | |
| Direct postoperative | Complete reversal of heparin |
| First 24 h | No action required, consider acetylsalicylic acid |
| Postoperative days 1 and 2 | IV heparin or alternative anticoagulation if no evidence of bleeding |
| Postoperative days 2 and 3 | Continue heparin and start warfarin and aspirin (81-325 mg daily) after removal of chest tubes; the use of LMWH for bridging during long-term support is recommended |
| During LVAD support | |
| A postoperative INR target between 2.0 and 3.0 is recommended | |
| Anticoagulation | Anticoagulation with warfarin to maintain an INR within a range as specified by each device’s manufacturer is recommended |
| Antiplatelet therapy | Chronic antiplatelet therapy with aspirin (81-325 mg daily) may be used in addition to warfarin, and additional antiplatelet therapy may be added according to the recommendations of specific device manufacturers |
| Complications | |
| Early postoperative bleeding | Urgently evaluate necessity of lowering, discontinuation, and/or reversal of anticoagulation and antiplatelet medications; in all cases of bleeding, exploration and treatment of a bleeding site should be considered |
| Gastrointestinal bleeding | Anticoagulation and antiplatelet therapy should be held in the setting of clinically significant bleeding; anticoagulation should be reversed in the setting of an elevated INR, and careful monitoring of the devices parameters is warranted |
| Neurologic event/deficit | Discontinuation or reversal of anticoagulation in the setting of hemorrhagic stroke is recommended |
| Hemolysis | Hemolysis in the presence of altered pump function should prompt admission for optimization of anticoagulation and antiplatelet management and possible pump exchange |
| Pump thrombosis | Heparin, GPIIb/IIIa inhibitors, and thrombolytics, either alone or in combination, have been proposed as treatment option for pump thrombosis; however, definitive therapy for pump stoppage is surgical pump exchange |
| Cessation of acetylsalicylic acid | After resolution of the first bleeding episode, discontinuation of long-term acetylsalicylic acid should be considered |
| DOAC | The use of novel oral anticoagulants is not recommended |
| Time course and events . | Management strategies . |
|---|---|
| Intraoperative period | |
| If intraoperative extracorporeal life support or off-pump implantation is performed, administration of a reduced dose of heparin may be considered | |
| Early postoperative period | |
| Direct postoperative | Complete reversal of heparin |
| First 24 h | No action required, consider acetylsalicylic acid |
| Postoperative days 1 and 2 | IV heparin or alternative anticoagulation if no evidence of bleeding |
| Postoperative days 2 and 3 | Continue heparin and start warfarin and aspirin (81-325 mg daily) after removal of chest tubes; the use of LMWH for bridging during long-term support is recommended |
| During LVAD support | |
| A postoperative INR target between 2.0 and 3.0 is recommended | |
| Anticoagulation | Anticoagulation with warfarin to maintain an INR within a range as specified by each device’s manufacturer is recommended |
| Antiplatelet therapy | Chronic antiplatelet therapy with aspirin (81-325 mg daily) may be used in addition to warfarin, and additional antiplatelet therapy may be added according to the recommendations of specific device manufacturers |
| Complications | |
| Early postoperative bleeding | Urgently evaluate necessity of lowering, discontinuation, and/or reversal of anticoagulation and antiplatelet medications; in all cases of bleeding, exploration and treatment of a bleeding site should be considered |
| Gastrointestinal bleeding | Anticoagulation and antiplatelet therapy should be held in the setting of clinically significant bleeding; anticoagulation should be reversed in the setting of an elevated INR, and careful monitoring of the devices parameters is warranted |
| Neurologic event/deficit | Discontinuation or reversal of anticoagulation in the setting of hemorrhagic stroke is recommended |
| Hemolysis | Hemolysis in the presence of altered pump function should prompt admission for optimization of anticoagulation and antiplatelet management and possible pump exchange |
| Pump thrombosis | Heparin, GPIIb/IIIa inhibitors, and thrombolytics, either alone or in combination, have been proposed as treatment option for pump thrombosis; however, definitive therapy for pump stoppage is surgical pump exchange |
| Cessation of acetylsalicylic acid | After resolution of the first bleeding episode, discontinuation of long-term acetylsalicylic acid should be considered |
| DOAC | The use of novel oral anticoagulants is not recommended |
Modified from the 2013 International Society for Heart and Lung Transplantation guideline recommendations and the 2019 European Association for Cardio-Thoracic Surgery expert consensus on long-term mechanical circulatory support.
DOAC, direct oral anticoagulant; GPIIb/IIIa, glycoprotein IIb/IIIa; INR, international normalized ratio; IV, intravenous; LMWH, lower-molecular weight heparin.